Testing a Novel Strategy to Improve Implementation of Medication-Assisted Treatment for Veterans with Opioid Use Disorders in Low Performing Facilities

测试一种新策略，以改善低绩效设施中患有阿片类药物使用障碍的退伍军人药物辅助治疗的实施

• 批准号: 9291653
• 负责人: Adam Joseph Gordon
• 金额: --
• 依托单位: MINNEAPOLIS VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-07-01 至 2021-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9291653
• 关键词: Academic Detailing; Academic Detailing; Address; Address; Adopted; Adopted; Agonist; Agonist; Budgets; Budgets; Buprenorphine; Buprenorphine; Clinic; Clinic; Clinical; Clinical; Consult; Consult; Consultations; Consultations; Cost Analysis; Cost Analysis; Data; Data; Development; Development; Diagnosis; Diagnosis; Education; Education; Effectiveness; Effectiveness; Eligibility Determination; Emergency department visit; Emergency department visit; Epidemic; Epidemic; Evaluation; Evaluation; Evidence based practice; Evidence based practice; Evidence based treatment; Evidence based treatment; Goals; Goals; Gold; Gold; Guidelines; Guidelines; HIV Infections; HIV Infections; Health Care Costs; Health Care Costs; Health Information System; Health Information System; Health Services; Health Services; Healthcare; Hepatitis C; Hepatitis C; Heroin; Individual; Individual; Instruction; Instruction; Intervention; Intervention; Interview; Interview; Leadership; Leadership; Mental Health; Mental Health; Mental Health Services; Mental Health Services; Mentors; Mentors; Methadone; Methadone; Methods; Methods; Monitor; Monitor; Morbidity - disease rate; Morbidity - disease rate; Naltrexone; Naltrexone; Newsletter; Newsletter; Opiate Addiction; Opiate Addiction; Opioid; Opioid; Opioid agonist; Overdose; Overdose; Patients; Patients; Pharmaceutical Preparations; Pharmaceutical Preparations; Pharmacotherapy; Pharmacotherapy; Physicians; Physicians; Policies; Policies; Primary Health Care; Primary Health Care; Production; Production; Provider; Provider; Psychotropic Drugs; Psychotropic Drugs; Resources; Resources; Safety; Services; Services; Site; Site; Site Visit; Site Visit; Speed; Speed; Substance Use Disorder; Substance Use Disorder; System; System; Techniques; Techniques; Telephone; Telephone; Testing; Testing; United States; United States; Veterans; Veterans; base; base; cost; cost; cost effective; cost effective; criminal behavior; criminal behavior; dashboard; dashboard; design; design; effective therapy; effective therapy; formative assessment; formative assessment; heroin use; implementation research; implementation research; implementation strategy; improved; improved; intervention cost; medication safety; medication-assisted treatment; medication-assisted treatment; mortality; mortality; novel strategies; novel strategies; operation; operation; opioid agonist therapy; opioid misuse; opioid misuse; opioid use disorder; opioid use disorder; prescription opioid; prescription opioid; primary outcome; primary outcome; programs; programs; resource guides; resource guides; symposium; symposium; treatment center; treatment center; waiver; waiver; webinar; webinar

Impacts: Currently, the United States is in the midst of an opioid use disorder (OUD) epidemic with the rates of emergency room visits and overdoses related to prescription opioids skyrocketing and the rates of heroin use increasing rapidly. OUD is associated with increased morbidity and mortality, increased HIV and HCV infection rates, and increased criminal behavior. Opioid agonist therapy (OAT) has been shown to be effective in treating OUD and decreasing these negative consequences. While the efficacy of OAT has been established, the predominant problem is that of implementation: too few providers offer or provide OAT to patients with OUD due to patient, provider or system impediments. While the VHA has made great strides in implementation of OAT over the past decade, national treatment rates remain low (30% of those Veterans eligible to receive OAT do) and several facilities continue to have very low prescribing rates. Background: OAT using methadone or buprenorphine is the most effective treatment available for OUD. While methadone prescribing must take place in highly regulated opioid treatment centers, buprenorphine may be prescribed in non-addiction treatment settings allowing for easier access for patients. When agonist treatment is contraindicated or not acceptable to the patient, antagonist medication (naltrexone) could be considered. Objectives: The objective of this study is to increase the percentage of Veterans with OUD initiating and sustaining OAT in long-term treatment (a minimum of 3 months) in facilities where the current percent of Veterans receiving medication for OUD is low (<15%). This project will not focus on establishing new methadone opioid treatment centers, but rather focus on using intensive external facilitation to increase access to buprenorphine and (in cases where buprenorphine is contraindicated or not acceptable to the patient) naltrexone prescribing. This objective will be accomplished by: 1) implementing intensive external facilitation at 8 low-performing sites and comparing the change in rate of OAT initiation and sustainment to the remaining low performing sites, 2) using formative evaluation methods to refine the intervention for further dissemination, and 3) assessing the cost and budget impact of the intervention. Methods: Eight sites will be selected based on prescribing rates and number of actionable patients (e.g., patients with OUD not currently receiving OAT) to receive the intervention. Remaining low-performing sites will continue to receive implementation as usual (e.g., MHS/OMHO and Academic Detailing interventions). Administrative data will be used to monitor the proportion of Veterans with OUD initiating and sustaining OAT at all low-performing sites. The intervention will include a site-specific developmental evaluation, a kick-off site visit and 12 months of ongoing facilitation. The developmental evaluation will consist of qualitative interviews with patients, substance use disorders clinic staff, and primary care and general mental health leadership to assess site level barriers. The site visit will include: 1) a review of site-specific barriers and potential implementation strategies; 2) instruction on using already available dashboards to track prescribing rates and identify actionable patients; and 3) education on OAT, including required education to obtain waivers for buprenorphine prescribing. On-going facilitation will consist of monthly conference calls with individual site teams and expert clinical consultation available via video conferencing. The primary outcomes will be the proportion of Veterans with a diagnosis of OUD initiating and sustaining OAT. Because implementation of OAT is a current focus of MHS/OMHO and the Academic Detailing Program, the percentage of Veterans with OUD initiating and sustaining OAT is expected to increase at all sites but the increase in the intervention sites is predicted to be significantly greater. Final qualitative interviews and a cost assessment will inform quantitative results.

