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Steiro A, Hestevik CH, Muller AE. Patient's and healthcare provider's experiences with Opioid Maintenance Treatment (OMT): a qualitative evidence synthesis. BMC Health Serv Res 2024; 24:333. [PMID: 38481254 PMCID: PMC10938774 DOI: 10.1186/s12913-024-10778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 02/23/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Opioid Maintenance Treatment (OMT) is the gold standard for people with opioid dependence. However, drop-out rates are high, and many patients do not reach desired outcomes. Understanding patients' and healthcare providers' experiences with the treatment can provide valuable information to improve the quality of OMT and to increase acceptability and accessibility of services. The aim of this systematic review is to explore and synthesise the experiences of OMT among persons with opioid dependence and health care providers, to inform policy makers and practitioners on how to improve OMT outcomes. METHODS We conducted a qualitative evidence synthesis. We systematically searched in electronic databases (CINAHL, Embase, MEDLINE, and nordic databases) and searched for grey literature. As we identified many studies that met our inclusion criteria, we purposively sampled a manageable number of studies to include in this review. Two researchers independently extracted and coded data from the included studies and used the Andersen's healthcare utilization model to organize and develop codes. We assessed the methodological limitations of the studies, and our confidence in the findings using GRADE CERQual. RESULTS We retrieved 56 relevant studies and purposively sampled 24 qualitative studies of patients' and healthcare providers' experiences with OMT. Our analyses resulted in six main themes: (1) External stigma prevents engagement and retention in treatment, (2) Being identified as in OMT contributed to an increased experience of stigma (3) Inadequate knowledge and expertise among healthcare providers affected patients' treatment experiences, (4) Quality of communication between personnel and patients impacts patients' engagement with treatment and treatment outcomes, (5) Patients wanted help with many aspects of their lives not just medication, and (6) Balancing positive expectations of OMT with treatment stigma. We found that stigma was an overarching theme across these themes. CONCLUSION Our findings suggest that OMT could be more beneficial for patients if treatment programs prioritize efforts to diminish societal and OMT provider stigma and find strategies to better address patient needs. Initiatives should focus on improving treatment knowledge among providers, encouraging the use of client perspectives, considering the context of family members, and establishing a more holistic and flexible treatment environment.
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Affiliation(s)
- Asbjørn Steiro
- Department of Health Services Research, Norwegian Institute of Public Health, Pb 222, 0213, Skoyen, Oslo, Norway.
| | - Christine Hillestad Hestevik
- Department of Health Services Research, Norwegian Institute of Public Health, Pb 222, 0213, Skoyen, Oslo, Norway
| | - Ashley Elizabeth Muller
- Department of Health Services Research, Norwegian Institute of Public Health, Pb 222, 0213, Skoyen, Oslo, Norway
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Rudy L, Lacroix E. Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention. Palliat Support Care 2024:1-9. [PMID: 38420710 DOI: 10.1017/s1478951523001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. METHODS A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. RESULTS Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. SIGNIFICANCE OF RESULTS By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.
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Affiliation(s)
- Lauren Rudy
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
| | - Emilie Lacroix
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
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Lubeya MK, Chibwesha CJ, Mwanahamuntu M, Mukosha M, Vwalika B, Kawonga M. Determinants of the Implementation of Human Papillomavirus Vaccination in Zambia: Application of the Consolidated Framework for Implementation Research. Vaccines (Basel) 2023; 12:32. [PMID: 38250845 PMCID: PMC10821054 DOI: 10.3390/vaccines12010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/10/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Cervical cancer can be prevented, primarily by the administration of the human papillomavirus (HPV) vaccine. Healthcare workers (HCWs) and teachers play important roles when schools are used for vaccine delivery; however, challenges exist. This study aimed to understand the barriers and facilitators to HPV vaccination that are perceived by HCWs and teachers. Guided by the consolidated framework for implementation research (CFIR), key informant interviews were conducted in Lusaka district between June 2021 and November 2021 using a semi-structured questionnaire. Recorded interviews were transcribed verbatim and imported into NVIVO 12 for data management and analysis. We coded transcripts inductively and deductively based on the adapted CFIR codebook. We reached saturation with 23 participants. We identified barriers and facilitators across the five CFIR domains. Facilitators included offering the HPV vaccine free of charge, HPV vaccine effectiveness, stakeholder engagement, and timely planning of the HPV vaccination. Barriers included vaccine mistrust due to its perceived novelty, low levels of parental knowledge, myths and misinformation about the vaccine, lack of parental consent to vaccinate daughters, lack of transport for vaccination outreach, lack of staff incentives, and inadequate sensitisation. Using the CFIR as a guiding framework, we have identified implementation barriers and facilitators to HPV vaccination among HCWs and teachers. Most of the identified barriers are modifiable, hence it is prudent that these are addressed for a high HPV vaccine uptake.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
| | - Carla J. Chibwesha
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg 2193, South Africa;
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
| | - Moses Mukosha
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka 10101, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka 10101, Zambia; (M.M.); (B.V.)
- Women and Newborn Hospital, University Teaching Hospitals, Nationalist Road, Ridgeway, Lusaka 10101, Zambia
| | - Mary Kawonga
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 3193, South Africa; (M.M.); (M.K.)
- Department of Public Health Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
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Pettersen G, Bjerke T, Hoxmark EM, Eikeng Sterri NH, Rosenvinge JH. From existing to living: Exploring the meaning of recovery and a sober life after a long duration of a substance use disorder. NORDIC STUDIES ON ALCOHOL AND DRUGS 2023; 40:577-589. [PMID: 38045010 PMCID: PMC10688400 DOI: 10.1177/14550725231170454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Aim: The study explores how former patients with substance use disorder (SUD) experience the benefits and challenges of a reoriented identity and way of living. Methods: Semi-structured interviews were conducted with 10 participants who had completed treatment for SUD and considered themselves either recovered or in an ongoing rehabilitation process. Interview transcripts were analysed using the content analysis approach. Results: The analysis furthers our understanding of several purposeful aspects of a reorientation towards a sober life in terms of: (1) avoiding illegal drugs, (2) avoiding contact with the substance use relations and milieu, (3) renewing relations and social network, (4) daily occupation, (5) discovering the value of the great, little things in everyday life, (6) new coping strategies, and (7) developing a new identity. Conclusion: The study indicates that rehabilitation from SUDs should take a broader focus than just sobriety. With attention to the present findings, a focus on psychosocial aspects of recovery could contribute to a more overarching framework for SUD treatment.
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Affiliation(s)
- Gunn Pettersen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromsø. Norway
| | - Trond Bjerke
- University Hospital of North Norway, Tromsø, Norway
| | | | | | - Jan H Rosenvinge
- Department of Psychology, Faculty of Health Sciences, UiT- The Arctic University of Norway, Tromsø, Norway
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Hodgkin D, Horgan CM, Jordan Brown S, Bart G, Stewart MT. Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2023; 26:149-158. [PMID: 38113385 PMCID: PMC10752219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/26/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care. AIMS To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability. METHODS We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far. RESULTS The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders. DISCUSSION A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends. IMPLICATIONS FOR HEALTH POLICY For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models. IMPLICATIONS FOR FURTHER RESEARCH For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.
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Affiliation(s)
- Dominic Hodgkin
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts 02453, United States
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Tata V, Al Saadi R, Cho SK, Varisco TJ, Wanat M, Thornton JD. Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis. BMC Health Serv Res 2023; 23:1185. [PMID: 37907915 PMCID: PMC10617230 DOI: 10.1186/s12913-023-10136-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 10/12/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications. METHODS We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7. RESULTS The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS. CONCLUSIONS This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.
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Affiliation(s)
- Vaishnavi Tata
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA.
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA.
| | - Randa Al Saadi
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA.
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA.
| | - Sang Kyu Cho
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Tyler J Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Matthew Wanat
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
- College of Pharmacy, Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - J Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
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Hancock C, Johnson A, Sladky M, Lawton Chen L, Shushan S, Parchman ML. Integrating MOUD and Primary Care: Outcomes of a Multicenter Learning Collaborative. Fam Med 2023; 55:452-459. [PMID: 37450845 PMCID: PMC10622073 DOI: 10.22454/fammed.2023.643371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Opioid use and overdose remain a central and worsening public health emergency in the United States and abroad. Efforts to expand treatment have struggled to match the rising incidence of opioid use disorder (OUD), and treating patients in primary care settings represents one of the most promising opportunities to meet this need. Learning collaboratives (LCs) are one evidence-based strategy to improve implementation of medication treatment for opioid use disorder (MOUD) in primary care. METHODS We developed and studied a multidisciplinary MOUD learning collaborative involving six underserved primary care clinics. We used a mixed-methods approach to assess needs, develop curriculum, and evaluate outcomes from these clinics. RESULTS We recruited six clinics to participate in the collaborative. Half had an established MOUD program. Approximately 80% of participants achieved their organizational quality improvement goals for the collaborative. After the collaborative, participants also reported a significant increase in their perceived competence to implement/improve a MOUD program (pre-LC competence=2.80, post-LC competence=6.33/10, P=.02). The most consistent barrier we identified was stigma around OUD and its effects on patients' ability to access services and staff/provider ability to provide services. The most frequent enablers of program success were trainee interest, organizational leadership support, and a dedicated MOUD care team. CONCLUSIONS Organizations used clinical and systems improvement knowledge to enhance their existing programs or to take steps to create new programs. All participants identified the need for additional staff/clinician training, especially to overcome stigma around OUD. The outcomes demonstrated the crucial importance of long-term organizational support for program success.
