Assessing and Reducing Opioid Misuse Among Veterans in VA and Non-VA Systems: Coordination of Fragmented Care

评估和减少退伍军人管理局和非退伍军人管理局系统退伍军人中阿片类药物滥用：分散护理的协调

• 批准号: 10394127
• 负责人: Joel Kupersmith
• 金额: --
• 依托单位: U.S. DEPT/VETS AFFAIRS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2024-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10394127
• 关键词: Address; Administrator; Area; Benzodiazepines; Caring; Clinical; Communication; Communities; Community Health; Consequentialism; Data; Data Analyses; Data Sources; Databases; Diagnosis; District of Columbia; Dose; Electronic Health Record; Ensure; Evaluation; Focus Groups; Goals; Guidelines; Health; Health Insurance; Health Personnel; Healthcare; Healthcare Systems; Information Systems; Injury; Insurance; Interview; Link; Maryland; Medicare; Methods; Mid-Atlantic Region; Musculoskeletal; National Health Interview Survey; Natural Language Processing; Opioid; Pain; Pain management; Patients; Policies; Policy Maker; Prevalence; Privatization; Provider; Recommendation; Reporting; Research; Risk Management; Safety; Statistical Methods; Stratification; Syndrome; System; Toxicant exposure; United States Centers for Medicare and Medicaid Services; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; War; Woman; addiction; care coordination; chronic pain; community center; complex data; deep learning; high risk; improved; informal caregiver; misuse of prescription only drugs; non-opioid analgesic; novel; operation; opioid abuse; opioid epidemic; opioid misuse; opioid overdose; opioid use; opioid use disorder; patient oriented; prescription monitoring program; prescription opioid; prescription opioid misuse; programs; psychiatric comorbidity; suicidal risk; tool; wound

Project Summary The US opioid epidemic has put a significant burden on Veterans and the VA. Veterans often suffer from chronic pain syndromes due to war injuries, toxic exposures, and deployment-related psychiatric comorbidities and are vulnerable to opioid use/misuse. Chronic pain syndromes occur in 65.4% of U.S. veterans, 9.1% of it severe, as against 56 and 6.4% in non-veterans respectively. Both opioid misuse and unrelieved pain have been linked to a higher risk of suicide among Veterans, greater among women. To address the opioid epidemic in the VA, in August 2013, the VA deployed the Opioid Safety Initiative (OSI) to ensure that opioids are used in a safe, effective, and judicious manner and the Stratification Tool for Opioid Risk Management (STORM). Although the implementation of OSI has substantially reduced risky and other opioid prescriptions in VHA and increased use of non-opioid treatments for pain, there remain major gaps in evidence to formulate comprehensive policy as current data is almost exclusively derived from Veterans receiving care within the VHA. This is important as ~80% of the Veterans have private health insurance. It has been reported that Veterans who receive dual VHA and non-VHA care received more opioid prescriptions and more risky prescriptions, that mono VHA users. Also, while opioid overdose rates have been increasing in VHA enrollees VHA Opioid prescriptions in these veterans declined. To address the prescription drug misuse problem, states use Prescription Drug Monitoring Programs (PDMPs), which are electronic databases that collect and track prescription data on controlled substances to reduce their abuse and diversion. However, despite access to these data via Health Information Exchanges (HIE), the guideline-discordant unsafe and concurrent prescriptions and fillings of opioids continue. Also, PDMP data alone are not suitable for policy decisions and practice recommendations as they lack the detailed clinical information necessary to make a comprehensive evaluation of underlying factors associated with non-guideline-concordant prescriptions. Our preliminary data show a decline in Opioid prescriptions with less decline in the diagnosis of Opioid Use Disorder. The absence of community data is also mentioned as a major deficiency in the study and analyses of the opioid misuse crisis in a 2017 VA Office of Inspector General Report. In this VHA HSR&D Merit Review Application we propose to examine factors associated with prescription opioid misuse, specifically the guideline-discordant use of opioids, in 3 Veterans groups, (1) VHA mono-users, (2) VHA paid dual users of both VHA and non-VHA care, and (3) non-VHA paid dual users. We also propose to conduct an interview/focus group study of VA and non-VA community health providers perspectives on: a) barriers and facilitators in providing guideline- concordant care to the dual users, and b) coordination strategies to reduce opioid misuse in the dual user groups. These aims will be achieved by analyzing the complex data using novel deep learning and natural language processing methods in addition to the state-of-the-art statistical methods. The data involved will include the VHA and MedStar Health (largest healthcare system in the Mid-Atlantic region) electronic health record (EHR), the Chesapeake Regional Information System for Patients (CRISP) and Medicare databases. We will also bring together VA and non-VA community health providers, including clinicians, administrators, policy makers, and patients. We have conducted preliminary studies and collected preliminary data to demonstrate the feasibility of the proposed deep learning and natural language processing methods as well as our access to VA and non-VA EHR data. The results of the proposed study will be shared with our VHA and community operational partners. Our ultimate goal is to evaluate and improve care coordination and reduce opioid misuse in Veterans who are dual users of VA and community care.

