Implementing alcohol use disorder pharmacotherapy in primary care settings: a qualitative analysis of provider-identified barriers and impact on implementation outcomes

Abstract

Background: Despite the high prevalence of alcohol use disorders (AUDs), in 2016, only 7.8% of individuals meeting diagnostic criteria received any type of AUD treatment. Developing options for treatment within primary care settings is imperative to increase treatment access. As part of a trial to implement AUD pharmacotherapy in primary care settings, this qualitative study analyzed pre-implementation provider interviews using the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. Methods: Three large Veterans Health Administration facilities participated in the implementation intervention. Local providers were trained to serve as implementation/clinical champions and received external facilitation from the project team. Primary care providers received a dashboard of patients with AUD for case identification, educational materials, and access to consultation from clinical champions. Veterans with AUD diagnoses received educational information in the mail. Prior to the start of implementation activities, 24 primary care providers (5-10 per site) participated in semi-structured interviews. Transcripts were analyzed using common coding techniques for qualitative data using the CFIR codebook Innovation/Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals domains. Number and type of barriers identified were compared to quantitative changes in AUD pharmacotherapy prescribing rates. Results: Four major barriers emerged across all three sites: complexity of providing AUD pharmacotherapy in primary care, the limited compatibility of AUD treatment with existing primary care processes, providers' limited knowledge and negative beliefs about AUD pharmacotherapy and providers' negative attitudes toward patients with AUD. Site specific barriers included lack of relative advantage of providing AUD pharmacotherapy in primary care over current practice, complaints about the design quality and packaging of implementation intervention materials, limited priority of addressing AUD in primary care and limited available resources to implement AUD pharmacotherapy in primary care. Conclusions: CFIR constructs were useful for identifying pre-implementation barriers that informed refinements to the implementation intervention. The number and type of pre-implementation barriers identified did not

The role of clinical champions in facilitating the use of evidence-based practice in drug and alcohol and mental health settings: A systematic review

“…One study described champions as being important in the initial adoption of an intervention, and as clinician self-efficacy increased, clinician experiences and that of colleagues became more important to sustained use (Green et al, 2014). In addition, the importance of stability in the clinical champion role as determining its effectiveness was also observed (Hagedorn et al, 2019). One study found that a change in the clinical champion in the implementation phase became a barrier to adoption, and immediately affected degree of implementation (Forchuk et al, 2013).…”

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study

“…31 The primary intervention characteristic barrier found in prior research is complexity. 28,29,32 Outer setting characteristics enabling intervention implementation in healthcare settings include the following: relationships between the healthcare organization and other organizations 31 and the presence of best practice examples in other healthcare organizations. 28 No outer setting barriers have been identified in CFIR research in the preparation phase.…”

“…28 Inner setting characteristics identified as barriers to interventions were: competing organizational priorities 29,31 and perceived lack of compatibility with existing work routines and technology systems. 32 Characteristics of individuals identified as facilitators in healthcare settings include the following: knowledge and beliefs about the intervention, 28 self-efficacy 29 and a sense of belonging among the staff. 31 Individual characteristic barriers include the following: resistance to new routines, 28 limited knowledge or negative attitudes about the intervention, 30,32,33 and turnover.…”

“…32 Characteristics of individuals identified as facilitators in healthcare settings include the following: knowledge and beliefs about the intervention, 28 self-efficacy 29 and a sense of belonging among the staff. 31 Individual characteristic barriers include the following: resistance to new routines, 28 limited knowledge or negative attitudes about the intervention, 30,32,33 and turnover. 29 The only process factor identified as a facilitator was a stepwise rollout.…”

The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness

“…(14) Finally, the fth domain focuses on the implementation process, such as the role of engagement and evaluation. (14) CFIR has been applied to the eld of smoking cessation (17,18) and substance use disorders, (19,20) but has not been utilized to understand the unique characteristics of smoking behavior change among those living with homelessness.…”