The Need for Multidisciplinary Hospital Teams for Injection Drug Use-related Infective Endocarditis : Journal of Addiction Medicine

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The Need for Multidisciplinary Hospital Teams for Injection Drug Use-related Infective Endocarditis

Weimer, Melissa B. DO, MCR, FASAM; Falker, Caroline G. MD; Seval, Nikhil MD; Golden, Marjorie MD; Hull, Sarah C. MD, MBE; Geirsson, Arnar MD; Vallabhajosyula, Prashanth MD, MS

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Journal of Addiction Medicine: 7/8 2022 - Volume 16 - Issue 4 - p 375-378
doi: 10.1097/ADM.0000000000000916
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Abstract

Injection drug use-related infective endocarditis (IDU-IE) has increased over the last 10 years.1 IDU-IE is often related to repetitive cardiac valvular injury and transient bacteremia episodes from injection drug use, typically of opioids or stimulants. Individuals who use injection drugs are at risk of IDU-IE from intravenous exposure to bacterial and fungal organisms from contaminated drugs or drug supplies. IDU-IE requires hospital treatment and is associated with high costs, long hospital length of stay, frequent hospital admissions, and high mortality.2–4 Compared to individuals with infective endocarditis not related to injection drug use, individuals with IDU-IE are younger, have higher incidence of HCV, HIV, alcohol use, and liver disease, and are more likely to have lower incomes.4 Despite many individuals with IDU-IE having substance use disorders (SUD), SUD treatment initiation remains low, and few individuals with IDU-IE and opioid use disorder (OUD) are offered medication for opioid use disorder (MOUD) during hospitalization or after discharge.5

The treatment of IDU-IE requires complex clinical decision making and involves multiple medical domains. Like other complex medical conditions, a multidisciplinary team may best address patients’ needs. A useful model is a “transplant selection committee” that decides patients’ eligibility for organ transplantation. Though the structure of these committees may vary among institutions, committees generally meet regularly, include a multidisciplinary team, and make recommendations based on a formalized evaluation process.6 For IDU-IE treatment, multidisciplinary teams may serve a similar function to address concerns about clinical rationing of cardiac surgery and practice variation.5 Like a transplant committee, the clinical decision making for IDU-IE can be standardized and include an evaluation and treatment approach that integrates addiction medicine. Current American Association for Thoracic Surgeons and American Heart Association guidelines recommend multidisciplinary care for patients with IDU-IE.7,8 Studies have shown improved mortality with multidisciplinary care including cardiologists infectious disease specialists and cardiac surgeons.9,10 However, there are few examples of formal multidisciplinary care that includes addiction medicine and many institutions do not offer addiction treatment for hospitalized patients.5,11

We describe the implementation of a multidisciplinary endocarditis evaluation team (MEET) whose role is to optimize and standardize the clinical decision making and clinical care for patients hospitalized with IDU-IE and treat underlying SUD.

CREATION OF THE MEET

The MEET was developed at a >1500 bed academic medical center serving a mixed urban and suburban population with diverse socioeconomic, racial, and ethnic composition. The MEET met regularly to discuss hospitalized patients with IDU-IE who had confirmed SUD. Patients were identified by the cardiac surgeons, infectious disease, or medicine clinicians who initiated the referral to MEET. MEET was comprised of addiction medicine, anesthesia, cardiology, cardiac surgery, infectious disease, case management, nursing, and social work. Other specialties such as neurology and psychiatry were engaged when needed. All patients were independently evaluated by each specialty.

To establish the MEET, leaders from cardiac surgery and addiction medicine met to understand gaps in clinical care. Health system deficiencies included the historical absence of addiction treatment, difficult coordination among specialists, poor patient attendance to post-hospital care, and negative bias among staff toward individuals who use drugs. With a shared goal to improve the care of patients with IDU-IE, a multidisciplinary team was engaged to improve the care of patients with IDU-IE and address treatment gaps.

Stakeholders from the various specialties were identified based on their interest in treating IDU-IE. These stakeholders met to develop a charter. A shared vision for better care coordination and addiction treatment was held by initial stakeholders which greatly facilitated collaboration. Stakeholders agreed to address the disease of IDU-IE and SUD with shared understanding and understood that changes in the treatment of IDU-IE could not happen only by initiating addiction treatment (Fig. 1). Rather, through the development of MEET, it became apparent that a re-evaluation of practices among all involved specialties was needed. The following practices were re-designed. MEET discussed collaboration between the addiction medicine consult service and other established teams and what addiction treatment would entail, including the use of MOUD. MEET agreed that all patients with IDU-IE, regardless of the cardiac surgeon involved in their care or need for cardiac surgery, should receive addiction medicine evaluation and worked to ensure consultation was obtained. MEET agreed that all patients with IDU-IE should receive standard treatment, including cardiac surgery, when indicated. The group agreed that surgical approaches for the treatment of IDU-IE should follow best evidence and involve valve replacement or valve repair over valvectomy. MEET also agreed that antibiotics options for patients who did not wish to pursue hospital-based medical or surgical treatments would be facilitated in the outpatient setting. The MEET chose a team leader to convene and organize the meeting. A workflow was established that incorporated multidisciplinary review and formalized meeting times.