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Affiliation(s)
| | - Ashley Johnson
- Department of Family Medicine, University of WashingtonSeattle, WA
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Choi S, O’Grady MA, Cleland CM, Knopf E, Hong S, D’Aunno T, Bao Y, Ramsey KS, Neighbors CJ. Clinics Optimizing MEthadone Take-homes for opioid use disorder (COMET): Protocol for a stepped-wedge randomized trial to facilitate clinic level changes. PLoS One 2023; 18:e0286859. [PMID: 37294821 PMCID: PMC10256218 DOI: 10.1371/journal.pone.0286859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 06/11/2023] Open
Abstract
INTRODUCTION Regulatory changes made during the COVID-19 public health emergency (PHE) that relaxed criteria for take-home dosing (THD) of methadone offer an opportunity to improve quality of care with a lifesaving treatment. There is a pressing need for research to study the long-term effects of the new PHE THD rules and to test data-driven interventions to promote more effective adoption by opioid treatment programs (OTPs). We propose a two-phase project to develop and test a multidimensional intervention for OTPs that leverages information from large State administrative data. METHODS AND ANALYSIS We propose a two-phased project to develop then test a multidimensional OTP intervention to address clinical decision making, regulatory confusion, legal liability concerns, capacity for clinical practice change, and financial barriers to THD. The intervention will include OTP THD specific dashboards drawn from multiple State databases. The approach will be informed by the Health Equity Implementation Framework (HEIF). In phase 1, we will employ an explanatory sequential mixed methods design to combine analysis of large state administrative databases-Medicaid, treatment registry, THD reporting-with qualitative interviews to develop and refine the intervention. In phase 2, we will conduct a stepped-wedge trial over three years with 36 OTPs randomized to 6 cohorts of a six-month clinic-level intervention. The trial will test intervention effects on OTP-level implementation outcomes and patient outcomes (1) THD use; 2) retention in care; and 3) adverse healthcare events). We will specifically examine intervention effects for Black and Latinx clients. A concurrent triangulation mixed methods design will be used: quantitative and qualitative data collection will occur concurrently and results will be integrated after analysis of each. We will employ generalized linear mixed models (GLMMs) in the analysis of stepped-wedge trials. The primary outcome will be weekly or greater THD. The semi-structured interviews will be transcribed and analyzed with Dedoose to identify key facilitators, barriers, and experiences according to HEIF constructs using directed content analysis. DISCUSSION This multi-phase, embedded mixed methods project addresses a critical need to support long-term practice changes in methadone treatment for opioid use disorder following systemic changes emerging from the PHE-particularly for Black and Latinx individuals with opioid use disorder. By combining findings from analyses of large administrative data with lessons gleaned from qualitative interviews of OTPs that were flexible with THD and those that were not, we will build and test the intervention to coach clinics to increase flexibility with THD. The findings will inform policy at the local and national level.
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Affiliation(s)
- Sugy Choi
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Megan A. O’Grady
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Charles M. Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Elizabeth Knopf
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Sueun Hong
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Thomas D’Aunno
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Kelly S. Ramsey
- New York State Office of Addiction Services and Supports (OASAS), New York, NY, United States of America
| | - Charles J. Neighbors
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
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Frimpong JA, Guerrero EG, Kong Y, Khachikian T, Wang S, D'Aunno T, Howard DL. Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 145:208947. [PMID: 36880916 DOI: 10.1016/j.josat.2022.208947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/03/2022] [Accepted: 11/29/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes. METHODS Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys. RESULTS The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only. CONCLUSIONS Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.
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Affiliation(s)
| | - Erick G Guerrero
- Research to End Healthcare Disparities Corp., United States of America
| | - Yinfei Kong
- California State University, Fullerton, United States of America.
| | | | - Suojin Wang
- Texas A&M University, United States of America.
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Barriers and facilitators to nurse practitioner buprenorphine prescribing for opioid use disorder in primary care settings. J Am Assoc Nurse Pract 2023; 35:112-121. [PMID: 36512806 DOI: 10.1097/jxx.0000000000000811] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine-naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine-naloxone prescribing laws, few providers hold buprenorphine-naloxone prescribing waivers and even fewer prescribe the medication. PURPOSE This study explores barriers and facilitators to buprenorphine-naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina. METHODOLOGY Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine-naloxone prescribing. RESULTS Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources. CONCLUSIONS The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD. IMPLICATIONS To our knowledge, this is the first qualitative study of NP buprenorphine-naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine-naloxone prescribing by NPs practicing in rural regions.
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Reed MK, Murali V, Sarpoulaki N, Zavodnick JH, Hom JK, Rising KL. Hospitalist perspectives on buprenorphine treatment for inpatients with opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100106. [PMID: 36844165 PMCID: PMC9948932 DOI: 10.1016/j.dadr.2022.100106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
Background Patients with opioid use disorder (OUD) have high hospital admission rates. Hospitalists, clinicians that work in inpatient medical settings, may have a unique opportunity to intervene on behalf of these patients, yet their experience with and attitudes towards treating patients with OUD need further exploration. Methods We conducted qualitative analysis of 22 semi-structured interviews with hospitalists between January and April 2021 in Philadelphia, PA. Participants were hospitalists in one major metropolitan university hospital and one urban community hospital in a city with a high prevalence of OUD and overdose deaths. Participants were asked about their experiences, successes, and difficulties in treating hospitalized patients with OUD. Results Twenty-two hospitalists were interviewed. Participants were majority female (14, 64%) and White (16, 73%). We identified the following common themes: lack of training/experience with OUD, a lack of community OUD treatment infrastructure, a lack of inpatient OUD/withdrawal treatment resources, the "X-waiver" as a barrier to prescribing buprenorphine, the "ideal" patient to start on buprenorphine, and the hospital as an ideal intervention setting. Conclusions Hospitalization due to acute illness or complication of drug use represents a potential intervention point to initiate treatment for patients with OUD. While hospitalists exhibit willingness to prescribe medications, provide harm reduction education, and link patients to outpatient addiction treatment, they identify training and infrastructure barriers that must first be addressed.
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Affiliation(s)
- Megan K Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,College of Population Health, Thomas Jefferson University, Philadelphia, PA, United States,Corresponding author at: Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States.
| | - Vignesh Murali
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nazanin Sarpoulaki
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jillian H. Zavodnick
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jeffrey K. Hom
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, PA, United States
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
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12
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Janet Ho J, Jones KF, Sager Z, Neale K, Childers JW, Loggers E, Merlin JS. Barriers to Buprenorphine Prescribing for Opioid Use Disorder in Hospice and Palliative Care. J Pain Symptom Manage 2022; 64:119-127. [PMID: 35561938 DOI: 10.1016/j.jpainsymman.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/23/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
CONTEXT Hospice and palliative care (HPC) clinicians increasingly care for patients with concurrent painful serious illness and opioid use disorder (OUD) or opioid misuse; however, only a minority of HPC clinicians have an X-waiver license or actively use it to prescribe buprenorphine as medication treatment for OUD. OBJECTIVES To understand barriers for HPC clinicians to obtaining an X-waiver and prescribing buprenorphine as medication treatment for OUD. METHODS We performed content analysis on 100 survey responses from members of the national Buprenorphine Peer Support Network, a group of HPC clinicians interested in buprenorphine, on X-waiver status, barriers to obtaining an X-waiver, and barriers to active prescribing. RESULTS Of 100 HPC clinicians surveyed, only 26 of 57 HPC clinicians with X-waivers had ever prescribed. Prominent barriers included discomfort managing concurrent pain, buprenorphine, and OUD; concerns about impacts on practice; unsupportive practice culture; insufficient practice support; patient facing challenges; and cumbersome regulatory policies. CONCLUSION Despite HPC clinicians' interest in buprenorphine prescribing for OUD, several steps are needed to facilitate the practice, including clinician education tailored to pain and to clinical challenges faced by HPC clinicians, mentorship on buprenorphine use, and cultural and practice changes to dismantle systemic stigma towards addiction. We propose evidence-based steps derived from our survey findings that individual clinicians, HPC leaders, and national HPC organizations can take to improve care for patients with painful serious illness and OUD.
