(96) Caring for Patients Hospitalized with Injection-related Severe Bacterial Infections

Background & Introduction: Injection-related severe bacterial infections (SBIs) are among the most serious consequences of the injection drug use epidemic and are increasing in incidence. Compounding the severity of these infections, persons who inject drugs (PWID) with SBIs also face negative health outcomes due to inequitable delivery of evidence-based medical care (e.g., outpatient parenteral antibiotic therapy), the pervasive stigma that exists toward these patients within the medical community, and mutual mistrust with healthcare providers. Prior data suggests high (and rising) healthcare costs are associated with SBI among PWID, partially driven by long lengths of stay compared to non-PWID. This suggests that disparities in healthcare delivery for this population may be affected by multiple competing or misaligned incentives among patients, care providers, and hospital administrators. While several pilot studies have explored interventions to improve care, there is minimal data on healthcare stakeholders’ needs for and barriers to implementing novel care models for this population.

Methods: In-depth semi-structured interviews with internal stakeholders involved in treatment of
SBI for PWID. Participants were recruited using purposive sampling from internal hospital leadership (including hospital administrative and finance staff) and healthcare workers (including hospitalist providers, addiction medicine providers, nursing leadership, and social work leadership) at NewYork-Presbyterian Cornell and Columbia campuses. Participants were recruited through email and provided informed consent. Each interview lasted 30-45 minutes and was conducted virtually using Zoom software with two members of the research team who were trained in qualitative interviewing. Sixteen participants were identified and interviewed. The majority of participants were physicians clinicians (n=13) and three were clinicians in hospital leadership (n=3). Study size was informed by data saturation, information power, and analytical and data sufficiency. Interviews were recorded, and transcripts were de-identified. The interviews were coded using thematic analysis in Nvivo. Codes were grouped into categories and emergent themes were identified through team meetings and consensus. Participants were compensated $50 for their participation.

Results: Participants shared insights into strategies for enhancing care for this patient population within the hospital setting. These strategies can be thematically categorized into three groups. Group 1 are strategies that would be aimed at empowering clinical teams to more effectively care for PWID These include providing education on opioid use disorder and medication-assisted therapies; advocating for primary teams to place addiction consults earlier in a patient’s hospital stay, and providing more inpatient training in motivational interviewing and cognitive behavioral technique. Group 2 focuses on patient-care interventions specific to the co-management of substance use disorders This includes more effective management of withdrawal, leveraging telemedicine services to improve post-discharge access to care; offering peer support services while the patient is admitted, providing transportation services for follow-up appointments, implementing echocardiogram screening programs, and offering harm-reduction tools and education as preventative resources. Group 3 involves strategies that are aimed at improving clinical workflows for interdisciplinary and transitional care. These involve improving communication among staff through more frequent interdisciplinary meetings, establishing standardized protocols for reaching out to patients who leave against medical advice, increasing the availability of consultation-liaison psychiatry consults, and coordinating outpatient substance use treatment by addiction teams.

Participants highlighted several barriers that hindered the delivery of comprehensive care for this patient population. These can be organized into those originating from the side of the provider or from the side of the patient Noted examples of the former include insurance constraints that limit providers from conducting follow-up visits, and the challenge of discharging PWID with PICC lines for intravenous. Additional barriers include the limited availability of providers capable of treating comorbid substance use and mental illness, the difficulty of scheduling follow-up appointments, and the complexity of arranging discharge to facilities that accept patients on methadone. Noted examples of barriers from the patient side include those related to their substance use disorder or their socioeconomic circumstance. The largest cited barrier included the high rate of leaving against medical advice (e.g. due to cravings), which hinders providers from coordinating with specific pharmacies or ensuring proper follow-up. The latter concerned housing insecurity, expenses for care, lack of phone, and lack of insurance, all of which prevent patients from the necessary follow-up services. Additionally, poor social support and environmental triggers once discharged further complicate a patient’s needs.

Conclusion & Discussion: This qualitative study of clinical providers offers insights into promising strategies to improve care of PWID with severe bacterial infections, while also shedding light on the multifaceted barriers that must simultaneously be addressed. Providers expressed their interest in strengthening knowledge and education about managing these patient populations, highlighting the need for additional educational programming and guideline development. Additionally, the importance of transitional care including follow-up appointments and addressing social needs, such as housing, emphasized the need to develop integrated programs that are capable of rapid follow-up with co-management of complex medical, behavioral, and social needs. Our study is limited by the single-institution nature and by the common limitations of qualitative work: not all perspectives are represented, and our results may not reflect the average response. However, these results are important for hospital-based providers looking to improve the quality of care for these common infections.

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