项目摘要 美国阿片类药物的流行给退伍军人和退伍军人事务部带来了沉重的负担。退伍军人经常遭受 战伤、毒物暴露和部署相关精神病合并症导致的慢性疼痛综合征 并且容易受到阿片类药物使用/滥用的影响。慢性疼痛综合征发生在65.4%的美国退伍军人，其中9.1% 严重，而非退伍军人分别为56%和6.4%。阿片类药物滥用和未缓解的疼痛 与退伍军人自杀风险较高有关，女性自杀风险更高。为了应对阿片类药物的流行， 在VA，2013年8月，VA部署了阿片类药物安全倡议（OSI），以确保阿片类药物用于 安全，有效，明智的方式和阿片类药物风险管理分层工具（STORM）。 尽管OSI的实施大大减少了VHA中的风险和其他阿片类药物处方， 尽管越来越多地使用非阿片类药物治疗疼痛，但在制定证据方面仍存在重大差距 全面的政策，因为目前的数据几乎完全来自退伍军人接受照顾内， VHA。这一点很重要，因为大约80%的退伍军人拥有私人医疗保险。据报 接受双重VHA和非VHA治疗的退伍军人接受了更多的阿片类药物处方， 处方，单VHA用户。此外，虽然VHA注册者的阿片类药物过量率一直在增加， 这些退伍军人的VHA阿片类药物处方下降。为了解决处方药滥用问题， 使用处方药监测程序（PDMP），这是一种电子数据库， 关于受管制物质的处方数据，以减少其滥用和转移。然而，尽管获得 这些数据通过健康信息交换（HIE），指南不一致的不安全和并发 阿片类药物的处方和填充仍在继续。此外，仅凭数据本身并不适用于政策决策， 实践建议，因为他们缺乏必要的详细临床信息，使全面的 评价与非指南一致处方相关的潜在因素。我们的初步数据 显示阿片类药物处方减少，阿片类药物使用障碍的诊断减少较少。没有 还提到社区数据的缺乏是阿片类药物滥用研究和分析的一个主要缺陷， 在2017年VA监察长报告办公室的危机。在此VHA HSR&D Merit Review申请中，我们 建议检查与处方阿片类药物滥用相关的因素，特别是指南不一致 阿片类药物使用，3个退伍军人组，（1）VHA单一使用者，（2）VHA和非VHA付费双重使用者 护理，和（3）非VHA付费双重用户。我们亦建议进行一项有关视障人士的访问/焦点小组研究， 非VA社区卫生服务提供者对以下问题的看法：a）提供指南的障碍和促进因素- 对双重使用者的协调护理，和B）减少双重使用者中阿片类药物滥用的协调策略 组这些目标将通过使用新的深度学习和自然分析复杂数据来实现。 除了最先进的统计方法之外，语言处理方法。所涉及的数据将 包括VHA和MedStar Health（中大西洋地区最大的医疗保健系统）电子健康 记录（EHR）、切萨皮克地区患者信息系统（CRISP）和医疗保险数据库。 我们还将汇集VA和非VA社区卫生服务提供者，包括临床医生，管理人员， 政策制定者和患者。我们已进行初步研究和收集初步数据， 展示了所提出的深度学习和自然语言处理方法的可行性， 我们对VA和非VA EHR数据的访问。拟议研究的结果将与我们的VHA共享， 社区业务合作伙伴。我们的最终目标是评估和改善护理协调， 阿片类药物滥用的退伍军人谁是VA和社区护理的双重用户。