Safety of Opioid use Among Veterans Receiving Care in Multiple Health Systems

 描述(由申请人提供)： 在过去十年中，退伍军人医疗保健系统(VA)分发的阿片类药物数量增加了一倍多。几乎25%的VA患者接受来自VA的阿片类药物治疗，人们非常关注阿片类药物的过度使用、过量使用和其他不良事件。退伍军人管理局已经采取了几项战略来减轻阿片类药物相关不良事件的风险，但这些努力几乎完全集中在监测退伍军人管理局内分发的处方上。超过75%的退伍军人有其他形式的医疗保险，可以在非退伍军人环境中获得医疗保健和处方。随着《平价医疗法案》下医疗补助和私人保险的扩大，退伍军人和非退伍军人保健和处方福利的双重使用可能会随着时间的推移而增加。两用的重要性对于阿片类药物来说被放大了，这种药物具有独特的风险，当护理分散时，这种风险可能会被放大。这项研究将与退伍军人管理局、退伍军人管理局、退伍军人用药安全中心和退伍军人国家疼痛计划办公室合作，解决退伍军人对阿片类药物使用认识的这一严重缺陷。混合方法研究包括两个定量目标(目标1-2)和一个定性目标(目标3)，将并行进行。其目的是：(1)描述在退伍军人管理局接受护理的退伍军人中来自退伍军人管理局和非退伍军人管理局(即联邦医疗保险、医疗补助)来源的阿片类药物的使用模式，并确定与阿片类药物双重使用相关的患者和设施特征；(2)评估退伍军人退伍军人同时使用阿片类药物和非退伍军人退伍军人阿片类药物对阿片类药物安全和与阿片类药物相关的严重不良事件的影响；以及(3)探索提供者和其他利益攸关方在确定和管理从事退伍军人护理的退伍军人中双重使用阿片类药物方面的观点。定量阶段将涉及对来自退伍军人管理局、联邦医疗保险和医疗补助的多个相关数据集的回顾分析，这些数据集针对从这些来源中的任何来源服用阿片类药物的登记退伍军人。分析将审查阿片类药物的来源(即仅限VA、仅限非VA、既有VA又有非VA)与患者和设施特征之间的关系。使用倾向评分和工具变量分析以及多重中介路径分析，我们将检验双重使用阿片类药物与阿片类药物安全性措施之间的关联，包括每天接受100毫克吗啡当量、重叠接受镇静/催眠药物，以及与阿片类药物相关的不良事件，包括过量死亡和因过量服药、药物妄想和跌倒而去医院或急诊室就诊。定性目标将通过对关键利益攸关方进行两个阶段的半结构化访谈来补充这些定量目标，探讨：(1)提供者对确定和管理阿片类药物双重使用的看法(阶段1)；(2)退伍军人管理局、医疗保险、医疗补助和私人保险领域利益攸关方领导人的观点，以解释和综合定量和定性结果，以最大限度地提高其相关性和对政策和未来干预措施的影响(阶段2)。总之，这些分析将为退伍军人管理局提供及时和有价值的信息，这些信息对于理解与阿片类药物双重使用相关的模式、影响和结果至关重要。因此，这项研究将填补制定最佳政策和临床干预措施以确保退伍军人安全和适当使用阿片类药物所需证据的一个关键空白。

 DESCRIPTION (provided by applicant): The number of opioid medications dispensed in the VA Healthcare System (VA) has more than doubled in the last decade. Almost 25% of VA patients receive an opioid medication from VA, and there is great concern about opioid overuse, overdose, and other adverse events. VA has adopted several strategies to mitigate the risks of opioid-related adverse events, but these efforts focus almost entirely on monitoring prescriptions dispensed within VA. More than 75% of Veterans have other forms of health insurance and can access healthcare and prescriptions in non-VA settings. Dual use of VA and non-VA health care and prescription benefits is likely to increase over time with the expansion of Medicaid and private insurance under the Affordable Care Act. The importance of dual use is magnified for opioid medications, which have unique risks that may be amplified when care is fragmented. In partnership with VA Pharmacy Benefits Management, the VA Center for Medication Safety, and the VA National Pain Program Office, this study will address this critical deficiency in the understanding of opioid use in Veterans. Ths mixed methods study consists of two quantitative aims (Aims 1-2) and one qualitative aim (Aim 3), that will be conducted in parallel. The aims are to: (1) describe the patterns of opioid use from VA and non-VA (i.e., Medicare, Medicaid) sources among Veterans receiving care in the VA and identify patient and facility characteristics associated with dual use of opioid medications; (2) evaluate the impact of dual use of VA and non-VA opioid medications on opioid safety and opioid-related serious adverse events; and (3) explore provider and other stakeholder perspectives on identifying and managing dual use of opioid medications among Veterans engaged in VA care. The quantitative phase will involve retrospective analyses of multiple linked datasets from VA, Medicare, and Medicaid for enrolled Veterans who filled an opioid medication from any of those sources. Analyses will examine the association between the source of opioids (i.e., VA only, non- VA only, both VA and non-VA) and patient and facility characteristics. Using propensity score and instrumental variable analyses and multiple mediation path analyses, we will examine the association between dual use of opioid medications and measures of opioid safety, including receipt of >100mg morphine equivalents daily, receipt of overlapping sedative/hypnotic medications, and opioid-related adverse events including overdose death and hospital or emergency room visits for overdose, drug delirium, and falls. The qualitative aim will complement these quantitative aims with two phases of semi-structured interviews of key stakeholders, exploring: (1) provider perceptions about identifying and managing dual use of opioid medications (Phase 1); and (2) the views of stakeholder leaders in VA, Medicare, Medicaid, and private insurance to interpret and synthesize the quantitative and qualitative results to maximize their relevance and impact on policy and future interventions (Phase 2). Together, these analyses will provide VA with timely and valuable information critical to understanding patterns, influences, and outcomes associated with dual use of opioid medications. The study will thus fill a crucial gap in evidence needed for development of optimal policy and clinical interventions to ensure the safe and appropriate use of opioids by Veterans.