Approval delays for high-cost OPAT common, associated with discharge to subacute care

Almost a third of patients who were prescribed outpatient parenteral antimicrobial therapy (OPAT) with daptomycin, ceftaroline, ertapenem, or a beta-lactam beta-lactamase inhibitor combination had to wait more than a day for prior authorization.

Delays in the approval of outpatient parenteral antimicrobial therapy (OPAT) were common when high-cost drugs were prescribed, and they were associated with later discharge and higher costs, a recent study found.

The retrospective study included 200 adult patients discharged on high-priced OPAT antibiotics from one hospital in 2017. The antibiotics included daptomycin, ceftaroline, ertapenem, and the novel beta-lactam beta-lactamase inhibitor combinations. Fifty-nine of the patients (30%) experienced a prior authorization delay, defined as a response taking longer than one day. More patients with a prior authorization delay were discharged to a subacute care facility than to an outpatient setting (37 [63%] vs. 22 [37%]; P=0.001). Results of the study were published by Clinical Infectious Diseases on Oct. 31.

Patients whose OPAT was delayed by prior authorization had significantly more days of inpatient treatment (7 days vs. 3 days; P<0.001), longer duration of hospitalization (13 days vs. 7 days; P<0.001), and higher total direct hospital costs ($19,576 vs. $7,770; P<0.001). Delayed hospital discharge, which the study defined as hospitalization continuing after the day the patient was deemed medically stable for discharge, was significantly more common in patients with OPAT delays (53% vs. 15%; P<0.001). Delayed discharge was also more likely in patients going to a subacute care facility (adjusted odds ratio [OR], 2.623, 95% CI, 1.298 to 5.299) or having only public insurance (adjusted OR, 2.282, 95% CI, 1.194 to 4.360), while it was less common in those over age 64 years (adjusted OR, 0.430; 95% CI, 0.206 to 0.898).

The study authors concluded that prior authorization delays for high-priced OPAT are common. They noted that the association with care in a subacute care facility could potentially be explained by the payment structure for those facilities not routinely allowing for reimbursement for these medications. “There is a need for creative solutions in supply or payment to provide these medications without requiring patients to remain hospitalized to receive intravenous therapy,” the authors said.

They also called on physicians and hospitals to work to improve transitions of care and avoid barriers and delays for these patients. The fact that 93% of the study patients ultimately received their OPAT regimen is evidence that these barriers can eventually be overcome, the authors said. They recommended that clinicians undertake collaborative efforts to identify patients who should receive OPAT early during hospitalization and begin planning their transitions. “Early discussion with patients, caregivers and case management about the costs of care should be considered,” they said.

The study's findings may not be generalizable to facilities with different OPAT processes and patient populations, but the steps and delays in the prior authorization process are likely similar across the country, according to the authors. The study did not assess the appropriateness of antibiotic selection or cause and effect, among other limitations.