Assessing and Reducing Opioid Misuse Among Veterans in VA and Non-VA Systems: Coordination of Fragmented 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管理局带来了沉重的负担。退伍军人经常患有 战伤、中毒暴露和部署相关精神疾病引起的慢性疼痛综合征 并且容易受到阿片类药物的使用/滥用的影响。65.4%的美国退伍军人患有慢性疼痛综合征，其中9.1%的人患有慢性疼痛综合征 严重，非退伍军人分别为56%和6.4%。阿片类药物滥用和无法缓解的疼痛 在退伍军人中自杀的风险更高，在女性中更高。为了应对阿片类药物的流行 在退伍军人事务部，2013年8月，退伍军人管理局部署了阿片类药物安全倡议(OSI)，以确保在 安全、有效和明智的方式和阿片类药物风险管理的分层工具(STORM)。 尽管OSI的实施大大减少了VHA和VHA的风险和其他阿片类药物处方 增加非阿片类药物治疗疼痛的使用，在证据方面仍然存在重大差距 综合政策，因为目前的数据几乎完全来自退伍军人在 VHA。这一点很重要，因为大约80%的退伍军人都有私人医疗保险。据报道， 接受双重VHA和非VHA护理的退伍军人获得更多阿片类药物处方和更多风险 处方，即单声道VHA使用者。此外，虽然VHA参与者中阿片类药物过量的比率一直在上升 这些退伍军人的VHA阿片类药物处方减少。为了解决处方药滥用问题，国家 使用处方药监测程序(PDMP)，这是收集和跟踪的电子数据库 关于管制物质的处方数据，以减少其滥用和转移。然而，尽管可以访问 这些数据通过卫生信息交换(HIE)、指南-不一致、不安全和并发 阿片类药物的处方和填充物仍在继续。此外，仅有PDMP数据不适合用于策略决策 实践建议，因为它们缺乏必要的详细临床信息来进行全面的 评估与不符合指南的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下降较少。《缺席》 还提到，社区数据的使用是研究和分析阿片类药物滥用的主要不足。 2017年退伍军人事务部监察长办公室报告中的危机。在此VHA HSR&D功绩审查应用程序中，我们 建议审查与处方阿片类药物滥用有关的因素，特别是指南--不一致 阿片类药物的使用，在3个退伍军人群体中，(1)VHA单一使用者，(2)VHA付费VHA和非VHA双重使用者 护理，以及(3)非VHA付费双用户。我们还建议对退伍军人管理局和 非退伍军人社区卫生服务提供者对以下方面的看法：a)提供指南方面的障碍和促进者- 对双重使用者的协调护理，以及b)协调战略以减少双重使用者中阿片类药物的滥用 组。这些目标将通过使用新颖的深度学习和自然语言来分析复杂的数据来实现 除了最先进的统计方法外，还有语言处理方法。所涉及的数据将 包括VHA和MedStar Health(大西洋中部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。 我们还将把退伍军人事务部和非退伍军人事务部社区卫生服务提供者聚集在一起，包括临床医生、管理人员、 政策制定者和患者。我们进行了初步研究并收集了初步数据，以 论证了所提出的深度学习和自然语言处理方法的可行性以及 我们可以访问退伍军人事务部和非退伍军人事务部的EHR数据。建议的研究结果将与我们的VHA和 社区运营合作伙伴。我们的最终目标是评估和改善护理协调，并减少 退伍军人中阿片类药物的滥用，他们是退伍军人和社区护理的双重使用者。

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.