WEBB FELLOW: National Survey of Treatment Decision-making in Recurrent Infective Endocarditis Due to Intravenous Drug Use

Background : CL psychiatrists often manage patients with intravenous drug use related infectious endocarditis (IDU-IE). IDU-IE cases have a higher morbidity and mortality than non-IDU-IE and are associated with an additional average cost of $20,000 per admission (Nguemeni Tiako 2019). Management remains complex and controversial. We aim to describe national trends in clinical decision-making approaches in patients with recurrent IDU-IE.

Methods: Of 167 hospitals in the Association of American Medical Colleges (AAMC), 158 adult general medicine hospitals were included. Infectious Disease providers from each hospital were contacted via email correspondence up to 3 times for recruitment to complete the online REDCap survey. Survey questions focused on decision-making and clinical management. The primary outcome was presence of a formal policy for recurrent IDU-IE management.

Results: Of 157 hospitals, 130 were contacted via email, and 32 responses were collected (response rate 24.6%). No respondents reported a hospital policy regarding decision-making for IDU-IE. Formal consults accounted for 83.3% of primary decision-making approaches. When Surgery acted independently of other teams' recommendations (24.1% of hospitals), it was mostly for refusal of surgery (85.7%), with an additional 41.4% of respondents reporting a complicated relationship with Surgery often due to lack of transparency in decision-making. Though willingness to start medication for opioid use disorder was the most common psychosocial factor in decision-making (65.5%), such medication is offered by only 77.4% of respondent hospitals.

Discussion: The results of the current study are consistent with prior research about provider attitudes and practices. Patients with IDU-IE often face stigma affecting whether or not surgery is offered, with 26.4% of surgeons reporting that they would operate on recurrent IDU-IE in contrast to 93.1% for recurrent non-IDU-IE (Nguemeni Tiako 2020). Inter-provider variability and a lack of decision-making transparency are previously identified issues (Hayden and Moore 2020). Formal guidelines that are evidence-based may help improve consistency in decision-making.

Conclusion: Surgical management of IDU-IE remains challenging, in part due to the lack of formal guidelines for these cases. Hospital policies, typical practices, and formal meetings for decision-making appear to be atypical for AAMC hospitals.

References:

Nguemeni Tiako MJ, Mori M, Bin Mahmood SU, Shioda K, Mangi A, Yun J, Geirsson A. Recidivism Is the Leading Cause of Death Among Intravenous Drug Users Who Underwent Cardiac Surgery for Infective Endocarditis. Semin Thorac Cardiovasc Surg. 2019 Spring;31(1):40-45.

Hayden M, Moore A. Attitudes and Approaches Towards Repeat Valve Surgery in Recurrent Injection Drug Use-associated Infective Endocarditis: A Qualitative Study. J Addict Med. 2020 May/Jun;14(3):217-223.

Nguemeni Tiako MJ, Mszar R, Brooks C 2nd, Mahmood SUB, Mori M, Geirsson A, Weimer MB. Cardiac Surgeons' Treatment Approaches for Infective Endocarditis Based on Patients' Substance Use History. Semin Thorac Cardiovasc Surg. 2020 Dec 3:S1043-0679(20)30426-3.