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

影响：目前，美国正处于阿片类药物使用障碍（OUD）流行之中， 与处方阿片类药物有关的急诊室就诊和过量用药以及海洛因使用率飙升 增长迅速。OUD与发病率和死亡率增加、HIV和HCV感染增加相关 犯罪率和犯罪行为增加。阿片类激动剂治疗（OAT）已被证明是有效的， 治疗OUD并减少这些不良后果。虽然OAT的功效已经确定， 主要的问题是执行问题：很少有提供者向患有 由于患者、提供者或系统障碍导致的OUD。虽然VHA在实施方面取得了很大进展， 在过去十年中，OAT的国民待遇率仍然很低（30%的退伍军人有资格获得 OAT确实）和一些设施继续有非常低的处方率。 背景：使用美沙酮或丁丙诺啡的OAT是OUD最有效的治疗方法。 虽然美沙酮处方必须在高度管制的阿片类药物治疗中心进行，但丁丙诺啡可能 在非成瘾治疗环境中开具处方，使患者更容易获得。当激动剂 治疗是禁忌的或不能接受的病人，拮抗剂药物（纳洛酮）可以是 考虑了 目的：本研究的目的是增加OUD退伍军人的百分比， 在长期治疗（至少3个月）的机构中维持OAT， 接受OUD药物治疗的退伍军人比例较低（<15%）。该项目将不会专注于建立新的 美沙酮阿片类药物治疗中心，而是侧重于使用密集的外部促进，以增加访问 丁丙诺啡和（在丁丙诺啡禁忌或患者不可接受的情况下） 纳洛酮处方。这一目标将通过以下方式实现：（1）实施密集的外部便利措施， 8个表现不佳的地点，并将开办和维持外地行政法庭的比率变化与其余地点进行比较 低性能的网站，2）使用形成性评估方法，以完善进一步传播的干预措施， （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（例如， 目前未接受OAT的OUD患者）接受干预。剩余的低性能站点将 继续照常接收实现（例如，MHS/OMHO和学术细节干预）。 管理数据将用于监测患有OUD的退伍军人启动和维持OAT的比例 在所有低性能的网站。干预措施将包括一个特定地点的发展评估，一个启动地点， 访问和12个月的持续便利。发展评估将包括定性访谈 与患者，物质使用障碍诊所工作人员，初级保健和一般精神卫生领导， 评估现场层面的障碍。实地考察将包括：1）审查具体地点的障碍和潜力 实施策略; 2）关于使用现有仪表板跟踪处方率的说明， 识别可采取行动的病人;及3）就审裁处进行教育，包括为申请豁免而须进行的教育， 丁丙诺啡处方持续促进将包括每月与各个研究中心召开电话会议 通过视频会议提供团队和专家临床咨询。主要成果将是 诊断为OUD的退伍军人启动和维持OAT的比例。由于OAT的实施 是MHS/OMHO和学术细节计划目前的重点，退伍军人与OUD的百分比 预计所有研究中心启动和维持OAT的人数都将增加，但干预研究中心的增加 预计会大得多。最后的定性访谈和成本评估将为定量分析提供信息。 结果

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.