A multi-team system implementation strategy to improve buprenorphine adherence for patients who initiate treatment in the emergency department

项目总结/摘要 在美国，药物过量死亡人数继续上升，主要是由于阿片类药物相关的死亡，尽管有 丁丙诺啡，阿片类药物使用障碍（OUD）的高效治疗。开始使用丁丙诺啡治疗OUD， 急诊室是一个越来越普遍的做法在美国。一项大型临床试验发现， 急诊科启动的丁丙诺啡加转诊到初级保健进行持续治疗， 丁丙诺啡治疗率增加，但效果在过去两个月内没有持续。有效战略 帮助患者开始，重新开始和维持丁丙诺啡治疗，以减少过量 死亡为了增加丁丙诺啡的治疗，加州建立了加州桥，这是一个由州政府资助的项目， >200家医院为OUD患者提供当天丁丙诺啡启动加初级保健转诊 在急诊室寻求治疗。然而，次优护理协调仍然存在，特别是对于低- 收入患者。这项研究的首要假设是，一个实施战略，鼓励 急诊科之间的协调涉及持续的伙伴关系，而不是一次性的合作 初级保健团队将改善丁丙诺啡治疗和保留率的患者谁开始 丁丙诺啡在急诊室目标是完善一项执行战略， 多团队系统理论，重点是改善OUD护理之间的紧急协调 部门和初级保健团队，然后在混合III型有效性实施中测试此策略 研究采用在研究中心水平随机化的阶梯式楔形设计。R61阶段将涉及收集和 分析来自两个CA Bridge站点的数据，以确定此实施的核心和外围元素 战略，并制定实施战略、初步实施蓝图和数据收集 R33阶段的协议。R33阶段的阶梯楔研究将涉及四个CA桥站点。 实施成果将包括团队之间的协调活动和护理过渡。有效性 结局将包括门诊丁丙诺啡启动率（填写≥1份门诊处方）和 患者离开急诊科后持续丁丙诺啡治疗3、6和12个月， 用来自加州处方药监测项目的数据进行评估。与成功相关的因素 实施和可持续性将通过实施前和实施后的访谈来确定， 每个急诊科和初级保健诊所的患者、工作人员和管理人员， 与相关利益相关者，包括患者，CA Bridge全州领导层和潜在付款人。研究 结果将用于制定实施蓝图，加州和美国各地的医院可以 用于改善在急诊室开始使用丁丙诺啡的患者的OUD治疗结果。这 研究将推动努力提高低收入人群的长期丁丙诺啡治疗率， 其他脆弱的病人谁不成比例地寻求OUD护理在急诊科。

PROJECT SUMMARY/ABSTRACT Drug overdose deaths continue to rise in the US due largely to opioid-related deaths, despite availability of buprenorphine, a highly effective treatment for opioid use disorder (OUD). Starting buprenorphine for OUD in emergency departments is an increasingly common practice across the US. A large clinical trial found that emergency department-initiated buprenorphine plus referral to primary care for ongoing treatment significantly increased buprenorphine treatment rates, but effects were not sustained past two months. Effective strategies to help patients start, restart, and sustain buprenorphine treatment are urgently needed to reduce overdose deaths. To increase buprenorphine treatment, California established CA Bridge, a state-funded program in >200 hospitals that offers same-day buprenorphine initiation plus referral to primary care for patients with OUD who seek care in emergency departments. However, suboptimal care coordination persists, especially for low- income patients. This study’s overarching hypothesis is that an implementation strategy that encourages coordination involving ongoing partnerships rather than one-time handoffs between emergency department and primary care teams will improve buprenorphine treatment and retention rates for patients who start buprenorphine in the emergency department. The objective is to refine an implementation strategy informed by multiteam systems theory that is focused on improving OUD care coordination between emergency department and primary care teams and then test this strategy in a hybrid type III effectiveness-implementation study using a stepped wedge design randomized at the site level. The R61 phase will involve collecting and analyzing data from two CA Bridge sites to identify core and peripheral elements of this implementation strategy and develop an implementation strategy, a preliminary implementation blueprint, and data collection protocols for the R33 phase. The stepped wedge study during the R33 phase will involve four CA Bridge sites. Implementation outcomes will include between-team coordinating activities and care transitions. Effectiveness outcomes will include rates of outpatient buprenorphine initiation (filling ≥1 outpatient prescription) and sustained buprenorphine treatment 3, 6, and 12 months after patients leave the emergency department, assessed with data from California’s prescription drug monitoring program. Factors associated with successful implementation and sustainability will be identified through pre- and post-implementation interviews with patients, staff, and managers at each emergency department and primary care clinic and through engagement with relevant stakeholders, including patients, CA Bridge statewide leadership and prospective payers. Study results will be used to develop an implementation blueprint that hospitals in California and across the US can use to improve OUD treatment outcomes for patients who start buprenorphine in emergency departments. This study will advance efforts to improve long-term buprenorphine treatment rates at scale for low-income and other vulnerable patients who disproportionately seek OUD care in emergency departments.