2023 HSR&D/QUERI National Conference

1100 — Towards increased access to medications for opioid use disorder within the inpatient hospital setting: rapid qualitative analysis and strategy mapping

Lead/Presenter: Allyson Varley,  Birmingham VA Health System
All Authors: Varley AL (Birmingham VA Health System), Hoge, AE (Birmingham VA Health System) Newbury, E (Iowa City VA) Parker, K (Birmingham VA Health System) Stewart, K (Birmingham VA Health System) Leisch, L (Birmingham VA Health System) Kertesz, S (Birmingham VA Health System) Mosher, H (Birmingham VA Health System)

To describe barriers to, facilitators of, and potential strategies for increasing adoption of practices to expand access to MOUD in the inpatient setting at two Veterans Affairs (VA) hospitals.

As part of a needs assessment for a multi-site, multi-project QUERI, Consortium to Disseminate and Understand Implementation of Opioid Use Disorder Treatment (CONDUIT), focused on testing the impact of implementation facilitation on expanding access to MOUD in the hospital, the study team conducted interviews with local stakeholders over WebEx. The interview guide was developed using the Consolidated Framework for Implementation Research (CFIR)’s interview guide tool and adapted to assess barriers and facilitators to 3 MOUD-relevant practices: screening and diagnosis, initiating MOUD, and referral and care coordination. Interviews were then coded to CFIR constructs and mapped to ERIC implementation strategies using the CFIR Barrier Buster Tool. Strategies were then ranked, selected, and tailored using a consensus-based approach with key stakeholders.

30 clinicians (hospitalists, pharmacists, nurses, consulting physicians) from two VA hospitals were interviewed. Barriers to MOUD included: problem prevalence (complications from chronic opioid prescriptions for pain were seen as more prevalent than frank OUD), a preference among hospital clinicians to “focus on acute needs”, lack of awareness of available resources and experts, and complicated referral paths to outpatient OUD care. Facilitators included: a new outpatient clinic to address pain and opioid-related issues, existing consultants for both inpatient and outpatient substance use care, and a recent push to educate residents on treatment of OUD. Strategies recommended by the CFIR tool included: engaging stakeholders, raising awareness of resources, and obtaining and using patient feedback. Examples of how these were tailored to OUR inpatient implementation challenges include: meeting with hospital, pharmacy, and nursing leadership to define priorities and request support from leadership for peer navigation as recommended by the Opioid Addiction and Recovery Veteran Engagement Board (OAR-VEB). A consult guide card was also developed and disseminated to raise awareness of consult services.

The inpatient hospital setting is complex, with multiple clinicians and services necessary to appropriately address OUD. Although resource gaps number among barriers to MOUD, this study suggests that a focus on MOUD alone may be something of a mismatch for the challenges seen by clinicians caring for older Veterans. Necessary next steps include testing the impact of the resulting multi-faceted strategy on the uptake of screening and diagnosis, initiating MOUD, and care coordination of Veterans with OUD in the inpatient hospital setting.

Systematic approaches to assessing implementation needs and context can facilitate selection of appropriate implementation strategies. Employing the CFIR Barrier Buster is helpful, but stakeholder input is critical to adapt the broad recommendations into strategies that are tailored to context specific implementation challenges.