Outpatient Parenteral Antimicrobial Therapy Practice Variability Across Veterans Affairs Hospitals

Importance: Challenges providing outpatient parenteral antimicrobial therapy (OPAT) can compromise patient safety and care quality, yet little is known about how OPAT is delivered by health care systems across the US. Objective: To understand and compare OPAT delivery at US Department of Veterans Affairs Medical Centers (VAMCs). Design, Setting, and Participants: This qualitative study using a mixed-methods approach was performed from February 6, 2024, through April 15, 2025. Six midwestern VAMCs were purposively selected, identifying physician and pharmacist leaders to participate in qualitative interviews via an antimicrobial stewardship listserv, and other participants involved in OPAT delivery were identified via snowball sampling. The VAMCs for the quantitative survey were identified through the 2020 Veterans Health Administration Antimicrobial Stewardship National Survey. Main Outcomes and Measures: Semistructured clinician interviews focused on OPAT decision-making, patient education, care coordination, and postdischarge management. Organizational surveys assessed OPAT program structure, characteristics, and care delivery challenges. After a structured rapid qualitative analysis and generation of descriptive statistics, findings were evaluated together. Results: Interviews were conducted with 31 participants from 6 VAMCs. Key informants from 106 of 139 VAMCs (76.3%) completed surveys. All participants were actively engaged in OPAT care at the time of data collection. Interviews showed heterogeneity in OPAT processes across medical centers, with challenges involving communication, coordination, support, and uncertainty about roles and responsibilities, particularly among sites without a designated OPAT team. Of 78 surveyed VAMCs (73.6%) offering OPAT, 60 (76.9%) identified designated persons who managed OPAT. Most facilities evaluated OPAT appropriateness (75 [96.2%]) and used contract pharmacy (72 [92.3%]) and contract nursing (62 [79.5%]) to deliver OPAT care, although primary responsibility for outpatient monitoring varied. Conclusions and Relevance: This study found that VAMC OPAT care processes were highly variable. Although a knowledgeable and interdisciplinary team may be ideal, having such a team may not always be possible due to staffing and cost constraints. Developing facility-level OPAT-dedicated processes, including policies and checklists, as well as increased support and protected time for staff may improve safe, effective OPAT delivery in VAMCs.