Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration

Abstract

Background Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. Methods Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. Results Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4–12.4) and 9.9% increase (95% CI 3.6–16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. Conclusions Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

Comparison of Substance Use Disorder Diagnosis Rates From Electronic Health Record Data With Substance Use Disorder Prevalence Rates Reported in Surveys Across Sociodemographic Groups in the Veterans Health Administration

“…The US Veterans Health Administration (VHA) is the largest integrated health care system 16 offering a critical population for examining SUD diagnoses because SUD is common among veterans, 17 improving SUD care is a priority, and the VHA—like other systems—uses care quality metrics that rely on clinically documented SUD diagnoses for quality improvement. 18 In a large, diverse sample of VHA patients, we compared clinically documented diagnosis rates of AUD, DUD, and total SUD (AUD and/or DUD) with the prevalence rates estimated by a structured, validated diagnostic assessment across demographic subgroups.…”

What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities

“…Following the site visit, facilities received 12 months of external facilitation which included monthly coaching calls, cross-facility quarterly community of practice calls, and as-needed consultation to work on goals set during the site visit. 12 Since a single VA facility is made up of one large medical center and smaller community-based outpatient clinics, goals could include changes within the medical center and/or outpatient clinics. After 12 months, each facility participated in an interpretive formative evaluation which included semi-structured interviews.…”

“…Furthermore, they believed that rurality challenged the ability to hire and retain staff with the appropriate knowledge and credentials. 12 After 12 months, there was a significant increase in the ratio of patients with OUD receiving MOUD at the intervention facilities, rising from an average of 18% to 30%. 11 While the external facilitation intervention effectively improved MOUD access during the implementation phase, it was time-limited and facilities’ ability to sustain their gains without study resources was unknown.…”

Expanding access to medications for opioid use disorder through locally-initiated implementation

“…A wide array of implementation strategies have guided efforts to overcome these barriers to MOUD access, with most centered around externally-facilitated approaches to practice change [ 3 , 4 , 10 , 15 , 22 – 24 ]. Implementation strategies targeting barriers identified at the individual level (e.g., lack of medication or addiction-treatment knowledge, stigmatized beliefs, training requirements) and clinic-level (e.g., staffing, space, referral process) have included implementation facilitation, consult services and coaching, academic detailing, outreach visits, designating a champion and team based approaches to MOUD provision [ 3 , 15 , 22 , 23 , 25 ].…”