Lead/Presenter: Madeline Frost, University of Washington School of Public Health
All Authors: Frost MC (Department of Health Systems and Population Health, University of Washington School of Public Health), Zhang L (VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System) Kim HM (VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System) Lin AL (VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System)
Objectives:
The coronavirus (COVID-19) pandemic prompted policy changes to allow increased telehealth delivery of buprenorphine, a potentially lifesaving medication for opioid use disorder (OUD). It is unclear how characteristics of patients who access different buprenorphine treatment modalities (in-person vs. telehealth, video vs. telephone) vary, and whether treatment modality is associated with retention—a key indicator of care quality. This study aimed to 1) compare patient characteristics across receipt of different buprenorphine treatment modalities, and 2) assess whether modality type was associated with retention during the year following COVID-19-related changes.
Methods:
Electronic health record data were extracted for national Veterans Health Administration (VHA) patients with OUD who received buprenorphine during 3/23/20-3/22/21. Treatment modality was examined as three mutually exclusive groups: video (?1 video visit), telephone (?1 telephone visit but no video visits), or in-person (in-person visits only). Patient characteristics (age, sex, race, ethnicity, VHA eligibility status, rurality, housing instability, comorbidities) were compared across modality groups. Retention was measured as having buprenorphine coverage for ?90 days with no gaps in coverage >30 days and was compared across modality groups, adjusted for patient characteristics. Comparisons were made using adjusted generalized linear models with generalized estimating equation (GEE) and a logit link function, accounting for clustering by facility. Analyses examining retention were stratified by time of buprenorphine initiation (year following COVID-19-related changes; year prior; >1 year prior).
Results:
Among 17,182 patients, 38.1% had ?1 video visit, 49.6% had ?1 telephone visit but no video, and 12.3% had only in-person visits. Patients who were younger, male, Black, unknown race, Hispanic, non-service connected, or who had specific mental health/substance use comorbidities were less likely to receive any telehealth. Among patients who received any telehealth, those who were older, male, Black, non-service connected, or who had homelessness/housing instability were less likely to have video visits. Retention was significantly higher for patients who received any telehealth compared to those who received only in-person visits regardless of when initiation occurred (adjusted odds ratio [aOR]: 1.31, 95% confidence interval [CI]: 1.12-1.53 for initiated in year following COVID-19-related changes; aOR: 1.45, 95% CI: 1.12-1.88 for initiated in year prior; aOR: 1.19, 95% CI: 1.01-1.40 for initiated >1 year prior). Among patients who received telehealth, higher retention was observed in those receiving any video visits compared to only telephone for patients who initiated in the year following COVID-19-related changes (aOR: 1.47, 95% CI: 1.26-1.71).
Implications:
Discontinuation or reduction of telehealth availability may disrupt treatment for many patients, and discontinuation of telephone-only access may have an outsized effect on groups who have historically faced disparities in buprenorphine access such as Black patients and those experiencing homelessness. Maintaining video and telephone telehealth modalities and improving access to video telehealth may be important for supporting retention.
Impacts:
Policymakers and clinical leaders should carefully consider the potential impacts of forthcoming decisions related to buprenorphine telehealth policies.