On-Site Infectious Disease Consultation Service at a VA Community Living Center: Answering an Unanticipated Need with Unexpected Cost Savings

Background:   An estimated 1.5 million patients reside in community liver centers (CLCs) and are treated with antibiotics, on average, once each year. Immunologic senescence, chronic medical disorders and both cognitive and functional impairments are among the conditions that place this population at increased risk for infections.  CLCs often lack the personnel and diagnostic equipment required to evaluate patients for suspected infection which may lead to over-utilization of antibiotics or transfer to an acute care setting. 

Objective:   Our objective was to determine if on-site infectious disease (ID) consultations at a CLC would reduce costs by curtailing unnecessary antibiotic use and decreasing patient transfers to acute-care settings or the outpatient ID clinic.

Methods:   A pilot study was initiated with a nurse practitioner and ID physician rounding weekly at a CLC affiliated with a tertiary care Veterans Affairs hospital.  The CLC staff and the hospital’s ID consult service refer patients.  Data on the number of patients seen, the numbers of visits per patient, diagnoses and appropriateness of antibiotics were collected.

Results:   During the first 90 days of this pilot project, 44 patients were seen for a total of 99 visits with an average of 7 patients each week.  Twelve patients (27%) were referred by the hospital ID service while 32 (73%) were identified by the CLC staff.  Patients possessed a wide array of diagnoses, including osteomyelitis/ulcers/wounds (22%), urinary tract infections (12%), fever/leukocytosis (10%) and Clostridium difficile infection (10%).  Antibiotics were stopped or modified for 11 (25%) patients.  Transportation to the hospital’s outpatient ID clinic was avoided for 12 patients, saving $8,400 in travel; at least 5 patients avoided transfer to the emergency room, saving $3,500 in travel and a minimum of $10,000 in emergency room costs. Factoring in $9,300 for the physician and nurse practitioner salary compensation, we estimate at least $12,600 in savings.

Conclusions: Our study indicates that an on-site ID consultation service at a VA CLC reduces costs and improves antibiotic use, emphasizing the CLC need for stewardship.  That nearly ¾ of the referrals came from the CLC staff was unexpected and suggests discovery of a previously unmet need for an ID specialist to assist with management of this vulnerable patient population.  Other benefits include improved quality and continuity of patient care, increased support to CLC staff and reduced burden on the hospital’s outpatient ID clinic and emergency room.  Our early experience with on-site ID consultation at a CLC suggests this could serve as a model for other subspecialties and potentially be implemented at other sites.