Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study

June-Ho Kim, Danielle R. Fine, Lily Li, Simeon D. Kimmel, H. Ngo, Joji Suzuki,Christin N. Price,
Matthew V. Ronan, Shoshana J. Herzig



Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD.


One of the many downstream consequences of the opioid crisis has been a marked increase in the incidence and associated costs of hospitalizations for serious bacterial infections associated with injection drug use such as endocarditis, osteomyelitis, septic arthritis, and epidural abscesses [1–6]. Treatment of these infections usually requires a prolonged course of intravenous (IV) antibiotics, which can often be completed from home in patients without another indication for a rehabilitation stay [7–11]. However, because this treatment involves sustained IV access, clinicians may be reluctant to discharge patients with opioid use disorder (OUD) to home, and home infusion companies may be reluctant to provide home services [12,13]. In addition, people with OUD face barriers to accessing post-acute care (PAC) facilities [13]. Taken together, these factors may result in longer hospital length of stay (LOS) and increased utilization of PAC facilities among people with OUD-associated infections, with important financial implications for hospitals and payers [14,15].


This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (S1 STROBE Checklist). A prospective analysis plan was developed in August 2018, with analysis conducted from August to December 2018. The supplementary propensity score analysis was done in January 2019 to confirm the primary results. Additional analyses in response to peer review in March 2020 included adding the hospital as a random intercept, which did not change the estimates, and assessing changes in the logistic regression models when adding and removing covariates, which showed that controlling for age and payor primarily account for changes in our estimates (S1 Table).


In this large, nationally representative study of inpatient hospitalizations from 2016, we found patients with OUD who were hospitalized for serious infections, compared to those without OUD, had longer LOS, were less likely to be discharged home, were more likely to be discharged to a PAC facility or have a patient-directed discharge, and had similar total hospital charges despite lower daily charges. Our results were robust to multiple analytic approaches and sensitivity analyses.

Citation: Kim J-H, Fine DR, Li L, Kimmel SD, Ngo LH, Suzuki J, et al. (2020) Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study. PLoS Med 17(8): e1003247. https://doi.org/10.1371/journal.pmed.1003247

Academic Editor: Andrew D. Wiese, Vanderbilt University Medical Center, UNITED STATES

Received: January 14, 2020; Accepted: July 8, 2020; Published: August 7, 2020

Copyright: © 2020 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because a Data Use Agreement is required before accessing the dataset. Data are available for purchase from the Healthcare Cost and Utilization Project (hcup-us.ahrq.gov) for researchers who meet the criteria for access to the database. Data from this study were from the 2016 National Inpatient Sample (NIS) database.

Funding: JK and DF were supported by a grant from the Health Resources and Services Administration (hrsa.gov) (National Research Service Award for Primary Care T32HP10251). SK was supported by grants from the Research in Addiction Medicine Scholars Program (drugabuse.gov) (R25DA033211) and the Boston University Clinical HIV/AIDS Research Training Program (niaid.nih.gov) (5T32AI05207409). JS was supported by a grant from the National Institute on Drug Abuse (drugabuse.gov) (K23DA042326). SH was supported by grants from the National Institute on Aging of the National Institutes of Health (nia.nih.gov) (K23AG042459) and the Agency for Healthcare Research and Quality (ahrq.gov) (R01HS026215). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: SK is a consultant for Abt Associates on a Massachusetts Department of Public Health funded project to provide technical assistance to skilled nursing facilities to improve addiction care. SH is funded by grant number K23AG042459 from the National Institute on Aging (NIH) and R01HS026215 from the Agency for Healthcare Research and Quality.

Abbreviations: aHR, adjusted hazard ratio; aOR, adjusted odds ratio; HCUP, Healthcare Cost and Utilization Project; ICD-10, International Classification of Diseases–10th Revision; IV, intravenous; LOS, length of stay; NIS, National Inpatient Sample; OPAT, outpatient parenteral antibiotic therapy; OUD, opioid use disorder; PAC, post-acute care.

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