Veterans Affairs initiative increases prescribing of medications for OUD
A multifaceted implementation initiative in nonaddiction clinics in the U.S. Veterans Affairs' health system appeared to increase prescribing of medications for opioid use disorder, according to study results published in JAMA Network Open.
“Despite several U.S. Department of Veteran Affairs (VA) initiatives to increase access to [medications for opioid use disorder (MOUD)], in 2017 a total of 35% of patients with an OUD in the VA health care system received MOUD, largely from [substance use disorder] specialty care,” Eric J. Hawkins, PhD, of the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, and colleagues wrote. “To enhance [medications for OUD] access, in 2018 the VA developed and implemented the Stepped Care for Opioid Use Disorder Train-the-Trainer (SCOUTT) initiative. SCOUTT aimed to improve access to MOUD, specifically buprenorphine and injectable naltrexone, in primary care, pain and mental health clinics, using a multifaceted implementation intervention.”
The researchers aimed to examine SCOUTT via a quality improvement initiative that incorporated interrupted time series design to compare trends in receiving medications for OUD. They matched 35 VA primary care, pain and mental health clinics and 35 nonintervention comparison clinics on pre-implementation medication for OUD prescribing trends, clinic size and facility complexity. Specifically, they analyzed data of patients with OUD who received care in these clinics in the year after Sept. 1, 2018, with the pre-implementation period ranging between Sept. 1, 2017, and August 31, 2018, and the postimplementation period ranging between Sept. 1, 2018, and August 31, 2019. Education, external facilitation and quarterly reports were included in the multifaceted implementation intervention. The proportion of patients who received medications for OUD and the number of patients per clinician prescribing these medications served as the main outcomes. Via segmented logician regression that adjusted for demographic and clinical covariates, the researchers evaluated monthly proportions of medications for OUD receipt 1 year before and after implementation of the initiative. They assessed yearly changes in clinician prescribing over the same frame using Poisson regression models.
A total of 7,488 patients (mean age, 53.3 years; 91.6% men) received care at intervention clinics and 7,558 patients (mean age, 53.4 years; 91.9% men) at comparison clinics. Results showed a monthly increase of 5% (adjusted OR = 1.05; 95% CI, 1.03-1.07) in the proportion of patients who received medications for OUD in intervention clinics during the pre-implementation year. The researchers accounted for this pre-implementation trend and noted an additional monthly increase of 2.3% (aOR = 1.02; 95% CI, 1-1.04) in the proportion of patients who received medications for OUD during the implementation year. Before implementation, comparison clinics showed a monthly increase of 2.6% (aOR = 1.03; 95% CI, 1.01-1.04), with Hawkins and colleagues reporting no changes after implementation. They noted greater increases in intervention clinics after implementation (aOR = 1.04; 95% CI, 1.01-1.08), despite trends during the pre-implementation year in monthly medications for OUD receipt appearing similar between intervention and comparison clinics. Patients who received medications for OUD per clinician in intervention clinics exhibited greater increases from before to after implementation vs. comparison clinics (incidence rate ratio = 1.5; 95% CI, 1.28-1.77).
“Implementing SCOUTT-like initiatives in clinics with infrastructure to support MOUD prescribing may assist health care systems in reaching patients who do not access traditional OUD treatment,” Hawkins and colleagues wrote. “Future investigations will determine whether specific implementation strategies are more effective for certain clinic types and patient populations.”