Background: Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. We describe barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings. Methods: We conducted a quality improvement project aimed at increasing the availability of medications for OUD (MOUD) to Veterans. This project focused on tele-prescribing buprenorphine to rural sites via a hub (centralized prescribers) and spoke (rural clinics) model. After soliciting a wide-range of inputs from site visits, qualitative interviews of key stakeholders at rural sites, and review of preliminary cases, a “how-to” toolkit was developed and iteratively refined to guide tele-prescribing of buprenorphine. After internal and external facilitation strategies were employed, Veterans with OUD at three clinics were transitioned to buprenorphine treatment via telemedicine. Results: Factors impacting adoption of the tele-prescribing intervention were mapped to the Consolidated Framework for Implementation Research (CFIR) constructs. Barriers to adoption included concerns about legality of tele-prescribing a controlled substance, conflicting interests between different stakeholders, and coordination with an existing buprenorphine program requiring more attendance and abstinence from Veterans than the tele-prescribing program required. Factors facilitating adoption included a sense of mission around combating the opioid epidemic, preexisting use of and comfort with tele-prescribing, and rural sites’ control over Veterans referred to tele-prescribers. A total of 12 patients from rural areas were successfully transitioned onto buprenorphine, of whom 9 remained on buprenorphine 6 months after initiation of treatment. Conclusions: Implementing tele-prescribing was negotiated with stakeholders at the target clinics and operationalized in a toolkit to guide future efforts. Implementation issues can be addressed by activities that foster collaboration between hubs (centralized prescribers) and spokes (rural clinics) and by a toolkit that operationalizes tele-prescribing procedures.

No abstract

Purpose The purpose of this umbrella review was to synthesize the evidence from published systematic reviews on the effectiveness of text message programs for adults with type 2 diabetes (T2DM) on glycemic management (A1C), self-management, and other clinical outcomes. The effect of directionality of the program was also explored. Methods A systematic search was conducted using multiple databases. Inclusion criteria were systematic review of text message programs for adults with T2DM, evaluated A1C, and English language. Quality assessment was completed using AMSTAR-2 guidelines. Data were extracted by multiple coders, and results were synthesized. Results The final sample included 9 systematic reviews published between 2011 and 2019, with 72 unique international studies. Text message programs focused on diabetes self-management and reducing health risks through educational and motivational content with some providing personalized feedback. A meta-analysis of program effect on A1C was conducted in 5 reviews with a pooled difference in A1C from −0.38% to −0.8%. Adults with T2DM of shorter duration and lower A1C had better treatment effects. Evidence on unidirectional versus bidirectional programs is conflicting; however, both improve outcomes. Evidence of text message programs targeting medication engagement was inconclusive. Some programs improved blood pressure, lipids, self-management, self-efficacy, and health behaviors. High satisfaction and an average of 9.6% to 18.7% attrition was reported. Conclusions Text messaging programs can improve T2DM outcomes, are a highly accessible mode of communication, are relatively inexpensive, and are an underutilized adjunct to clinical care.

No abstract