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Affiliation(s)
- Jiunling Janet Ho
- Division of Palliative Medicine (J.J.H.), University of California, San Francisco and Addiction Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.
| | - Katie Fitzgerald Jones
- Boston College Connell School of Nursing (K.F.J.), VA Boston Healthcare System; Boston, Massachusetts, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care (Z.S.), VA Boston Healthcare System, Dana Farber Cancer Institute, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle Neale
- Department of Palliative Medicine and Supportive Care (K.N.), The Lois U. and Harry R. Horvitz Palliative Medicine Program, Taussig Cancer Institute, Cleveland Clinic; Cleveland, Ohio, USA
| | - Julie W Childers
- Division of General Internal Medicine (J.W.C., J.S.M.), Section of Palliative Care and Medical Ethics; Section of Treatment, Research, and Education in Addiction Medicine, University of Pittsburgh School of Medicine; Pittsburgh, Pennsylvania, USA
| | - Elizabeth Loggers
- Clinical Research Division (E.L.), Fred Hutchinson Cancer Research Center, Division of Oncology, University of Washington School of Medicine; Seattle, Washington, USA
| | - Jessica S Merlin
- Division of General Internal Medicine (J.W.C., J.S.M.), Section of Palliative Care and Medical Ethics; Section of Treatment, Research, and Education in Addiction Medicine, University of Pittsburgh School of Medicine; Pittsburgh, Pennsylvania, USA
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13
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Wyse JJ, Mackey K, Lovejoy TI, Kansagara D, Tuepker A, Gordon AJ, Todd Korthuis P, Herreid-O'Neill A, Williams B, Morasco BJ. Expanding access to medications for opioid use disorder through locally-initiated implementation. Addict Sci Clin Pract 2022; 17:32. [PMID: 35725648 PMCID: PMC9207874 DOI: 10.1186/s13722-022-00312-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted. Methods Guided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies. Results Interviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes—including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators’ perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving. Conclusions This study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00312-7.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA. .,School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA.
| | - Katherine Mackey
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA.,Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anders Herreid-O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Beth Williams
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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14
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Champions Among Us: Leading Primary Care to the Forefront of Opioid Use Disorder Treatment. J Gen Intern Med 2022; 37:1771-1773. [PMID: 35018566 PMCID: PMC8751461 DOI: 10.1007/s11606-021-07355-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022]
Abstract
Despite more than a decade of investment in opioid use disorder (OUD) treatment infrastructure, the year 2020 saw the highest mortality related to opioid overdose in American history. Treatment access remains critically limited, with less than half of people living with OUD receiving any treatment. Primary care has been referred to as the "sleeping giant" of addiction care, as few primary care doctors currently prescribe medications to treat OUD. The "clinical champions" framework is a tool that has shown promise in creating the type of mentorship and culture change necessary to expand uptake of medication-based OUD treatment among primary care providers. The early success of this model and the increased availability of tools for broad implementation warrant further investment as a means of leading primary care into a larger role in combatting the opioid addiction epidemic.
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15
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Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022; 399:555-604. [PMID: 35122753 PMCID: PMC9261968 DOI: 10.1016/s0140-6736(21)02252-2] [Citation(s) in RCA: 175] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amy S B Bohnert
- Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA
| | | | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yasmin L Hurd
- Addiction Institute, Icahn School of Medicine, New York, NY, USA
| | - David N Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erin E Krebs
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery and Outcomes Research, Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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16
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Taylor EN, Timko C, Binswanger IA, Harris AHS, Stimmel M, Smelson D, Finlay AK. A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration. Subst Abus 2022; 43:556-563. [PMID: 34586978 PMCID: PMC9423124 DOI: 10.1080/08897077.2021.1975867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.
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Affiliation(s)
- Emmeline N. Taylor
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Psychology, University of Colorado Colorado Springs, Colorado Springs, CO, USA
| | - Christine Timko
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA,Colorado Permanente Medical Group, Denver, CO, USA,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex H. S. Harris
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew Stimmel
- U.S. Department of Veterans Affairs, Veterans Justice Programs, Menlo Park, CA, USA
| | - David Smelson
- U.S. Department of Veterans Affairs, Edith Nourse Rodgers VA Medical Center, Center for Organization and Implementation Science, Bedford, MA, USA
| | - Andrea K. Finlay
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Menlo Park, CA, USA
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17
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Frost MC, Lampert H, Tsui JI, Iles-Shih MD, Williams EC. The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review. Addict Sci Clin Pract 2021; 16:62. [PMID: 34635170 PMCID: PMC8504567 DOI: 10.1186/s13722-021-00266-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/10/2021] [Indexed: 01/01/2023] Open
Abstract
Background Methamphetamine/amphetamine use has sharply increased among people with opioid use disorder (OUD). It is therefore important to understand whether and how use of these substances may impact receipt of, and outcomes associated with, medications for OUD (MOUD). This systematic review identified studies that examined associations between methamphetamine/amphetamine use or use disorder and 3 classes of outcomes: (1) receipt of MOUD, (2) retention in MOUD, and (3) opioid abstinence during MOUD. Methods We searched 3 databases (PubMed/MEDLINE, PsycINFO, CINAHL Complete) from 1/1/2000 to 7/28/2020 using key words and subject headings, and hand-searched reference lists of included articles. English-language studies of people with documented OUD/opioid use that reported a quantitative association between methamphetamine/amphetamine use or use disorder and an outcome of interest were included. Study data were extracted using a standardized template, and risk of bias was assessed for each study. Screening, inclusion, data extraction and bias assessment were conducted independently by 2 authors. Study characteristics and findings were summarized for each class of outcomes. Results Thirty-nine studies met inclusion criteria. Studies generally found that methamphetamine/amphetamine use or use disorder was negatively associated with receiving methadone and buprenorphine; 2 studies suggested positive associations with receiving naltrexone. Studies generally found negative associations with retention; most studies finding no association had small samples, and these studies tended to examine shorter retention timeframes and describe provision of adjunctive services to address substance use. Studies generally found negative associations with opioid abstinence during treatment among patients receiving methadone or sustained-release naltrexone implants, though observed associations may have been confounded by other polysubstance use. Most studies examining opioid abstinence during other types of MOUD treatment had small samples. Conclusions Overall, existing research suggests people who use methamphetamine/amphetamines may have lower receipt of MOUD, retention in MOUD, and opioid abstinence during MOUD. Future research should examine how specific policies and treatment models impact MOUD outcomes for these patients, and seek to understand the perspectives of MOUD providers and people who use both opioids and methamphetamine/amphetamines. Efforts to improve MOUD care and overdose prevention strategies are needed for this population.
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Affiliation(s)
- Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States. .,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States.
| | - Hannah Lampert
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Matthew D Iles-Shih
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States
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18
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Kerins C, Kelly C, Reardon CM, Houghton C, Toomey E, Hayes CB, Geaney F, Perry IJ, McSharry J, McHugh S. Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study. Front Public Health 2021; 9:707668. [PMID: 34485232 PMCID: PMC8414889 DOI: 10.3389/fpubh.2021.707668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/14/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals. Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis. Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information. Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.
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Affiliation(s)
- Claire Kerins
- Discipline of Health Promotion, School of Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - Colette Kelly
- Discipline of Health Promotion, School of Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Elaine Toomey
- Faculty of Education and Health Sciences, School of Allied Health, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Catherine B Hayes
- Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Fiona Geaney
- School of Public Health, University College Cork, Cork, Ireland
| | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
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19
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Zucco L, Levy N, Li Y, Golen T, Shainker SA, Hess PE, Ramachandran SK. Rapid Cycle Implementation and Retrospective Evaluation of a SARS-CoV-2 Checklist in Labor and Delivery. BMC Health Serv Res 2021; 21:775. [PMID: 34362350 PMCID: PMC8342983 DOI: 10.1186/s12913-021-06787-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/13/2021] [Indexed: 02/01/2023] Open
Abstract
Background Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient. Methods Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time. Conclusion We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06787-5.
