Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine
Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine
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DOI：
10.1001/jamanetworkopen.2020.4561
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发表时间：
2020-05-11
影响因子：
13.8
通讯作者：
Edelman, E. Jennifer
中科院分区：
文献类型：
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作者：
Hawk, Kathryn F.;D'Onofrio, Gail;Edelman, E. Jennifer
这种定性分析调查的障碍和促进者准备启动丁丙诺啡管理在急诊科，并确定机会，以促进临床医生准备治疗阿片类药物使用disorder.Question的患者中，什么是关键的障碍和促进者临床医生启动丁丙诺啡在艾德与阿片类药物使用障碍的治疗转诊？结果一个混合方法的评价268名主治医生，住院医师，和先进的实践临床医生在学术急诊科发现，9 258（3.5%）报告完成了2000年的药物成瘾治疗法的培训，和56 268（20.9%）有高水平的准备在急诊科开丁丙诺啡。主要障碍包括缺乏治疗阿片类药物使用障碍的培训和经验，对与持续护理联系的能力的担忧，以及在忙碌的急诊室中对时间和资源的竞争需求。意义虽然在这项研究中，很少有急诊科临床医生有高水平的准备启动丁丙诺啡与转诊进行持续治疗，许多人表示愿意学习有足够的支持，表明临床医生和系统水平的变化的重要性。重要性治疗阿片类药物使用障碍（OUD）与丁丙诺啡减少阿片类药物的使用，并防止发病率和死亡率。急诊科（ED）是未治疗OUD患者开始丁丙诺啡治疗的重要场所;然而，艾德临床医生的准备情况各不相同。目的描述在艾德中开始丁丙诺啡治疗OUD的准备障碍和促进因素，并确定促进多种临床医生类型准备就绪的机会。设计，设置和参与者使用从2018年4月1日收集的数据，到2019年1月11日，这种混合方法的形成性评价基于促进行动的研究实施卫生服务框架包括4个地理上不同的学术ED。主治医生（n = 113）、住院医师（n = 107）和高级实践临床医生（APC）（n = 48）完成了以电子方式分发给所有艾德临床医生（n = 396）的调查。一部分参与者（n = 74）还参加了11个焦点小组讨论中的1个。分析了2018年6月1日至2020年2月22日的数据。主要结果和测量使用视觉模拟量表评估临床医生开始丁丙诺啡治疗和为艾德治疗的OUD患者提供持续治疗的转诊准备。应答者（396例中的268例[67.7%]）被分为准备不足（评分0-6）或准备最充分（评分7-10）。采用ED适应的组织变革准备评估（ORCA）和11个焦点小组来评估证据和背景相关因素的评级和观点，以促进ED启动的丁丙诺啡，并分别转诊进行持续治疗。结果在268名调查受访者中（260名受访者中有153名男性[58.8%]，完成正式培训后的平均[SD]为7.1 [9.8]年），56名（20.9%）表示愿意为OUD艾德患者开始丁丙诺啡治疗。258人中有9人（3.5%）报告完成了2000年《毒瘾治疗法》培训。与那些准备不足的人相比，最准备开始丁丙诺啡的临床医生在所有ORCA证据子量表中的平均得分更高（3.50 [95% CI，3.35-3.65]至4.33 [95% CI，4.13-4.53] vs 3.11 [95% CI，3.03-3.20]至3.60 [95% CI，3.49-3.70]; P < .001）和ORCA上下文子量表的松弛资源（3.32 [95% CI，3.08-3.55] vs 3.0 [95% CI，2.87-3.12]; P = .02）。ED启动丁丙诺啡的障碍包括缺乏用丁丙诺啡治疗OUD的培训和经验，对与持续护理联系的能力的担忧，以及艾德时间和资源的竞争需求和优先事项。ED启动丁丙诺啡的促进者包括接受教育和培训，制定当地部门协议，并接收有关患者体验和护理质量差距的反馈。结论和相关性只有少数艾德临床医生有一个高水平的准备开始丁丙诺啡，但是，许多人表示愿意学习有足够的支持。努力促进ED引发的丁丙诺啡的采用将需要临床医生和系统级的变化。
This qualitative analysis surveys barriers and facilitators of readiness to initiate buprenorphine administration in the emergency department and identifies opportunities to promote readiness among clinicians to treat patients with opioid use disorder.Question What are the key barriers and facilitators for clinician initiation of buprenorphine in the ED with referral for the treatment of opioid use disorder? Findings A mixed-methods evaluation of 268 attending physicians, resident physicians, and advanced practice clinicians in academic emergency departments found that 9 of 258 (3.5%) reported completion of Drug Addiction Treatment Act of 2000 training, and 56 of 268 (20.9%) had high levels of readiness to prescribe buprenorphine in the emergency department. Key barriers included lack of training and experience in treating opioid use disorder, concerns about ability to link to ongoing care, and competing needs for time and resources in a busy emergency department. Meaning Although few emergency department clinicians in this study had high levels of readiness to initiate buprenorphine with referral for ongoing treatment, many expressed a willingness to learn with sufficient support, indicating the importance of clinician and system-level changes.Importance Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. Objective To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Design, Setting, and Participants Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Main Outcomes and Measures Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Results Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Conclusions and Relevance Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.