F1
Figure 1:
Multidisciplinary Endocarditis Evaluation Team (MEET) Values and Roles.

The MEET occurred biweekly for 30 to 45 minutes, initially in person, and later transitioned to virtual meetings, with review of 2 to 4 patients per session. Participation was enhanced as specialists from various disciplines became “clinical champions” (Fig. 1). Participation was voluntary. Patient cases were summarized using a standard framework, after which each specialty presented their evaluation, resulting in a mutual plan for inpatient care and post-discharge treatment needs. Disagreements were addressed until consensus was established which generally involved a conversation between the MEET leader and the MEET member, followed by a MEET team conversation. Using this approach cultivated collaboration. Team meetings were arranged with patients and/or families when needed. For instance, some patients declined surgical intervention due to concern about pain management or due to surgical risks. Patient meetings helped understand patient values and goals.

Before hospital discharge, MEET arranged outpatient care. Outpatient clinicians from cardiac surgery and infectious disease attended the MEET to facilitate care. Nurse care managers from cardiac surgery followed patients in the outpatient setting and addiction medicine followed patients via phone call at 30 days. The addiction medicine service maintains a close relationship with community SUD treatment providers which allowed for support to patients after 30 days to increase treatment retention, a crucial component to improve outcomes. Patients who were re-hospitalized would be re-engaged with MEET as needed.

DISCUSSION

A team for patients with IDU-IE that integrates hospital-based addiction medicine is a practice innovation that utilizes a multidisciplinary approach to address a complex disease. Such a team is crucial for patients with IDU-IE to receive optimal including completion of medical treatments, receipt of addiction care during hospitalization, outpatient follow-up, and retention in addiction treatment.

Multidisciplinary teams for infective endocarditis have been described but most do not address the SUD needs of patients with IDU-IE.10 Studies cite the benefit of clinician communication to reduce delays in care and improve patient outcomes but fail to recognize addiction as an unmet need.10 The recognition that addiction treatment is a critical component of hospital-based IDU-IE treatment has gained traction with increasing IDU-IE incidence.1 This is the first described model of integrating addiction medicine into a multidisciplinary team for patients with IDU-IE.

Though addiction treatment is increasingly accessible in some hospital settings, deficits in care remain. Even when hospital-based addiction treatment is available, referral for services and initiation of MOUD during hospitalization remains low.5 The MEET model demonstrates how addiction treatment can be better integrated. One study of patients with their first episode of IDU-IE showed referral to addiction treatment was associated with reduction in all-cause mortality.12 Another study of patients with IDU-IE found that exposure to MOUD after hospital discharge was associated with improved survival during months when it was received; patients who discontinued treatment did not have mortality benefit.13 Another study found that patients with IDU-IE who received MOUD within 30 days of hospitalization had lower opioid overdose and hospital readmission at 1 year than those who did not receive MOUD.14 All studies highlight the importance of access to addiction treatment for patients with IDU-IE, though it is critical to continue these treatments after hospitalization and retain patients in addiction care for sustained benefit.

Addiction treatment retention is particularly important for patients with IDU-IE whose relapse to injection drug use can have devastating consequences. To prevent re-infection and high mortality in patients with IDU-IE, OUD remission and ongoing MOUD treatment are essential. There can be many barriers for MOUD continuation, so hospital-based interventions would benefit from a longitudinal outpatient component to increase retention in medical and addiction treatment as well.15

Future studies are needed to assess the efficacy of a multidisciplinary IDU-IE team with integrated addiction treatment on patient outcomes such as retention in addiction treatment. Cost analysis would be helpful to justify teams such as the MEET in other health systems.

Multidisciplinary collaboration in the care of patients with IDU-IE that treats addiction as a medical illness and offers patients evidence-based treatment of their serious infection along with addiction treatment should be the stan-dard of practice, and the next generation of clinicians and patients will benefit from its widespread implementation.

ACKNOWLEDGMENTS

The Yale New Haven Hospital Multidisciplinary Endocarditis Evaluation Team. We thank David Fiellin, MD for his review.

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Keywords:

cardiac surgery; endocarditis; patient care team; substance-related disorders

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