影响：目前，美国正处于阿片使用障碍(OUD)流行之中， 与处方阿片类药物暴涨和海洛因使用率相关的急诊室就诊和过量 增长迅速。OUD与发病率和死亡率增加、艾滋病毒和丙型肝炎病毒感染增加有关 利率，以及犯罪行为的增加。阿片类激动剂疗法(OAT)已被证明对 善待和减少这些负面后果。虽然燕麦片的功效已经确立， 主要的问题是实施方面的问题：很少有提供者向患有癌症的患者提供或提供燕麦片 由于患者、提供者或系统障碍而导致的OUD。虽然VHA在实施方面取得了长足的进步 在过去十年中，国民待遇比率仍然很低(30%的退伍军人有资格领取 燕麦片(燕麦片)和一些设施仍然有非常低的处方率。 背景：使用美沙酮或丁丙诺啡的燕麦片是目前治疗OUD最有效的方法。 虽然美沙酮处方必须在高度监管的阿片类药物治疗中心进行，但丁丙诺啡可以 在非成瘾治疗环境中开具处方，使患者更容易接近。当激动剂 治疗是禁忌的或患者不能接受，拮抗剂药物(纳曲酮)可能是 考虑过了。 目标：这项研究的目的是增加退伍军人在退伍军人中的比例 在设施中维持燕麦片的长期治疗(至少3个月)，目前 退伍军人接受OUD药物治疗的比例很低(&lt；15%)。该项目不会将重点放在建立新的 美沙酮阿片类药物治疗中心，而是专注于利用密集的外部便利来增加获得机会 丁丙诺啡和(在丁丙诺啡禁忌或患者不接受的情况下) 开纳曲酮的处方。这一目标将通过以下方式实现：1)在以下方面实施密集的外部便利化 8个绩效较低的地点，并比较启动和维持燕麦区服务的比率与其余地点的变化 低绩效网站，2)使用形成性评估方法来改进干预措施，以便进一步传播， 以及3)评估干预的成本和预算影响。 方法：将根据处方率和可采取行动的患者数量选择八个地点(例如， 目前没有接受燕麦片治疗的患者)接受干预。其余表现较差的站点将 继续照常执行(例如，MHS/OMHO和学术细节干预)。 行政数据将用于监测退伍军人中发起和维持OAT的比例 在所有表现不佳的网站上。干预措施将包括特定地点的发展评估、启动地点 访问和12个月的持续协助。发展性评估将包括定性访谈。 与患者、物质使用障碍诊所工作人员以及初级保健和一般精神卫生领导一起 评估场地水平的障碍。现场访问将包括：1)审查特定地点的障碍和潜力 实施战略；2)关于使用现有仪表板跟踪处方费率和 确定可采取行动的患者；以及3)关于燕麦片的教育，包括获得豁免所需的教育 丁丙诺啡处方。持续的促进工作将包括每月与个别站点举行电话会议 通过视频会议提供团队和专家临床咨询。主要结果将是 被诊断为OUD启动和持续OAT的退伍军人比例。因为OAT的实现 是目前MHS/OMHO和学术细节计划的一个焦点，即退伍军人中有OUD的百分比 预计在所有地点发起和维持OAT的人数都会增加，但干预地点的增加 预计会明显更大。最后的定性访谈和成本评估将为量化 结果。