2023 HSR&D/QUERI National Conference
1015 — Effect of implementation facilitation on initiation and retention on medications for opioid use disorder in a large pragmatic clinical trial
Lead/Presenter: Anne Black, COIN - West Haven
All Authors: Black AC (PRIME Center of Innovation/VA Connecticut Healthcare System, Yale School of Medicine), Zeliadt, SB (Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, University of Washington) Douglas, JH (Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System) Edmond, SN (PRIME Center of Innovation, VA Connecticut Healthcare System, Yale School of Medicine) Becker, WC (PRIME Center of Innovation, VA Connecticut Healthcare System, Yale School of Medicine)
The objective of the QUERI-funded Consortium to Disseminate and Understand Implementation of Opioid Use Disorder Treatment (CONDUIT) is to unite six inter-related pilot Partnered Implementation Initiative projects in a concerted effort to improve access to medications for opioid use disorder (MOUD) and alternative therapies for pain for Veterans with opioid use disorder (OUD) in over 50 VHA sites spanning six VISNs.
In this pragmatic clinical trial led by 9 Principal Investigators between October 2019-September 2022, internal and external implementation facilitation activities including education, guideline development, training, patient referral, and prescribing supports were conducted in VA healthcare settings across the OUD continuum of care: Primary Care, Specialty Care, Telehealth, and Acute Care (inpatient and Emergency Department). For the four projects focused on non-acute settings spanning 26 sites, CONDUITâ€™s Quantitative Outcomes Core used VA electronic health record data to assess rates of (1) MOUD initiation, defined as first MOUD dose following at least 180 days of no MOUD and (2) MOUD retention, defined as treatment adherence for >180 days, for all at-risk Veterans receiving treatment at CONDUIT-engaged sites. MOUD was identified by recorded VA prescriptions for sublingual buprenorphine or naltrexone (injectable and oral formulations), or treatment at a clinic certified to dispense methadone (stop code = 523). Veterans were eligible for MOUD initiation if they had at least one primary care visit at a CONDUIT-engaged site, had a recorded OUD diagnosis, and had not received MOUD for at least 180 days. Veterans eligible for MOUD retention were those with a MOUD prescription from a CONDUIT-engaged site that occurred at least 180 days prior to the end of the study phase. Using logistic regression modeling accounting for differences in duration of sitesâ€™ exposure to implementation supports, we estimated the effect of implementation facilitation on MOUD initiation and retention relative to a 12-month pre-implementation period.
A total of 6,119 Veterans were included in the initiation evaluation and 1,953 Veterans were included in the retention evaluation. Sites were exposed to implementation supports for an average of 18 months (range 3 to 35 months). Regression models revealed a positive effect of implementation facilitation on MOUD initiation (OR = 1.42, p < 0.001) but a nonsignificant effect on MOUD retention (OR = 1.08, p = 0.525). MOUD initiation increased across sites from 30% pre-implementation facilitation to 40% during the implementation facilitation phase. MOUD retention increased, although not significantly, from 31% to 36% across phases.
Despite substantial interruptions to implementation efforts due to the onset of COVID-19, results demonstrated that CONDUITâ€™s MOUD implementation supports were associated with increased initiation of this critical treatment for Veterans with OUD, but on average were not associated with MOUD retention. As three months remain in data collection, MOUD initiation and retention rates continue to be monitored. Outcomes will be tracked into a post-implementation maintenance phase.
Implementation facilitation is effective in expanding access to evidence-based MOUD and remains a priority for VA. Future analyses will explore the unique effects of individual implementation facilitation approaches on MOUD-associated outcomes.