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Affiliation(s)
- Liana Zucco
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Nadav Levy
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Yunping Li
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Toni Golen
- Department of Obstetrics, Gynecology and Reproductive Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Scott A Shainker
- Department of Obstetrics, Gynecology and Reproductive Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Philip E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
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Banta-Green CJ, Hansen RN, Ossiander EM, Wasserman CR, Merrill JO. Buprenorphine utilization among all Washington State residents' based upon prescription monitoring program data - Characteristics associated with two measures of retention and patterns of care over time. J Subst Abuse Treat 2021; 127:108446. [PMID: 34049724 DOI: 10.1016/j.jsat.2021.108446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid use disorder is a serious health condition for which buprenorphine is proven effective, yet providers substantially underutilize buprenorphine. We present two approaches to measuring treatment duration, factors associated with retention, and patterns of care. METHODS The study determined incident buprenorphine prescribing for all Washingtonians utilizing prescription monitoring program data from 2012 to 2019. The study calculated episode of care and cumulative time in care. Generalized linear models estimated associations among the length of the first episode of care and cumulative time in care with sex, age, and rurality. Cox proportional hazards models estimated the time to discontinuing buprenorphine for the first four episodes of care and time to discontinuing the last episode of care. RESULTS Mean and median duration of the first episode were 320 and 84 days, respectively, and for cumulative time in care 308 and 195 days. A minority of peoples' first episodes exceeded 180 days (37%). Being female and older were significantly associated with longer first episodes and cumulative time in care. Survival analyses indicated that the proportion of those still in care at 6, 12, and 24 months into their first episode of care declined for those with more than one episode of care; conversely the study found much smaller differences in retention for the last episode of care, indicating that many people were eventually able to be retained in care for longer periods of time. CONCLUSION Episodes of care and cumulative time on buprenorphine were both short compared to minimum quality recommendations of 180 days. Median cumulative time in care was double that of the first episode, highlighting that many people engage in subsequent episodes of substantial length. Episode of care and cumulative care analyses should inform states, payers, health care systems and providers in measuring and setting treatment duration goals.
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Affiliation(s)
- Caleb J Banta-Green
- Addictions, Drug & Alcohol Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, 1107 NE 45th St, Suite 120, Seattle, WA 98105, United States of America.
| | - Ryan N Hansen
- School of Pharmacy University of Washington, Box 357630, Seattle, WA 98195-7630, United States of America
| | - Eric M Ossiander
- Washington State Department of Health, 101 Israel Road SE, Tumwater, WA 98501, United States of America
| | - Cathy R Wasserman
- Washington State Department of Health, 101 Israel Road SE, Tumwater, WA 98501, United States of America
| | - Joseph O Merrill
- Department of Medicine, University of Washington, Harborview Medical Center, 401 Broadway, Seattle, WA 98122, United States of America
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21
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Campbell CI, Saxon AJ, Boudreau DM, Wartko PD, Bobb JF, Lee AK, Matthews AG, McCormack J, Liu DS, Addis M, Altschuler A, Samet JH, LaBelle CT, Arnsten J, Caldeiro RM, Borst DT, Stotts AL, Braciszewski JM, Szapocznik J, Bart G, Schwartz RP, McNeely J, Liebschutz JM, Tsui JI, Merrill JO, Glass JE, Lapham GT, Murphy SM, Weinstein ZM, Yarborough BJH, Bradley KA. PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment. Addict Sci Clin Pract 2021; 16:9. [PMID: 33517894 PMCID: PMC7849121 DOI: 10.1186/s13722-021-00218-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here. Methods PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16–90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims (“electronic health records,” [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization. Discussion The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings. Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1
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Affiliation(s)
- Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA.
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | | | | | - David S Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, Three White Flint North, 11601 Landsdown Street, North Bethesda, MD, 20852, USA
| | - Megan Addis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA, 94612, USA
| | - Jeffrey H Samet
- Boston Medical Center/Boston University School of Medicine: Clinical Addiction Research & Education (CARE) Unit Crosstown Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, 02118, USA
| | - Colleen T LaBelle
- Boston Medical Center/Boston University School of Medicine: Clinical Addiction Research & Education (CARE) Unit Crosstown Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, 02118, USA
| | - Julia Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Ryan M Caldeiro
- Kaiser Permanente Washington, 9800 4th Ave. N.E., Seattle, WA, 98115, USA
| | - Douglas T Borst
- Kootenai Clinic Family Medicine, 1919 Lincoln Way, Suite 315, Coeur d Alene, ID, 83814, USA
| | - Angela L Stotts
- Department of Family & Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston School, 7000 Fannin Street, Houston, TX, 77030, USA
| | - Jordan M Braciszewski
- Department of Psychiatry, Center for Health Policy and Health Services Research, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - José Szapocznik
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, 10th Floor, Miami, FL, 33136, USA
| | - Gavin Bart
- University of Minnesota/Hennepin Healthcare, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Jennifer McNeely
- NYU Grossman School of Medicine, 180 Madison Ave., New York, NY, 10016, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research On Health Care, University of Pittsburgh School of Medicine, 200 Lothrop Street, 933West, Pittsburgh, PA, 15213, USA
| | - Judith I Tsui
- University of Washington/Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
| | - Joseph O Merrill
- University of Washington/Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| | - Sean M Murphy
- Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA
| | - Zoe M Weinstein
- Clinical Addiction Research & Education (CARE) Unit, Boston University School of Medicine, Crosstown Center, 801 Massachusetts Ave., 2nd Floor, Boston, MA, 02118, USA
| | - Bobbi Jo H Yarborough
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227-1098, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
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22
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O'Grady MA, Lincourt P, Greenfield B, Manseau MW, Hussain S, Genece KG, Neighbors CJ. A facilitation model for implementing quality improvement practices to enhance outpatient substance use disorder treatment outcomes: a stepped-wedge randomized controlled trial study protocol. Implement Sci 2021; 16:5. [PMID: 33413493 PMCID: PMC7789887 DOI: 10.1186/s13012-020-01076-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022] Open
Abstract
Background The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder. Methods A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data. Discussion This study will provide the field with a strong test of a multicomponent intervention to improve providers’ capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system. Trial registration Trial #NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020
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Affiliation(s)
- Megan A O'Grady
- Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT, 06030-2635, USA.
| | - Patricia Lincourt
- New York State Office of Addiction Services and Supports, 1450 Western Ave., Albany, NY, 12203, USA
| | - Belinda Greenfield
- New York State Office of Addiction Services and Supports, 501 7th Ave., 8th Floor, New York, NY, 10018, USA
| | - Marc W Manseau
- New York State Office of Addiction Services and Supports, 501 7th Ave., 8th Floor, New York, NY, 10018, USA
| | - Shazia Hussain
- New York State Office of Addiction Services and Supports, 1450 Western Ave., Albany, NY, 12203, USA
| | - Kamala Greene Genece
- Partnership to End Addiction, 485 Lexington Avenue, 3rd Floor, New York, NY, 10017-6706, USA
| | - Charles J Neighbors
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA.,NYU Wagner Graduate School of Public Service, 295 Lafayette Street, New York, NY, 10012, USA
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23
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Soares NSA, Fernandes MA, Ribeiro HKP, Rocha DDM, Ribeiro ÍAP. Harm reduction in primary healthcare: an integrative review of care strategies. Rev Esc Enferm USP 2020; 54:e03591. [PMID: 32965442 DOI: 10.1590/s1980-220x2018051803591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 09/30/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To analyze the evidence available in the literature on harm reduction actions developed by primary healthcare. METHOD Integrative literature review carried out in the databases MEDLINE, CINAHL, SCOPUS, Web of ScienceTM and LILACS. RESULTS Seventeen (17) primary studies published from 2008 to 2017 were included in this review. Care strategies for harm reduction included maintenance treatment with methadone, therapy with opioid agonists, needle and syringe distribution programs and the creation of rooms for supervised drug consumption. Health professionals were essential for consolidating inclusion strategies, possessing skills to listen without judgment and prejudice. CONCLUSION Harm reduction care strategies have been disseminated in different countries and healthcare levels, aiming toward safe practice and quality, effective and risk-free care actions.
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Stoner CR, Chandra M, Bertrand E, Du B, Durgante H, Klaptocz J, Krishna M, Lakshminarayanan M, Mkenda S, Mograbi DC, Orrell M, Paddick SM, Vaitheswaran S, Spector A. A New Approach for Developing "Implementation Plans" for Cognitive Stimulation Therapy (CST) in Low and Middle-Income Countries: Results From the CST-International Study. Front Public Health 2020; 8:342. [PMID: 32850583 PMCID: PMC7411173 DOI: 10.3389/fpubh.2020.00342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Even with a strong evidence base, many healthcare interventions fail to be translated to clinical practice due to the absence of robust implementation strategies. For disorders such as Alzheimer's disease and other dementias, access to evidence-based interventions beyond research settings is of great importance. Cognitive Stimulation Therapy (CST) is a brief, group-based intervention, with consistent evidence of effectiveness. Methods: An implementation focused, three-phase methodology was developed using extensive stakeholder engagement. The methods resulted in a standardized Implementation Plan for the successful translation of CST from research to practice. The methodology was developed using the Consolidated Framework for Implementation Research (CFIR) and refined in three countries that vary in levels of economic development and healthcare systems (Brazil, India and Tanzania). Results: Five Implemention Plans for CST were produced. Each plan contained implementation strategies and action plans devised in conjunction with policy professionals, healthcare professionals, people with dementia and family carers, and an international team of researchers and clinicians. Conclusion: This novel methodology can act as a template for implementation studies in diverse healthcare systems across the world. It is an effective means of devising socio-culturally informed Implementation Plans that account for economic realities, health equity and healthcare access.
