Association Between Hospital Adoption of an Emergency Department Treatment Pathway for Opioid Use Disorder and Patient Initiation of Buprenorphine After Discharge

Abstract

ImportanceEmergency department (ED)–based initiation of buprenorphine has been shown to increase engagement in outpatient treatment and reduce the risk of subsequent opioid overdose; however, rates of buprenorphine treatment in the ED and follow-up care for opioid use disorder (OUD) remain low in the US. The Opioid Hospital Quality Improvement Program (O-HQIP), a statewide financial incentive program designed to increase engagement in OUD treatment for Medicaid-enrolled patients who have ED encounters, has the potential to increase ED-initiated buprenorphine treatment.ObjectiveTo evaluate the association between hospitals attesting to an ED buprenorphine treatment O-HQIP pathway and patients’ subsequent initiation of buprenorphine treatment.Design, Setting, and ParticipantsThis cohort study included Pennsylvania patients aged 18 to 64 years with continuous Medicaid enrollment 6 months before their OUD ED encounter and at least 30 days after discharge between January 1, 2016, and December 31, 2020. Patients with a claim for medication for OUD 6 months before their index encounter were excluded.ExposuresHospital implementation of an ED buprenorphine treatment O-HQIP pathway.Main Outcomes and MeasuresThe main outcome was patients’ receipt of buprenorphine within 30 days of their index OUD ED visit. Between August 2021 and January 2023, data were analyzed using a difference-in-differences method to evaluate the association between hospitals’ O-HQIP attestation status and patients’ treatment with buprenorphine after ED discharge.ResultsThe analysis included 17 428 Medicaid-enrolled patients (female, 43.4%; male, 56.6%; mean [SD] age, 37.4 [10.8] years; Black, 17.5%; Hispanic, 7.9%; White, 71.6%; other race or ethnicity, 3.0%) with OUD seen at O-HQIP–attesting or non–O-HQIP–attesting hospital EDs. The rate of prescription fills for buprenorphine within 30 days of an OUD ED discharge in the O-HQIP attestation hospitals before the O-HQIP intervention was 5%. The O-HQIP attestation was associated with a statistically significant increase (2.6 percentage points) in prescription fills for buprenorphine within 30 days of an OUD ED discharge (β, 0.026; 95% CI, 0.005-0.047).Conclusions and RelevanceIn this cohort study, the O-HQIP was associated with an increased initiation of buprenorphine in patients with OUD presenting to the ED. These findings suggest that statewide incentive programs may effectively improve outcomes for patients with OUD.

Improving emergency department care for adults presenting with mental illness: a systematic review of strategies and their impact on outcomes, experience, and performance

“…Eleven of the 46 articles reported on strategies focusing on substance-related and addictive disorder presentations ( Table 2 ). Four types of strategies were evaluated, including the ED-initiated Medications for Opioid Use Disorder (MOUD) model of care ( 42 – 45 , 49 – 52 ), decision support tools ( 42 , 46 , 47 ), ED-initiated social support model of care ( 48 ), and discharge and transfer of care ( 42 , 46 ). Overall, the ED-initiated MOUD model of care reported effects across all four domains of interest; however, not one study reported on all four.…”

“…This systematic review found illness-specific strategies oriented to longer-term care delivery beyond the ED, and general mental illness interventions oriented to process improvements. Substance-related and addictive disorder interventions focused on the initiation of initial dose (e.g., buprenorphine or naloxone) with take home doses and clinic follow-up ( 42 – 45 , 49 – 52 ). Similarly, strategies for suicide and deliberate self-harm presentations focused on assessment, care plan development and connecting with community-based support ( 53 – 55 , 58 – 61 ).…”

“…One of the eight articles also included a private hospital (42). Three of the 11 studies did not report the type of participating hospital (48,50,52). Eight of the 11 articles were conducted in urban settings (43,44,(46)(47)(48)(49)(50)(51), with one reporting an additional rural site (49).…”

“…Eight of the 11 articles were conducted in urban settings (43,44,(46)(47)(48)(49)(50)(51), with one reporting an additional rural site (49). Three of the 11 studies did not report the setting as either urban or rural (42, 45,52). Three articles reported that the participating EDs were connected with psychiatric crisis centres or psychiatric EDs (44,45,47).…”