ECCO - Evaluation of Outcomes Associated with Community Care Prescribed Opioids

背景：从2013年开始，VA的阿片类药物安全倡议扩大了疼痛管理的资源， 成功减少了高风险阿片类药物处方。使命法案扩大VA社区护理（CC） 包括授权CC提供者处方阿片类药物用于急性和慢性疼痛的门诊治疗， 但要求退伍军人管理局确保这些药物从退伍军人管理局药房安全适当地分发。退伍军人 同时使用VA和非VA服务的人可能特别容易受到阿片类药物相关伤害，但过去的工作 在《使命法案》实施之前进行，主要解决非VA保险公司支付的服务。 虽然《使命法案》的主要目标是改善退伍军人的医疗保健服务，但目前尚不清楚CC 扩大影响了阿片类药物的安全性和退伍军人的患者报告结果。 重要性和影响：减少阿片类药物相关的危害和改善慢性疼痛的治疗是高- VA HSRD和临床服务的优先目标。鉴于现在使用CC的退伍军人数量不断增加， 迫切需要更好地了解与CC接收相关的退伍军人，社区和VA设施因素 阿片类药物，并探讨与VA处方阿片类药物相比，高风险CC处方的潜在差异。 此外，对退伍军人为中心的疼痛结局的检查将解决增加真实的- 全球影响力研究。 创新：这项研究将是第一个评估与CC阿片类药物相关的以退伍军人为中心的结果， 包括功能和健康相关的生活质量。拟议的设计还包括多个元素， 严格解决多层次混杂因素，包括社区阿片类药物处方模式的变化。我们使用 在我们的预测模型中采用创新的因果估计方法，以了解 各种因素有助于接受CC阿片类药物的可能性。 具体目的：1）确定接受任何CC与仅VA处方阿片类药物的关键多水平预测因素， 门诊疼痛治疗，并评估高风险阿片类药物处方的潜在差异;以及2）对于 接受任何CC与仅VA处方阿片类药物的退伍军人的国家前瞻性队列，检查差异 患者报告的结果和1年以上的急性护理事件。 方法：首先，我们将使用1月至12月的全国VA数据进行回顾性分析 2021年确定预测接受任何CC规定的关键退伍军人，社区和VA设施因素 阿片类药物。然后，我们将使用倾向评分调整模型来检查高风险阿片类药物的差异 接受任何CC的退伍军人与仅VA处方阿片类药物之间的处方。就目标2而言，我们将招收一名 前瞻性国家队列，评价接受任何CC与仅VA处方相关的结局 阿片类药物。我们将使用调查数据（基线和1年随访）评估患者报告的结局（疼痛- 相关功能、疼痛严重程度、生活质量和对疼痛护理的满意度）和急性护理事件 （住院和急诊）。 实施和下一步：我们将向包括退伍军人在内的各种利益相关者传播研究结果， 领导干部，领导干部。确切的下一步将取决于调查结果的性质及其直接影响。 与不同利益相关者的关系。我们将与我们的运营合作伙伴在VA疼痛计划 管理，阿片类药物安全和药物管理，药物安全办公室和社区护理办公室制定 传播计划。我们还将寻求我们的退伍军人参与小组的反馈， 努力我们将通过演讲和出版物、网络研讨会和参与交流研究结果。 与团体或网络专注于改善CC服务和疼痛治疗的退伍军人。

Background: Starting in 2013, VA's Opioid Safety Initiative expanded resources for pain management and successfully reduced high-risk opioid prescriptions. MISSION Act expansion of VA Community Care (CC) includes authorization for CC providers to prescribe opioids for outpatient treatment of acute and chronic pain, but charges VA with ensuring that these are safely and appropriately dispensed from VA pharmacies. Veterans who use both VA and non-VA services may be particularly at risk for opioid-related harms, but past work was conducted before MISSION Act implementation and mainly addressed services paid by non-VA insurers. Although the main goal of MISSION Act is to improve Veterans' health care access, it remains unclear how CC expansion has impacted opioid safety and patient-reported outcomes for Veterans. Significance & Impact: Reducing opioid-related harms and improving treatment for chronic pain are high- priority goals for VA HSRD and clinical services. Given increasing numbers of Veterans now using CC, there is an urgent need to better understand Veteran, community, and VA facility factors associated with receipt of CC opioids, and explore potential differences in higher-risk CC prescriptions, compared with VA-prescribed opioids. Moreover, examination of Veteran-centered pain outcomes will address the ORD-wide priority of increasing real- world impact of VA research. Innovation: This study will be the first to evaluate Veteran-centered outcomes associated with CC opioids, including functioning and health-related quality of life. The proposed design also includes multiple elements to rigorously address multilevel confounders, including variation in community opioid prescribing patterns. We use innovative causal estimation methods in our predictive models, in order to understand the relative importance of a variety of factors in contributing to likelihood of receiving CC opioids. Specific Aims: 1) Identify key multilevel predictors of receiving any CC vs. only VA-prescribed opioids for outpatient pain treatment, and evaluate potential differences in higher-risk opioid prescriptions; and 2) for a national prospective cohort of Veterans receiving any CC vs. only VA-prescribed opioids, examine differences in patient-reported outcomes and acute care episodes over 1 year. Methodology: First, we will conduct a retrospective analysis using national VA data from January-December 2021 to determine key Veteran, community, and VA facility factors that predict receiving any CC-prescribed opioids. Then, we will use propensity score adjusted models to examine differences in higher-risk opioids prescriptions between Veterans receiving any CC vs. only VA-prescribed opioids. For Aim 2, we will enroll a prospective national cohort to evaluate outcomes associated with receiving any CC vs. only VA-prescribed opioids. We will use survey data (at baseline and 1-year follow-up) to assess patient-reported outcomes (pain- related functioning, pain severity, quality of life, and satisfaction with pain care) and acute care episodes (hospitalizations and emergency department visits). Implementation & Next Steps: We will disseminate study results to various stakeholders, including Veterans, VA staff, and VA leadership. The exact next steps will depend on the nature of findings and their immediate relevance to different stakeholders. We will work with our operational partners in the VA Program for Pain Management, Opioid Safety and PDMP, Office for Medication Safety, and Office of Community Care to develop the dissemination plan. We will also seek feedback from our Veteran Engagement Panel to inform dissemination efforts. We will communicate findings through presentations and publications, cyber-seminars, and involvement with groups or networks focused on improving CC services and pain treatment for Veterans.