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Affiliation(s)
- Charlotte R Stoner
- Centre for Chronic Illness and Ageing, Centre for Mental Health, Institute for Lifecourse Development, School of Human Sciences, University of Greenwich, London, United Kingdom
| | - Mina Chandra
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Bangabandhu Sheikh Mujeeb Marg, New Delhi, India
| | - Elodie Bertrand
- Department of Psychology, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Helen Durgante
- Department of Psychology, Federal University of Rio Grande do Sul (UFRGS), Rio Grande do Sul, Brazil
| | - Joanna Klaptocz
- Newcastle University Hospitals NHS Foundation Trust, Royal Vic Infirmary, Newcastle upon Tyne, United Kingdom
| | | | | | - Sarah Mkenda
- Occupational Therapy Department, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Daniel C Mograbi
- Department of Psychology, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Martin Orrell
- Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
| | - Stella-Maria Paddick
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sridhar Vaitheswaran
- Dementia Care in Schizophrenia Research Foundation (DEMCARES in SCARF), Chennai, India
| | - Aimee Spector
- Research Department of Clinical, Educational and Health Psychology, University College London (UCL), London, United Kingdom
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25
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Bergman BG, Ashford RD, Kelly JF. Attitudes toward opioid use disorder medications: Results from a U.S. national study of individuals who resolved a substance use problem. Exp Clin Psychopharmacol 2020; 28:449-461. [PMID: 31556675 PMCID: PMC7096254 DOI: 10.1037/pha0000325] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The attitudes of individuals who receive, provide, or influence opioid use disorder (OUD) medication services, also called stakeholders, may enhance or hinder their dissemination and adoption. Individuals who have resolved a significant alcohol or other drug (AOD) problem are a group of key stakeholders whose OUD medication attitudes are not well understood empirically. This group subsumes, but is not limited to, individuals who identify as being "in recovery." Analyses leveraged the National Recovery Study, a geo-demographically representative survey of U.S. adults who resolved a significant AOD problem (N = 1,946). We examined the prevalence of positive, neutral, and negative attitudes toward agonists, such as buprenorphine/naloxone and methadone, and antagonists, such as oral and extended-release depot injection naltrexone. Single-predictor logistic regression models tested for demographic, clinical, and recovery-related correlates of these attitudes and, for those significant at the .1 level, multivariable-predictor logistic regression models tested unique associations between these correlates and attitudes. Results showed that participants were equally likely to hold positive (21.4 [18.9-24.0]%) and negative agonist (23.8 [21.2-26.7]%) attitudes but significantly more likely to hold negative (30.3 [27.4-33.3]%) than positive antagonist attitudes (18.0 [15.9-20.4]%). Neutral attitudes were most commonly endorsed for both agonists (54.8 [51.6-57.9]%) and antagonists (51.7 [48.5-54.8]%). For agonists, more recent AOD problem resolution was a unique predictor of positive attitude, whereas Black and Hispanic races/ethnicities, compared with White, were unique predictors of negative attitude. For antagonists, older age group (45-59 and 60 + vs. 18-29 years), lifetime opioid antagonist medication prescription, and past 90-day non-12-step mutual-help attendance were unique predictors of positive attitude, whereas greater spirituality was a unique predictor of negative attitude. This population-level study of U.S. adults who resolved an AOD problem showed that agonist attitudes may be more positive than anecdotal evidence suggests. Certain characteristics and experiences, however, highlight a greater likelihood of negative attitudes, suggesting these factors may be potential barriers to OUD medication adoption. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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26
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Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 17:183-192. [PMID: 32021588 DOI: 10.1176/appi.focus.17206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Am J Psychiatry 2017;174:738-747).
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Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
| | - Roger D Weiss
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
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27
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Mooney LJ, Valdez J, Cousins SJ, Yoo C, Zhu Y, Hser YI. Patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD): Rationale, methodology, and preliminary results. J Subst Abuse Treat 2020; 108:115-122. [PMID: 31668516 PMCID: PMC7397558 DOI: 10.1016/j.jsat.2019.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS As treatment for opioid use disorder (OUD) expands within general healthcare settings such as primary care, mechanisms to facilitate decision-making processes are increasingly necessary. Decision aids have the capacity to bolster existing resources in diverse treatment settings by increasing knowledge of treatment options and facilitating shared decision making. The aim of this study is to develop and test a patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD) that assists individuals with OUD in making informed decisions about treatment at the time of initial clinical visit. Use of the PtDA-MOUD will be further tested in diverse treatment settings within the California Hub and Spoke System developed under the SAMHSA State Targeted Response to the Opioid Crisis grants. METHODS The PtDA-MOUD was iteratively developed with input from a scientific expert panel and both patient and provider focus groups, incorporating International Patient Decision Aid Standards. Thirty-six patients with OUD entering treatment pilot tested the PtDA and completed assessments, and results from clinical records were compared with matched controls who did not receive the PtDA. A clinical profile based on assessment data was created for use within the clinical visit. RESULTS The developed decision aid provides information on MOUD and captures patient characteristics relevant to medication treatment decisions. Feedback indicated that the PtDA-MOUD was feasible to implement and useful. Though the small sample size limited the ability to detect significant differences (p > .05), a greater number of individuals who reviewed the PtDA (37%) were inducted on MOUD than controls (11%) and received MOUD for more days (M = 14.0, SD = 24.7) than controls (M = 8.4; SD = 22.5). Moreover, the difference in means for days receiving MOUD had an approximately medium effect size (r = 0.25). CONCLUSIONS Patient perceptions of the decision aid were favorable and it showed promise as a tool in the OUD treatment process. Pilot testing results suggested preliminary positive effects on MOUD initiation. Future phases of this study will further investigate the usefulness of this tool. ClinicalTrials.govIdentifier:NCT03394261.
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Affiliation(s)
- Larissa J Mooney
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America; Department of Psychiatry, Veterans Affairs Greater Los Angeles Healthcare System, United States of America.
| | - Jonathan Valdez
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America
| | - Sarah J Cousins
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America
| | - Caroline Yoo
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America
| | - Yuhui Zhu
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America
| | - Yih-Ing Hser
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States of America
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28
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Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review. BMC FAMILY PRACTICE 2019; 20:157. [PMID: 31729957 PMCID: PMC6857230 DOI: 10.1186/s12875-019-1047-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine. METHODS Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings. RESULTS Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients. CONCLUSIONS Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.
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29
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Finlay AK, Wong JJ, Ellerbe LS, Rubinsky A, Gupta S, Bowe TR, Schmidt EM, Timko C, Burden JL, Harris AHS. Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs. J Stud Alcohol Drugs 2019. [PMID: 30573022 DOI: 10.15288/jsad.2018.79.909] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Despite evidence of effectiveness, pharmacotherapy-methadone, buprenorphine, or naltrexone-is prescribed to less than 35% of Veterans Health Administration (VHA) patients diagnosed with opioid use disorder (OUD). Among veterans whose OUD treatment is provided in VHA residential programs, factors influencing pharmacotherapy implementation are unknown. We examined barriers to and facilitators of pharmacotherapy for OUD among patients diagnosed with OUD in VHA residential programs to inform the development of implementation strategies to improve medication receipt. METHOD VHA electronic health records and program survey data were used to describe pharmacotherapy provided to a national cohort of VHA patients with OUD in residential treatment programs (N = 4,323, 6% female). Staff members (N = 63, 57% women) from 44 residential programs (response rate = 32%) participated in interviews. Barriers to and facilitators of pharmacotherapy for OUD were identified from transcripts using thematic analysis. RESULTS Across all 97 residential treatment programs, the average rate of pharmacotherapy for OUD was 21% (range: 0%-67%). Reported barriers included provider or program philosophy against pharmacotherapy, a lack of care coordination with nonresidential treatment settings, and provider perceptions of low patient interest or need. Facilitators included having a prescriber on staff, education and training for patients and staff, and support from leadership. CONCLUSIONS Contrary to our hypothesis, barriers to and facilitators of pharmacotherapy for OUD in VHA residential treatment programs were consistent with prior research in outpatient settings. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VHA providers, may help improve receipt of pharmacotherapy for OUD.
