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The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

Minton, Jane; Murray, Carolyn Czoski; Meads, David; Hess, Stephane; Vargas-Palacios, Armando; Mitchell, Elizabeth; Wright, Judy; Hulme, Claire; Raynor, David K; Gregson, Angela; Stanley, Philip; McLintock, Kate; Vincent, Rachel; Twiddy, Maureen

Authors

Jane Minton

Carolyn Czoski Murray

David Meads

Stephane Hess

Armando Vargas-Palacios

Elizabeth Mitchell

Judy Wright

Claire Hulme

David K Raynor

Angela Gregson

Philip Stanley

Kate McLintock

Rachel Vincent



Abstract

Background

Outpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.

Objectives

The aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.

Methods

This mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.

Results

The systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.

Limitations

Recruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.

Conclusions

The quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.

Future work

Further research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.

Citation

Minton, J., Murray, C. C., Meads, D., Hess, S., Vargas-Palacios, A., Mitchell, E., …Twiddy, M. (2017). The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. Health Services and Delivery Research, 5(6), 1-272. https://doi.org/10.3310/hsdr05060

Acceptance Date Oct 1, 2016
Publication Date Feb 1, 2017
Deposit Date Dec 11, 2017
Publicly Available Date Dec 11, 2017
Journal Health Services and Delivery Research
Print ISSN 2050-4349
Electronic ISSN 2050-4357
Publisher NIHR Journals Library
Peer Reviewed Peer Reviewed
Volume 5
Issue 6
Pages 1-272
DOI https://doi.org/10.3310/hsdr05060
Public URL https://hull-repository.worktribe.com/output/499837
Publisher URL https://www.journalslibrary.nihr.ac.uk/hsdr/hsdr05060/#/abstract
Copyright Statement © Queen’s Printer and Controller of HMSO 2017. This work was produced by Minton et al. under the terms of a commissioning
contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and
study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Additional Information Contractual start date: 02-2013; Editorial review begun: 12-2015; Accepted for publication: 06-2016

Files

CIVAS Final NIHR Report 2017 (3.2 Mb)
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Copyright Statement
© Queen’s Printer and Controller of HMSO 2017. This work was produced by Minton et al. under the terms of a commissioning
contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and
study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement
is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be
addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre,
Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.





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