Developing an opioid use disorder treatment cascade: A review of quality measures

Abstract

Background Despite increasing opioid overdose mortality, problems persist in the availability and quality of treatment for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and naltrexone) have high quality evidence supporting their use, but most individuals with OUD do not receive them and many experience relapse following care episodes. Developing and organizing quality measures under a unified framework such as a Cascade of Care could improve system level practice and treatment outcomes. In this context, a review was performed of existing quality measures relevant to the treatment of OUD and the literature assessing the utility of these measures in community practice. Methods Systematic searches of two national quality measure clearinghouses (National Quality Forum and Agency for Healthcare Research and Quality) were performed for measures that can be applied to the treatment of OUD. Measures were categorized as structural, process, or outcome measures. Second stage searches were then performed within Ovid/Medline focused on published studies investigating the feasibility, reliability, and validity of identified measures, predictors of their satisfaction, and related clinical outcomes. Results Seven quality measures were identified that are applicable to the treatment of OUD. All seven were process measures that assess patterns of service delivery. One recently approved measure addresses retention in medication-assisted treatment for patients with OUD. Twenty-nine published studies were identified that evaluate the quality measures, primarily focused on initiation and engagement in care for addiction treatment generally. Most measures and related studies do not specifically incorporate the evidence base for the treatment of OUD or assess patient level outcomes such as overdose. Conclusion Despite considerable progress, gaps exist in quality measures for OUD treatment. Development of a unified quality measurement framework such as an OUD Treatment Cascade will require further elaboration and refinement of existing measures across populations and settings. Such a framework could form the basis for applying strategies at clinical, organizational, and policy levels to expand access to quality care and reduce opioid-related mortality.

Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment

“…The Rhode Island Cascade of Care for Opioid Use Disorder provides statewide data-sharing partners and policymakers with a starting point for understanding and assessing engagement in care, a system-level "snapshot" for prioritizing the datasets that would be useful in measuring the annual state of the system [14,17,26,56]. The 2 processes of undertaking a communitydriven stakeholder process and prioritizing available datasets to populate this new model helped to operationalize and apply the cascade for the state.…”

“…With this framework informing the foundation of the adapted cascade of care, stakeholders were presented with the available measures of healthcare access and quality to represent each stage [16,17] and discussed the feasibility of using these metrics to develop a "snapshot" of the current state of the cascade of care for OUD in Rhode Island in the year 2016. This process led to additional refinements to the cascade and finalization of the operational definitions of each stage while also helping to define the target population (e.g., those experiencing OUD) and the healthcare systems and data-sharing partners for the cascade [20,26].…”

“…This process led to additional refinements to the cascade and finalization of the operational definitions of each stage while also helping to define the target population (e.g., those experiencing OUD) and the healthcare systems and data-sharing partners for the cascade [20,26]. By using national quality metrics, the cascade could be designed to enhance existing statewide policy and surveillance tools by (1) creating an annual measure of statewide engagement in care using available datasets, (2) setting targets and standards for improving linkages across stages of care, and (3) defining successful endpoints for treatment of OUD through consensus among the stakeholders [17,18,29,30].…”

“…Stage 1 represents those diagnosed with OUD. This stage is operationalized as the number of individuals with a medical claim tied to a diagnosis of OUD in a given year, based on existing national quality metrics [17].…”

“…Researchers and policymakers have called for a cascade of care framework to be applied to understand gaps in treatment engagement among those experiencing substance use disorder, and opioid use disorder (OUD) in particular [2,15,16]. Specifically, a new framework for assessing the availability and quality of care for OUD has recently been defined by Williams and colleagues using metrics defined by the National Quality Forum and the Agency for Healthcare Research and Quality [17]. Preliminary evidence suggests that improvements in health delivery processes at a system level are linked to improved health outcomes and lower mortality among patients with OUD [18].…”