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Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California.,National Center on Homelessness Among Veterans, Department of Veterans Affairs, Menlo Park, California
| | - Jessie J Wong
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California.,Center on Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Laura S Ellerbe
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Anna Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco and VA San Francisco Health Care System, San Francisco, California
| | - Shalini Gupta
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Thomas R Bowe
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Eric M Schmidt
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California.,Center on Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Christine Timko
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Jennifer L Burden
- Department of Veterans Affairs, Veterans Health Administration, Salem, Virginia
| | - Alex H S Harris
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California
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Changing Clinical Practice: Evaluation of Implementing Recommendations for Opportunistic Salpingectomy in British Columbia and Ontario. Int J Gynecol Cancer 2019; 28:1101-1107. [PMID: 29757870 DOI: 10.1097/igc.0000000000001288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of the study was to explore the factors that contributed to the adoption of opportunistic salpingectomies (removal of fallopian at the time of hysterectomy or in lieu of tubal ligation) by gynecologic surgeons in British Columbia (where a knowledge translation initiative took place) and in Ontario (a comparator where no knowledge translation initiative took place). We aimed to understand why the knowledge translation initiative undertaken by OVCARE in British Columbia resulted in such a dramatic uptake in opportunistic salpingectomy. METHODS We undertook a qualitative evaluation of clinicians' decisions about whether or not they should adopt the practice of opportunistic salpingectomy based on interviews with gynecologic surgeons in British Columbia and Ontario (n = 28). The analysis draws from the Consolidated Framework for Implementation Research. RESULTS Regional cohesion combined with practice change information exposure and thought leader support were important in explaining differences in adoption levels between participants. The British Columbian knowledge translation campaign was successful because provincial thought leaders exposed gynecologic surgeons to recommendations through multiple sources within a highly socially cohesive environment wherein clinicians felt pressure to adopt the recommendations. In both provinces, high adopters often believed that the workload and surgical risk associated with the adoption was low and the potential benefit-because of limited ovarian cancer detection and treatment options-was high. CONCLUSION This research points to the important role that local professional networks can play in encouraging clinicians to change their practice by creating a cohesive regional environment where clinicians are repeatedly exposed to important information and supported in their practice change by local thought leaders.
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Lambert-Kerzner AC, Aasen DM, Overbey DM, Damschroder LJ, Henderson WG, Hammermeister KE, Bronsert MR, Meguid RA. Use of the consolidated framework for implementation research to guide dissemination and implementation of new technologies in surgery. J Thorac Dis 2019; 11:S487-S499. [PMID: 31032067 DOI: 10.21037/jtd.2019.01.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Improving surgical outcomes is important to patients, providers, and healthcare systems. Understanding best methods to ensure evidence based practices are successfully implemented and sustained in clinical practices leads to improved care. Dissemination and implementation (D&I) science facilitates the successful pathway from clinical trials to sustained implementation. Methods We describe D&I science, introduce the consolidated framework for implementation research (CFIR), a D&I framework, and provide an example of how CFIR was utilized to facilitate the translational process from design adaptations to implementation, broad utilization by clinicians, and sustainability of the SUrgical Risk Preoperative Assessment System (SURPAS) tool into regular clinical practice. SURPAS creates data-driven individualized risk assessments of common adverse postoperative outcomes to enhance the informed consent process, shared decision making, and consequently improved surgical outcomes. The CFIR provided a structured systematic way to identify constructs influencing the D&I of SURPAS, including adaptations for the process and tool. Results We identified three domains, each with specific constructs, that participants believed would strongly influence effectiveness of SURPAS implementation efforts: the importance of patients' perspectives (outer setting); the quality of SURPAS (intervention characteristic); and integration of SURPAS into the electronic health record (inner setting). Additionally, providers' positive attitudes toward and support of SURPAS (characteristics of individuals); and the ease of integration of SURPAS into the workflow (process), were also identified. Tension emerged between patients' preference of the provision of risk information and providers' concern about additional clinic time required for formal risk discussion with low-risk patients. Conclusions Systematically identifying constructs from the beginning of the design through the implementation process can guide design of a multi-component strategy for future large-scale implementation by assessing the relative impact of factors on implementation using the CFIR framework. In the example studied, this allows key stakeholders to ensure success of D&I of SURPAS at multiple levels and times, continuously optimizing the process.
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Affiliation(s)
- Anne C Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Davis M Aasen
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Douglas M Overbey
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - William G Henderson
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Karl E Hammermeister
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Collaborative for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Collaborative for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Finlay AK, Binswanger IA, Timko C, Smelson D, Stimmel MA, Yu M, Bowe T, Harris AHS. Facility-level changes in receipt of pharmacotherapy for opioid use disorder: Implications for implementation science. J Subst Abuse Treat 2018; 95:43-47. [PMID: 30352669 PMCID: PMC6209329 DOI: 10.1016/j.jsat.2018.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The U.S. is facing an opioid epidemic, but despite mandates for pharmacotherapy for opioid use disorder to be available at Veterans Health Administration (VHA) facilities, the majority of veterans with opioid use disorder do not receive these medications. In implementation research, facilities are often targeted for qualitative inquiry or quality improvement efforts based on quality measure performance during a one-year period. However, sites that experience quality performance changes from one year to the next may be highly informative because mechanisms that impact facility change may be more discoverable. The current study examined changes in receipt of pharmacotherapy for opioid use disorder in a national healthcare system to determine the extent to which sites fluctuated in performance over a two-year period and illustrate how changes in quality measures over time may be useful for implementation research and healthcare surveillance of quality measures. METHODS Using national VHA data from Fiscal Years (FY) 2016 and 2017, we calculated quality measure performance as the number of patients who received pharmacotherapy for opioid use disorder (i.e., methadone, buprenorphine, and naltrexone) divided by the number of patients with a current non-remitted opioid use disorder diagnosis for each FY at each facility (n = 129) and examined change from FY16 to FY17. RESULTS The mean rate of receipt of pharmacotherapy for opioid use disorder was 38% (facility range = 3% to 74%) in FY16 and 41% (facility range = 2% to 76%) in FY17. The average facility-level change in performance was 3% and ranged from -19% to 26%. There were 32 facilities that decreased in provision of pharmacotherapy, 12 facilities with no change, and 85 facilities that increased. CONCLUSIONS For facilities with average or high performance, it was difficult to maintain their performance over time. Identifying and learning from facilities with recent fluctuations may be more informative to guide the design of future quality improvement efforts than studying facilities with stable high or low performance.
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Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066, USA; Division of General Internal Medicine, University of Colorado School of Medicine 12631 E. 17(th) Ave., Academic Office One, Campus Box B180, Aurora, CO 80045, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Medicine, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, 200 Springs, Bedford, MA 01730, USA.
| | - Matthew A Stimmel
- Veterans Justice Outreach Program, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Mengfei Yu
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Tom Bowe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, Stanford, CA 94305-2200, USA.
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Finlay AK, Wong JJ, Ellerbe LS, Rubinsky A, Gupta S, Bowe TR, Schmidt EM, Timko C, Burden JL, Harris AHS. Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs. J Stud Alcohol Drugs 2018; 79:909-917. [PMID: 30573022 PMCID: PMC6308173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/23/2018] [Indexed: 01/29/2024] Open
Abstract
OBJECTIVE Despite evidence of effectiveness, pharmacotherapy-methadone, buprenorphine, or naltrexone-is prescribed to less than 35% of Veterans Health Administration (VHA) patients diagnosed with opioid use disorder (OUD). Among veterans whose OUD treatment is provided in VHA residential programs, factors influencing pharmacotherapy implementation are unknown. We examined barriers to and facilitators of pharmacotherapy for OUD among patients diagnosed with OUD in VHA residential programs to inform the development of implementation strategies to improve medication receipt. METHOD VHA electronic health records and program survey data were used to describe pharmacotherapy provided to a national cohort of VHA patients with OUD in residential treatment programs (N = 4,323, 6% female). Staff members (N = 63, 57% women) from 44 residential programs (response rate = 32%) participated in interviews. Barriers to and facilitators of pharmacotherapy for OUD were identified from transcripts using thematic analysis. RESULTS Across all 97 residential treatment programs, the average rate of pharmacotherapy for OUD was 21% (range: 0%-67%). Reported barriers included provider or program philosophy against pharmacotherapy, a lack of care coordination with nonresidential treatment settings, and provider perceptions of low patient interest or need. Facilitators included having a prescriber on staff, education and training for patients and staff, and support from leadership. CONCLUSIONS Contrary to our hypothesis, barriers to and facilitators of pharmacotherapy for OUD in VHA residential treatment programs were consistent with prior research in outpatient settings. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VHA providers, may help improve receipt of pharmacotherapy for OUD.
