Inequitable access to an outpatient parenteral antimicrobial therapy service: linked cross-sectional study

STUDY AIM: To assess whether Outpatient Parenteral Antimicrobial Therapy (OPAT) is provided equitably across gender and social groups in a tertiary care setting. BACKGROUND: OPAT is a widely used and growing approach in high income countries to early discharge or admission avoidance for patients requiring intravenous antimicrobials. There is however a risk that equitable access to healthcare could be eroded unintentionally by expansion of outpatient or ambulatory approaches such as this. Anecdotal evidence in our service, and from published studies, have identified a gender and social group equity gap in outpatient services. METHODS: Service data on inpatient cellulitis episodes over a seven-year period were matched to OPAT referral data to create a retrospective cross-sectional linked dataset. All individuals admitted from 2012 to 2017 inclusive for a primary diagnosis of cellulitis were included: 6295 admissions of 4944 individuals. Demographics, number of co-morbidities, length of hospital stay, number of admissions, distance from OPAT unit and Scottish Index of Multiple Deprivation (SIMD; as a metric of deprivation) were recorded. Adjusted odds of a referral to OPAT across SIMD quintiles and for females compared to males were calculated using multiple logistic regression. RESULTS: Inequitable access to OPAT was identified. Deprivation was negatively associated with likelihood of OPAT referral. Inpatients from the most affluent SIMD quintile were more than twice as likely to have received an OPAT referral compared to those resident in the most deprived quintile (adjusted OR 2.08, 95% CI: 1.60–2.71, p < 0.0001). Women were almost a third less likely to receive an OPAT referral than men (adjusted OR 0.69, 95% CI: 0.58 to 0.82, p < 0.001). Results were adjusted for age, number of co-morbidities, admissions, length of stay, distance from nearest OPAT unit, time since first admission, deprivation and gender. CONCLUSIONS: OPAT services and other ambulatory care programmes should routinely evaluate the equity of their service provision and consider how they can reduce any identified imbalance. It is a critical responsibility of service planning to ensure an inequitable system does not develop, with those least able to access ambulatory care dispossessed of the associated benefits.