Strategies to improve Utilization of Post-overdose Evidence-based Risk mitigation among Non-fatal Overdoses in VA (SUPER NOVA)

背景：吸毒过量是主要死亡原因，占美国死亡人数的70630人 (美国)20193。大多数药物过量涉及阿片类药物，与阿片类药物有关的兴奋剂死亡人数正在上升。 每4例与可卡因有关的死亡中有3例涉及阿片类药物，53%的与精神刺激剂有关的死亡 涉及阿片类药物7。退伍军人中的药物过量死亡率反映了这些趋势5，6。 死于阿片类药物过量的个人中，每6人中就有1人在前12个月中有非致命性过量17。 这些非致命的过量是预防阿片类药物过量努力的一个有希望的目标，特别是在 循证治疗，如阿片类药物使用障碍(Moud)。兴奋剂的增加- 涉及的阿片类药物过量也突显了调查策略的必要性，以改善证据的获取- 兴奋剂使用障碍的基础治疗。 意义：2019年3月，VHA心理健康和自杀预防办公室发布了一份全国性的 临床病历模板、自杀行为和过量用药报告(SBOR)。Sbor标准化了 报告流程，增强自杀和过量服药事件在医疗记录中的可见性，并旨在 在这些事件发生后改善临床护理(例如，纳入过量用药的风险因素和战略 降低风险，包括转诊治疗)。然而，Sbor目前被要求故意服药过量 仅推荐用于非故意过量用药。此外，目前还不清楚它被使用的程度 以及它的使用是否如预期的那样改善了过量用药后的护理。 创新和影响：拟议的研究将描述非致命性阿片类药物、兴奋剂和联合 VHA患者的阿片类药物和兴奋剂过量以及他们接受建议治疗后的程度 服药过量。鉴于Sbor很快将被授权处理所有过量使用，并确保VHA正在做 尽其所能防止退伍军人服药过量死亡，关键是要了解SBOR 是否正在按预期改善服药过量后的护理，如果可能需要额外的战略。 具体目标：拟议的研究将追求以下具体目标： 目标1：确定VHA内非致命性阿片类药物和/或兴奋剂过量的特征 与过量用药后治疗利用相关的环境相关因素。 目的2：描述非致命性阿片类药物和/或兴奋剂提供者对Sbor的使用情况 服药过量与舒巴坦的使用、服药后的治疗利用和治疗结果之间的关系。 目标3：通过与VHA的访谈，确定过量用药后护理的障碍和促进者，以及改进的方法 患者、患者关心的其他人和治疗提供者。 方法：覆盖范围、有效性、采用、实施和维护-RE-AIM-框架 将指导我们的学习。目标1：使用公司数据确定非致命性过量的VHA患者 从2014财年到2021财年(2014财年到2021财年)的仓库(CDW)、社区护理和医疗保险数据。 回归模型将描述与过量用药后护理相关的患者、处方医生和环境因素。 目标2：使用CDW、社区护理和医疗保险数据与退伍军人死亡率数据仓库数据相结合， 初步分析将检查提供者的Sbor使用是否与患者服药后过量有关 使用边际结构COX中介模型研究治疗利用率和降低死亡率。目标3：最多60人 总面谈将与VHA患者进行，这些患者经历了非致命的过量用药，他们担心 其他人，以及记录了非致命过量服药的VHA提供者。快速深入的定性分析 将使用各种方法；前者允许向业务伙伴迅速提供可采取行动的反馈意见。 下一步/实施：我们的研究团队拥有强大的业务合作伙伴关系，并帮助开发和 落实工作重点。我们的团队将确保研究结果迅速转化为改善服药过量后的护理。

Background: Drug overdose is a leading cause of death, accounting for 70,630 deaths in the United States (US) in 20193. The majority of drug overdoses involve opioids, and opioid-involved stimulant deaths are rising with 3 out of every 4 cocaine-related deaths involving opioids and 53% of psychostimulant-related deaths involving opioids7. Drug overdose mortality among Veterans mirror these trends5,6. In Massachusetts, among individuals who died of an opioid overdose, 1 in 6 had a non-fatal overdose in the preceding 12 months17. These non-fatal overdoses serve as a promising target for opioid overdose prevention efforts, especially for evidence-based treatments such as medications for opioid use disorder (MOUD). The increase in stimulant- involved opioid overdoses also highlights the need to investigate strategies to improve uptake of evidence- based treatments for stimulant use disorders. Significance: In March 2019, the VHA Office of Mental Health and Suicide Prevention released a national clinical note template, the Suicide Behavior and Overdose Report (SBOR). The SBOR standardizes the reporting process, enhances the visibility of suicide and overdose events in the medical record, and is intended to improve clinical care after these events (e.g., by incorporating risk factors for overdose and strategies to mitigate risk, including referrals for care). However, the SBOR is currently mandated for intentional overdose and only recommended for unintentional overdose. Moreover, it is unclear the extent to which it is being used and whether its use improves post-overdose care as intended. Innovation and Impact: The proposed study will characterize non-fatal opioid-, stimulant-, and combined opioid and stimulant overdoses among VHA patients and the extent to which they receive recommended post- overdose care. Given that the SBOR will soon be mandated for all overdoses, and to ensure that VHA is doing everything it can to prevent overdose mortality among Veterans, it is critical to understand whether the SBOR is improving post-overdose care as intended and if additional strategies may be needed. Specific Aims: The proposed study will pursue the following specific aims: Aim 1: Characterize non-fatal opioid and/or stimulant overdoses within VHA and patient-, prescriber-, and setting-related factors associated with post-overdose treatment utilization. Aim 2: Describe utilization of the SBOR among providers of patients with non-fatal opioid and/or stimulant overdoses and associations between SBOR use, post-overdose treatment utilization, and treatment outcomes. Aim 3: Identify barriers and facilitators of post-overdose care and ways to improve it via interviews with VHA patients, patients’ concerned others, and treatment providers. Methodology: The Reach, Effectiveness, Adoption, Implementation, and Maintenance—RE-AIM—framework will guide our study. Aim 1: VHA patients with non-fatal overdoses will be identified using Corporate Data Warehouse (CDW), Community Care, and Medicare data from Fiscal Years 2014 to 2021 (FY2014-2021). Regression models will describe patient, prescriber, and setting factors associated with post-overdose care. Aim 2: Using CDW, Community Care, and Medicare data combined with VA Mortality Data Repository data, primary analyses will examine whether providers’ SBOR use is associated with patients’ post-overdose treatment utilization and reduced mortality using marginal structural Cox mediational models. Aim 3: Up to 60 total interviews will be conducted with VHA patients who experienced a non-fatal overdose, their concerned others, and VHA providers who documented a non-fatal overdose. Rapid and in-depth qualitative analytic approaches will be used; the former allows for rapid provision of actionable feedback to operations partners. Next Steps/Implementation: Our research team has strong operational partnerships and helped develop and implement the SBOR. Our team will ensure that findings are quickly translated to improve post-overdose care.