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Affiliation(s)
- Andrea K. Finlay
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
- National Center on Homelessness Among Veterans, Department of Veterans Affairs, Menlo Park, California
| | - Jessie J. Wong
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
- Center on Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Laura S. Ellerbe
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Anna Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco and VA San Francisco Health Care System, San Francisco, California
| | - Shalini Gupta
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Thomas R. Bowe
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Eric M. Schmidt
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
- Center on Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Christine Timko
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Jennifer L. Burden
- Department of Veterans Affairs, Veterans Health Administration, Salem, Virginia
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Emergency Physicians' Perception of Barriers and Facilitators for Adopting an Opioid Prescribing Guideline in Ohio: A Qualitative Interview Study. J Emerg Med 2018; 56:15-22. [PMID: 30342861 DOI: 10.1016/j.jemermed.2018.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/02/2018] [Accepted: 09/01/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Ohio has the fifth highest rate of prescription opioid overdose deaths in the United States. One strategy implemented to address this concern is a state-wide opioid prescribing guideline in the emergency department (ED). OBJECTIVE Our aim was to explore emergency physicians' perceptions on barriers and strategies for the Ohio ED opioid prescribing guideline. METHODS Semi-structured interviews with emergency physicians in Ohio were conducted from October to December 2016. Emergency physicians were recruited through the American College of Emergency Physicians Ohio State Chapter. The interview guide explored issues related to the implementation of the guidelines. Interview data were transcribed and thematically analyzed and coded using a scheme of inductively determined labels. RESULTS In total, we conducted 20 interviews. Of these, 11 were also the ED medical director at their institution. Main themes we identified were: 1) increased organizational responsibility, 2) improved prescription drug monitoring program (PDMP) integration, 3) concerns regarding patient satisfaction scores, and 4) increased patient involvement. In addition, some physicians wanted the guidelines to contain more clinical information and be worded more strongly against opioid prescribing. Emergency physicians felt patient satisfaction scores were perceived to negatively impact opioid prescribing guidelines, as they may encourage physicians to prescribe opioids. Furthermore, some participants reported that this is compounded if the emergency physicians' income was linked to their patient satisfaction score. CONCLUSIONS Emergency physicians interviewed generally supported the state-wide opioid prescribing guideline but felt hospitals needed to take additional organizational responsibility for addressing inappropriate opioid prescribing.
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Abstract
OBJECTIVE Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment. METHOD The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment. RESULTS Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance? CONCLUSIONS High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
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Affiliation(s)
- Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, MIRECC 151D, West Haven, CT 06516, 203-932-5711 x 7403,
| | - Roger D. Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill St. Belmont, MA 02478, 617-855-2242, , Department of Psychiatry, Harvard Medical School, Boston, MA 02215
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Stumbo SP, Yarborough BJH, McCarty D, Weisner C, Green CA. Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement. J Subst Abuse Treat 2017; 73:47-54. [PMID: 28017184 PMCID: PMC5193128 DOI: 10.1016/j.jsat.2016.11.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 10/20/2016] [Accepted: 11/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Risk factors associated with developing opioid use disorders (OUD) are documented, but less is known about different pathways to initiation of opioids or opioid dependence, or how such pathways affect treatment engagement. METHODS We recruited 283 adults with electronic medical record (EMR) evidence of opioid dependence diagnoses. Open-ended and structured interview items focused on prior opioid treatment experiences, barriers to and knowledge of treatment options. Interviews were audio-recorded, transcribed, and coded. In exploratory analyses, we used a modified grounded theory approach to organize emergent, patient-reported themes describing participants' perceived pathways to opioid dependence. RESULTS 121 participants described one or more pathways to OUD. Qualitative analyses revealed five pathway themes. Three pathways were related to pain control: inadequately controlled chronic pain, exposure to opioids during acute pain episodes, and chronic pain among individuals with prior substance use disorders. A fourth pathway included individuals for whom opioids provided relief from emotional distress; the fifth related to recreational or non-medically supervised opioid use. We identified pain-related barriers to reducing/stopping opioids and treatment engagement barriers among individuals who perceived themselves solely as pain patients. CONCLUSION Patients' perceptions of inadequately controlled pain, patients' previous substance use disorders, and the relief from emotional distress that some patients feel while using opioids are relevant when making clinical decisions about whether to initiate or sustain opioid therapy, and for how to monitor certain individuals. Among individuals with pain and OUD, treatment barriers include fear of uncontrolled pain, and stigmatization of being treated alongside people with non-medical opioid use.
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Affiliation(s)
- Scott P Stumbo
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA.
| | - Bobbi Jo H Yarborough
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA.
| | - Dennis McCarty
- OHSU/PSU School of Public Health, Oregon Health & Science University, 3181 S.W. Sam Jackson Hill Road, CB 669, Portland, OR 97239, USA.
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway Ave., Oakland, CA 94612, USA; Department of Psychiatry, University of California, San Francisco, 401 Parnassus, Box 0984, San Francisco, 94143, USA.
| | - Carla A Green
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA.
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Liang S, Kegler MC, Cotter M, Emily P, Beasley D, Hermstad A, Morton R, Martinez J, Riehman K. Integrating evidence-based practices for increasing cancer screenings in safety net health systems: a multiple case study using the Consolidated Framework for Implementation Research. Implement Sci 2016; 11:109. [PMID: 27485452 PMCID: PMC4970264 DOI: 10.1186/s13012-016-0477-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Implementing evidence-based practices (EBPs) to increase cancer screenings in safety net primary care systems has great potential for reducing cancer disparities. Yet there is a gap in understanding the factors and mechanisms that influence EBP implementation within these high-priority systems. Guided by the Consolidated Framework for Implementation Research (CFIR), our study aims to fill this gap with a multiple case study of health care safety net systems that were funded by an American Cancer Society (ACS) grants program to increase breast and colorectal cancer screening rates. The initiative funded 68 safety net systems to increase cancer screening through implementation of evidence-based provider and client-oriented strategies. Methods Data are from a mixed-methods evaluation with nine purposively selected safety net systems. Fifty-two interviews were conducted with project leaders, implementers, and ACS staff. Funded safety net systems were categorized into high-, medium-, and low-performing cases based on the level of EBP implementation. Within- and cross-case analyses were performed to identify CFIR constructs that influenced level of EBP implementation. Results Of 39 CFIR constructs examined, six distinguished levels of implementation. Two constructs were from the intervention characteristics domain: adaptability and trialability. Three were from the inner setting domain: leadership engagement, tension for change, and access to information and knowledge. Engaging formally appointed internal implementation leaders, from the process domain, also distinguished level of implementation. No constructs from the outer setting or individual characteristics domain differentiated systems by level of implementation. Conclusions Our study identified a number of influential CFIR constructs and illustrated how they impacted EBP implementation across a variety of safety net systems. Findings may inform future dissemination efforts of EBPs for increasing cancer screening in similar settings. Moreover, our analytic approach is similar to previous case studies using CFIR and hence could facilitate comparisons across studies. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0477-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shuting Liang
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Michelle C Kegler
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Megan Cotter
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Phillips Emily
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Derrick Beasley
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - April Hermstad
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Rentonia Morton
- Statistics and Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., 250 Williams St., Atlanta, GA, 30303, USA
| | - Jeremy Martinez
- Statistics and Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., 250 Williams St., Atlanta, GA, 30303, USA
| | - Kara Riehman
- Statistics and Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., 250 Williams St., Atlanta, GA, 30303, USA
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A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci 2016; 11:72. [PMID: 27189233 PMCID: PMC4869309 DOI: 10.1186/s13012-016-0437-z] [Citation(s) in RCA: 628] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/06/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND In 2009, Damschroder et al. developed the Consolidated Framework for Implementation Research (CFIR), which provides a comprehensive listing of constructs thought to influence implementation. This systematic review assesses the extent to which the CFIR's use in implementation research fulfills goals set forth by Damschroder et al. in terms of breadth of use, depth of application, and contribution to implementation research. METHODS We searched Scopus and Web of Science for publications that cited the original CFIR publication by Damschroder et al. (Implement Sci 4:50, 2009) and downloaded each unique result for review. After applying exclusion criteria, the final articles were empirical studies published in peer-review journals that used the CFIR in a meaningful way (i.e., used the CFIR to guide data collection, measurement, coding, analysis, and/or reporting). A framework analysis approach was used to guide abstraction and synthesis of the included articles. RESULTS Twenty-six of 429 unique articles (6 %) met inclusion criteria. We found great breadth in CFIR application; the CFIR was applied across a wide variety of study objectives, settings, and units of analysis. There was also variation in the method of included studies (mixed methods (n = 13); qualitative (n = 10); quantitative (n = 3)). Depth of CFIR application revealed some areas for improvement. Few studies (n = 3) reported justification for selection of CFIR constructs used; the majority of studies (n = 14) used the CFIR to guide data analysis only; and few studies investigated any outcomes (n = 11). Finally, reflections on the contribution of the CFIR to implementation research were scarce. CONCLUSIONS Our results indicate that the CFIR has been used across a wide range of studies, though more in-depth use of the CFIR may help advance implementation science. To harness its potential, researchers should consider how to most meaningfully use the CFIR. Specific recommendations for applying the CFIR include explicitly justifying selection of CFIR constructs; integrating the CFIR throughout the research process (in study design, data collection, and analysis); and appropriately using the CFIR given the phase of implementation of the research (e.g., if the research is post-implementation, using the CFIR to link determinants of implementation to outcomes).
