Implementation facilitation to promote emergency department-initiated buprenorphine for opioid use disorder: protocol for a hybrid type III effectiveness-implementation study (Project ED HEALTH)

Abstract

Background Patients with opioid use disorder (OUD) frequently present to the emergency department (ED) after overdose, or seeking treatment for general medical conditions, their addiction, withdrawal symptoms, or complications of injection drug use, such as soft tissue infections. ED-initiated buprenorphine has been shown to be effective in increasing patient engagement in treatment compared with brief intervention with a facilitated referral or referral alone. However, adoption into practice has lagged behind need. To address this implementation challenge, we are evaluating the impact of implementation facilitation (IF) on the adoption of ED-initiated buprenorphine for OUD into practice. Methods This protocol describes a study that is being conducted through the National Institute on Drug Abuse’s Center for the Clinical Trials Network. A hybrid type III effectiveness-implementation study design is used to evaluate the effectiveness of a standard educational dissemination strategy versus IF on implementation (primary) and effectiveness (secondary) outcomes in four urban, academic EDs. Sites start with a standard 60-min “Grand Rounds” educational intervention describing the prevalence of ED patients with OUD, the evidence for opioid agonist treatment and for innovative interventions with ED-initiated buprenorphine; followed by a 1-year baseline evaluation period. Using a modified stepped wedge design, sites are randomly assigned to the IF intervention which is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess evidence, context, and facilitation-related factors impacting the adoption of ED-initiated buprenorphine. During the 6 months of IF through the 1-year IF evaluation period, external facilitators work with local stakeholders to tailor and refine a bundle of activities to meet the site’s needs. The primary analyses compare the baseline evaluation period to the IF evaluation period ( n = 120 patients with untreated OUD enrolled during each period) on (1) rates of provision of ED-initiated buprenorphine by ED providers with referral for ongoing medication (implementation outcome) and (2) rates of patient engagement in addiction treatment on the 30th day after the ED visit (effectiveness outcome). Finally, we will perform a cost-effectiveness analysis (CEA) to determine if the effectiveness benefits are worth the additional costs. Discussion Results will generate novel information regarding the impact of IF as a strategy to promote ED-initiated buprenorphine. Trial registration ClinicalTrials.gov NCT03023930 first posted 1/10/2017, https://clinicaltrials.gov/ct2/show/NCT03023930?term=0069&rank=1 Electronic supplementary material The online version of this article (10.1186/s13012-019-0891-5) contains supplementary material, which is available to authorized users.

Interrupted Time Series of User‐centered Clinical Decision Support Implementation for Emergency Department–initiated Buprenorphine for Opioid Use Disorder

“…More in-depth qualitative analyses of implementation barriers are under way in four additional urban, academic EDs to determine additional ways to promote adoption of ED initiation of BUP. 41 The decision to incorporate training as part of the intervention turned out to be one of the study's strengths. Although not statistically significant, increased rates of the primary outcome with one-on-one training component suggests that this feature of the intervention is necessary to increase user recognition of its presence and value.…”

Barriers and Facilitators to Clinician Readiness to Provide Emergency Department–Initiated Buprenorphine

“…Project ED Health is being conducted in 4 academic, urban EDs in Baltimore, Maryland (annual visit volume, >70 000), New York, New York (annual visit volume, >90 000), Cincinnati, Ohio (annual Downloaded From: https://jamanetwork.com/ on 11/02/2020 visit volume, >75 000), and Seattle, Washington (annual visit volume, >60 000). 18 Clinicians who were potential ED-based buprenorphine prescribers, including attending physicians, residents, and APCs (inclusive of physician assistants and nurse practitioners), and who had been employed at the respective EDs for at least 6 months before the study onset (n = 396) were invited to participate.…”

“…31 and resources needed to implement this practice. 18,32 All focus groups were digitally recorded and transcribed.…”

<p>Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions</p>

“…A significant gap in providing ED-based induction still remains: one analysis suggested that only one in three patients who had screened positive for OUD actually receive effective treatment for OUD. 14 This review summarizes the evidence and best practices for initiating buprenorphine treatment for OUDs in the ED. We also identify barriers to implementing EDbased buprenorphine induction, limitations in the extant literature, and opportunities for enhancing the care of these patients in the ED.…”