Measuring Improvement in the Quality of ED-initiated Treatment for OUD using Observation

丁丙诺啡(BUP)治疗阿片使用障碍(OUD)具有重要的个体和社会意义 有益于健康，并降低过量用药的死亡风险。然而，几乎没有人能够获得这些治疗。 通过扩大急诊科(ED)的治疗机会来缩小治疗差距是 被广泛视为公共卫生优先事项。距离多诺弗里奥等人发表具有里程碑意义的S论文已有3年 证明了ED启动的BUP的可行性、安全性和有效性，尽管阿片类药物非常明显 在艾滋病流行期间，很少有急诊科医生采取这种挽救生命的干预措施。与不断加剧的阿片类药物流行相吻合， 越来越多的人呼吁制定和使用质量措施来跟踪和提高质量 关注和实施政策战略，以确定和鼓励使用最佳做法。通过我们的 工作，包括领导正在进行的两项NIDA临床试验网络多中心研究的实施和 教育署发起的BUP和转介的有效性，我们的团队已经确定了实施的独特挑战 和收集有关护理质量的信息。通过在教育局内提供环境并由教育局管理 这为加强护理提供了足够的时间，而不仅仅是4-6小时的急诊、礼仪驱动的急诊观察单元 (EDOU)将缓解许多已确定的挑战，并促进更好地利用现有基础设施。 此外，它将使因服药过量而出现的患者在急诊室停留足够长的时间来接受他们的第一次治疗 出院前的BUP剂量。 在R61阶段，我们将建立在我们现有的临床方案以及相关的过程和结果的基础上 与ED发起的BUP和转诊相关的质量措施将在(1)标准的ED访问和转诊期间交付 (2)加强教育署在鄂尔多岛的探访。然后，对于R33阶段，我们提出了多中心、随机对照的方法 未经治疗的OUD患者出现在纽约大学布鲁克林肯塔基大学(NYC)的试验中 贝尔维尤医院(NYC)的急救人员被随机(1：1)治疗，通过两种临床方案之一进行治疗 在ED访问、1、3和6个月时评估结果。我们将对过程和结果进行精细评估，以 使用可以在没有过重负担的情况下捕获的数据，为制定可靠、有效的措施提供信息。 我们将比较两种方法在接受急救的患者比例上的相对有效性。 启动BUP和转诊，在7天内与正式的OUD治疗联系起来，并在30天内进行治疗 几天。我们将评估患者报告的结果和药物使用的变化，并进行经济 从第三方付款人的角度进行评估。将结构和流程措施与人口层面挂钩 结果将使我们能够指导和定义质量改进，以便为问责和政策提供信息。正在评估 患者水平特征、测量完成度和结果之间的关联将有助于确定 人口需求，并采取战略，以提高质量和减少差距。

Treatment of opioid use disorder (OUD) with buprenorphine (BUP) has significant individual and societal benefits, and decreases the risk of death from overdose. Yet, few individuals have access to these treatments. Narrowing the treatment gap by expanding access to treatment in Emergency Department (ED) settings is widely viewed to be a public health priority. It has been 3 years since D’Onofrio et al.’s landmark paper demonstrated the feasibility, safety, and efficacy of ED-initiated BUP, and, despite a highly visible opioid epidemic, few EDs have adopted this life-saving intervention. Coincident with the intensifying opioid epidemic, there have been increasing calls for development and use of quality measures to track and improve the quality of care for OUD and implement policy strategies to identify and incentivize use of best practices. Through our work, including leading two ongoing NIDA Clinical Trials Network multicenter studies of the implementation and effectiveness of ED-initiated BUP and referral, our team has identified unique challenges to implementation and collection of information about care quality. By providing an environment within and managed by the ED that allows sufficient time for enhanced care, beyond a 4-6 hour ED visit, protocol-driven ED Observation Units (EDOUs) would mitigate many identified challenges and promote better utilization of existing infrastructure. Further, it would enable patients presenting for overdose to remain in the ED long enough to receive their first dose of BUP prior to discharge. In the R61 phase, we will build on our existing clinical protocols as well as linked process and outcome measures of quality related to ED-initiated BUP and referral to be delivered during (1) a standard ED visit and (2) an enhanced ED visit in EDOU. Then, for the R33 phase, we propose a multicenter, randomized controlled trial in which patients with untreated OUD presenting to the University of Kentucky, NYU-Brooklyn (NYC), and Bellevue Hospital (NYC) EDs are randomized (1:1) to treatment though one of the two clinical protocols with outcomes assessed at the ED visit, 1, 3, and 6 months. We will evaluate processes and outcomes granularly to inform the development of reliable, valid measures using data that could be captured without undue burden. We will compare the relative effectiveness of the two approaches on the proportion of patients who receive ED- initiated BUP and referral, are linked to formal OUD treatment within 7 days and engaged in treatment at 30 days. We will assess changes in patient reported outcomes and drug use, and conduct an economic evaluation from a third-party payer perspective. Linking structural and process measures to population-level outcomes will allow us to guide and define quality improvement to inform accountability and policy. Evaluating the associations between patient-level characteristics, measure completion, and outcomes will help identify population needs and apply strategies to improve quality and reduce disparities.