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Methadone, buprenorphine and preferences for opioid agonist treatment: A qualitative analysis. Drug Alcohol Depend 2016; 160:112-8. [PMID: 26796596 PMCID: PMC4767611 DOI: 10.1016/j.drugalcdep.2015.12.031] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/19/2015] [Accepted: 12/21/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients and clinicians have begun to recognize the advantages and disadvantages of buprenorphine relative to methadone, but factors that influence choices between these two medications remain unclear. For example, we know little about how patients' preferences and previous experiences influence treatment decisions. Understanding these issues may enhance treatment engagement and retention. METHODS Adults with opioid dependence (n=283) were recruited from two integrated health systems to participate in interviews focused on prior experiences with treatment for opioid dependence, knowledge of medication options, preferences for treatment, and experiences with treatment for chronic pain in the context of problems with opioids. Interviews were audio-recorded, transcribed verbatim, and coded using Atlas.ti. RESULTS Our analysis revealed seven areas of consideration for opioid agonist treatment decision-making: (1) awareness of treatment options; (2) expectations and goals for duration of treatment and abstinence; (3) prior experience with buprenorphine or methadone; (4) need for accountability and structured support; (5) preference to avoid methadone clinics or associated stigma; (6) fear of continued addiction and perceived difficulty of withdrawal; and (7) pain control. CONCLUSION The availability of medication options increases the need for clear communication between clinicians and patients, for additional patient education about these medications, and for collaboration and patient influence over choices in treatment decision-making. Our results suggest that access to both methadone and buprenorphine will increase treatment options and patient choice and may enhance treatment adherence and outcomes.
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Edelman EJ, Hansen NB, Cutter CJ, Danton C, Fiellin LE, O'Connor PG, Williams EC, Maisto SA, Bryant KJ, Fiellin DA. Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics. Addict Sci Clin Pract 2016; 11:1. [PMID: 26763048 PMCID: PMC4711105 DOI: 10.1186/s13722-015-0048-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022] Open
Abstract
Background
Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists. Methods We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes. Results From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention. Conclusions Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Nathan B Hansen
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA. .,College of Public Health, University of Georgia, 131 Wright Hall, Health Sciences Campus, Athens, GA, 30602, USA.
| | - Christopher J Cutter
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Cheryl Danton
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Lynn E Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Patrick G O'Connor
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Emily C Williams
- VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA, 98101, USA. .,Department of Health Services, University of Washington, 1959 NE Pacific Street, Magnuson Health Sciences Center, Room H-664, Seattle, WA, 98195, USA.
| | - Stephen A Maisto
- Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244, USA.
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, 5635 Fishers Lane, Bethesda, MD, 20892-7003, USA.
| | - David A Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
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Varsi C, Ekstedt M, Gammon D, Ruland CM. Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based Patient-Provider Communication Service in Five Settings: A Qualitative Study. J Med Internet Res 2015; 17:e262. [PMID: 26582138 PMCID: PMC4704938 DOI: 10.2196/jmir.5091] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022] Open
Abstract
Background Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge. Objective The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success. Methods This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients. Results Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers’ beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies. Conclusions The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR’s strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions. ClinicalTrial Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY)
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Affiliation(s)
- Cecilie Varsi
- Center for Shared Decision Making and Collaborative Care Research, Oslo University Hospital, Oslo, Norway
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Molfenter T, Sherbeck C, Zehner M, Starr S. Buprenorphine Prescribing Availability in a Sample of Ohio Specialty Treatment Organizations. ACTA ACUST UNITED AC 2015; 4. [PMID: 26380328 DOI: 10.4172/2324-9005.1000140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Buprenorphine, a medication for treating opioid dependence, is underutilized in specialty addiction treatment organizations. Only physicians who have obtained a buprenorphine prescribing license or "waiver" may administer this medication. A limited number of physicians are pursuing this waiver, and a concern in the substance use disorder treatment field is that the shortage of prescribers could be contributing to the low use of buprenorphine at specialty addiction treatment centers. The objective of this study is to assess Ohio specialty treatment organizations' access to buprenorphine prescribers and the barriers they encounter when seeking new physician prescribing capacity. METHODS Forty-one Ohio specialty addiction treatment organizations were invited to complete a survey of their buprenorphine practices and availability of buprenorphine prescribers during August-October 2014. Data was collected on pharmacotherapies used in the treatment of opioid dependence, arrangements treatment organizations have with prescribing physicians, buprenorphine prescribing capacity, and barriers encountered in recruiting new physician prescribers. RESULTS Thirty-seven treatment organizations responded, for a response rate of 90.2%. Seventy-eight percent (n=29) of the sample provided buprenorphine therapy. Of those treatment organizations, 48.3% (n=14) reported insufficient prescribing capacity. Of those, 50% (n=7) indicated they had to turn patients away from buprenorphine therapy due to limited physician prescribing capacity. CONCLUSION The study suggests that buprenorphine use is constrained by limited physician prescribing capacity, to the degree that 24.1% of the organizations surveyed using buprenorphine therapy had to turn patients away. Potential remedies include encouraging more specialty treatment organizations to have physicians on staff, removing the Drug Addiction Treatment Act (DATA 2000) cap that limits physician buprenorphine caseloads at 100 patients (after year 1), and developing strategies to recruit physicians into addiction treatment practice. Additional research is needed to increase the knowledge of physician prescribing capacity as a barrier to buprenorphine use, how to overcome these barriers, and to understand the extent physician capacity shortages are affecting buprenorphine use.
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Affiliation(s)
| | | | - Mark Zehner
- University of Wisconsin-Madison, Wisconsin 53706, USA
| | - Sandy Starr
- Ohio Department of Mental Health and Addiction Services (OhioMHAS), Columbus, Ohio 43215, USA
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Lynch FL, McCarty D, Mertens J, Perrin NA, Green CA, Parthasarathy S, Dickerson JF, Anderson BM, Pating D. Costs of care for persons with opioid dependence in commercial integrated health systems. Addict Sci Clin Pract 2014; 9:16. [PMID: 25123823 PMCID: PMC4142137 DOI: 10.1186/1940-0640-9-16] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 06/24/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND When used in general medical practices, buprenorphine is an effective treatment for opioid dependence, yet little is known about how use of buprenorphine affects the utilization and cost of health care in commercial health systems. METHODS The objective of this retrospective cohort study was to examine how buprenorphine affects patterns of medical care, addiction medicine services, and costs from the health system perspective. Individuals with two or more opioid-dependence diagnoses per year, in two large health systems (System A: n = 1836; System B: n = 4204) over the time span 2007-2008 were included. Propensity scores were used to help adjust for group differences. RESULTS Patients receiving buprenorphine plus addiction counseling had significantly lower total health care costs than patients with little or no addiction treatment (mean health care costs with buprenorphine treatment = $13,578; vs. mean health care costs with no addiction treatment = $31,055; p < .0001), while those receiving buprenorphine plus addiction counseling and those with addiction counseling only did not differ significantly in total health care costs (mean costs with counseling only: $17,017; p = .5897). In comparison to patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care (p < .001), other medical visits (p = .001), and emergency services (p = .020). Patients with counseling only (compared to patients with buprenorphine plus counseling) used less inpatient detoxification (p < .001), and had significantly more PC visits (p = .001), other medical visits (p = .005), and mental health visits (p = .002). CONCLUSIONS Buprenorphine is a viable alternative to other treatment approaches for opioid dependence in commercial integrated health systems, with total costs of health care similar to abstinence-based counseling. Patients with buprenorphine plus counseling had reduced use of general medical services compared to the alternatives.
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Affiliation(s)
- Frances L Lynch
- Kaiser Permanente Center for Health Research, 3800 N, Interstate Avenue, Portland, OR 97227, USA.
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