The Effect of Insurance on Appropriate Hospital Discharge Antibiotics for Patients with Staphylococcus aureus Bacteremia

Background: Inappropriate antimicrobial therapy of Staphylococcus aureus bacteremia (SAB) is associated with worsened outcomes. The impact of insurance coverage on appropriate selection of antibiotics at discharge is poorly understood. Methods: We used a retrospective cohort design to evaluate whether patients with SAB at a large academic medical center over 2 years were more likely to receive inappropriate discharge antibiotics, depending on their category of insurance. Insurance was classified as Medicare, Medicaid, commercial, and none. Logistic regression was used to determine the odds of being prescribed inappropriate discharge therapy. Results: A total of 273 SAB patients met inclusion criteria, with 14.3% receiving inappropriate discharge therapy. In the unadjusted model, there was 2-fold increased odds of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively (odds ratio [OR], 2.08; 95% CI, 1.39-3.13). After controlling for discharge with nursing assistance and infectious diseases (ID) consult, there were 1.6-fold increased odds (OR, 1.57; 95% CI, 0.998-2.53; P = .064) of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively. We found that being discharged home without nursing assistance resulted in 4-fold increased odds of being prescribed inappropriate therapy (OR, 4.16; 95% CI, 1.77-9.77; P < .01), and failing to consult an ID team resulted in 59-fold increased odds of being prescribed inappropriate therapy (OR, 59.2; 95% CI, 11.4-306.9; P < .001). Conclusions: We found strong evidence that noncommercial insurance, discharging without nursing assistance, and failure to consult ID are risk factors for being prescribed inappropriate antimicrobial therapy for SAB upon hospital discharge.