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Mahal JJ, Bijur P, Sloma A, Starrels J, Lu T. Addressing System and Clinician Barriers to Emergency Department-initiated Buprenorphine: An Evaluation of Post-intervention Physician Outcomes. West J Emerg Med 2024; 25:303-311. [PMID: 38801034 PMCID: PMC11112658 DOI: 10.5811/westjem.18320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 05/29/2024] Open
Abstract
Introduction Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions. Methods This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience. Results Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively). Conclusion Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.
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Affiliation(s)
- Jacqueline J Mahal
- Jacobi Medical Center, Department of Emergency Medicine, Bronx, New York
- Albert Einstein College of Medicine, Department of Emergency Medicine, Bronx, New York
| | - Polly Bijur
- Albert Einstein College of Medicine, Department of Emergency Medicine, Bronx, New York
| | - Audrey Sloma
- Jacobi Medical Center, Department of Emergency Medicine, Bronx, New York
| | - Joanna Starrels
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine, Bronx, New York
| | - Tiffany Lu
- Jacobi Medical Center, Department of Psychiatry & Behavioral Sciences, Bronx, New York
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Hu T, McCormack D, Juurlink DN, Campbell TJ, Bayoumi AM, Leece P, Kent JT, Gomes T. Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario. CMAJ 2023; 195:E1709-E1717. [PMID: 38110219 PMCID: PMC10727793 DOI: 10.1503/cmaj.231014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Emergency department visits and hospital admissions for opioid toxicity are opportunities to initiate opioid agonist therapy (OAT), which reduces morbidity and mortality in patients with opioid use disorder (OUD). The study objectives were to evaluate OAT initiation rates after a hospital encounter for opioid toxicity in Ontario, Canada, and determine whether publication of a 2018 Canadian OUD management guideline was associated with increased initiation. METHODS We conducted a retrospective, population-based serial cross-sectional study of hospital encounters for opioid toxicity among patients with OUD between Jan. 1, 2013, and Mar. 31, 2020, in Ontario, Canada. The primary outcome was OAT initiation (methadone, buprenorphine-naloxone, or slow-release oral morphine) within 7 days of discharge, measured quarterly. We examined the impact of the release of the OUD management guideline on OAT initiation rates using Autoregressive Integrated Moving Average models. RESULTS Among 20 702 hospital visits for opioid toxicity among patients with OUD, the median age was 35 years, and 65.1% were male. Over the study period, the percentage of visits leading to OAT initiation within 7 days rose from 1.7% or less (Q1 2013) to 5.6% (Q1 2020); however, the publication of the Canadian OUD management guideline was not associated with a significant increase in these rates (0.14% slope change, 95% confidence interval -0.11% to 0.38%; p = 0.3). INTERPRETATION Among hospital encounters for opioid toxicity, despite rising prevalence over time, only 1 in 18 patients were dispensed OAT within a week of discharge in early 2020. These findings highlight missed opportunities to initiate therapies proven to reduce mortality in patients with OUD.
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Affiliation(s)
- Tina Hu
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Daniel McCormack
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - David N Juurlink
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Tonya J Campbell
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Ahmed M Bayoumi
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Pamela Leece
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Jessica T Kent
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont
| | - Tara Gomes
- Department of Family and Community Medicine (Hu, Leece), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Family Medicine (Hu), McMaster University, Hamilton, Ont.; ICES (McCormack, Juurlink, Kent, Gomes), Toronto, Ont.; Sunnybrook Research Institute (Juurlink); MAP Centre for Urban Health Solutions (Campbell, Bayoumi, Gomes), Li Ka Shing Knowledge Institute of St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Bayoumi, Gomes), University of Toronto; Health Promotion, Chronic Disease and Injury Prevention (Leece), Public Health Ontario; Department of Emergency Medicine (Kent), University of Toronto, Toronto, Ont.
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