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A Multi-Faceted Intervention to Improve Alcohol Dependence Pharmacotherapy Access
Hildi J. Hagedorn, PhD
Minneapolis VA Health Care System, Minneapolis, MN
Alexander Sox-Harris PhD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: May 2014 - October 2016
The VA Uniform Mental Health Services Handbook states that evidence-based pharmacotherapy is to be offered and available to all Veterans diagnosed with alcohol dependence. Meta-analyses of the efficacy and safety of naltrexone and acamprosate inform the guideline recommendations, indicating that both medications are associated with improved outcomes. Despite the evidence and guideline recommendations, use of these medications within VA has been very low overall and highly variable across facilities. The goal of this project is to develop, implement, and evaluate a multifaceted intervention to increase prescribing rates of medications for alcohol dependence (AD). The project has the strong support of the Office of Mental Health Operations (OMHO) which is tasked with implementing the requirements of the Uniform Mental Health Services Handbook and is particularly interested in increasing access to alcohol pharmacotherapy.
The objectives of this project are to: 1) Increase access to AD pharmacotherapy through a multifaceted implementation intervention targeting Veterans with alcohol dependence, and substance use disorders (SUD), primary care mental health integration (PCMHI), and primary care providers; 2) Use formative evaluation strategies to refine the intervention; and 3) Assess the costs of the intervention.
Three sites participated in this feasibility trial. To inform the details of the intervention, a developmental evaluation comprised of Veteran and provider interviews was completed. SUD and PCMHI providers from each site participated in an in-person collaborative learning session to educate them about AD pharmacotherapy and train them to serve as local clinical champions at their facilities. They also received ongoing facilitation through monthly team meetings and feedback on prescribing rates. Through a project website, primary care providers received AD pharmacotherapy educational materials, a personalized list of patients on their caseload with AD diagnoses, quarterly feedback on their facility's prescribing practices compared to other facilities, and contact information for their local SUD and PCMHI clinical champions willing to provide personal consultation. Veterans diagnosed with AD received AD pharmacotherapy educational materials in the mail and encounter educational materials in other formats, such as handouts in clinics. An interrupted time series design (with three intervention series and three control series) was used to evaluate the effect of the intervention. The primary outcome was the proportion of Veterans diagnosed with AD within the past six months who had an upcoming primary care appointment and who were sent pre-PC visit educational materials who then filled a prescription for an AD medication within one month of the targeted appointment. Secondary outcomes included an assessment of consultation rates to SUD specialty care for targeted patients and an assessment of the impact of the intervention on prescribing rates for non-targeted patients with AD (those that do not receive educational materials). To assess consideration of and patient acceptance of AD pharmacotherapy, a random subsample of patients with alcohol dependence diagnoses that do not fill a prescription were selected and their charts reviewed to determine whether medications were considered but rejected. To help refine the intervention for future implementation efforts, the project included an assessment of the intervention costs and collection of formative evaluation data.
Segmented logistic regression results indicated a significant increase in prescribing rate slope from the pre-implementation to the post-implementation phase for the intervention sites with the overall monthly mean proportion of pharmacotherapy receipt increasing from 3.6% in the pre-implementation period to 5.1% in the post-implementation period. Examination of individual sites indicated that two of three had an increase in prescribing rate slope from pre- to post-implementation periods, however this was statistically significant for only one site. In comparing the intervention to the control sites, intervention sites had a slightly lower baseline prescribing rate and a steeper pre-implementation trend (both significant). However, post-implementation parameters did not differ significantly between control and intervention sites, with control sites also demonstrating a significant increase in prescribing rate slope from the pre- to the post-implementation period. For control sites the overall monthly mean proportion of pharmacotherapy receipt increased from 3.6% to 4.4%.
Qualitative formative evaluation data informed the lower than anticipated impact of the intervention by highlighting the extent of provider-level barriers to implementation. The most prominent themes regarding barriers cited by providers included: 1) Patients with alcohol use disorders are too complex and VHA facilities have substance use disorder specialists readily available to treat them; 2) Addressing alcohol use is rarely the patient's presenting priority when they come for a primary care appointment; 3) Other organizational priorities were taking precedence during the implementation period, specifically access issues and opioid over-prescribing; 4) Primary care providers were feeling they were being asked to take on more and more care that would have traditionally been referred to specialty care, e.g., hepatitis treatment; and 5) Persisting negative attitudes toward using medications to treat substance use disorders, e.g., "substituting one substance for another". Many of these themes can be subsumed into a broader sentiment that primary care providers were feeling they had too much to address in too short of an appointment time and no open space in their schedules to learn new skills or contemplate practice improvements.
While the impact of the intervention was less than anticipated, the qualitative results highlight the substantial barriers and challenges to ongoing efforts to integrate substance use disorder treatment into primary care settings. The finding that control clinics also demonstrated a significant increase in prescribing slope highlights the impact of ongoing operations level efforts toward this goal. The fact that the rate of change was minimal (3% to 4-5%) for both groups suggests that to change the culture surrounding how or whether substance use disorders are managed in the primary care setting will require intensive and ongoing effort. It is likely that the implementation period of this particular intervention was too short to demonstrate substantial change. However, it is possible that a trend was initiated that may continue to grow with time. Post-implementation provider interviews (data not yet analyzed) may reveal changes in provider attitudes resulting from the intervention which may impact future prescribing trends. We plan future analysis of prescribing rates to monitor for continued change. The results strongly suggest that successful changes in primary care practices may require restructuring of primary care clinics to specifically allow time for providers and teams to contemplate and plan for practice improvement and to allow for longer or more frequent appointments for more complex patients.
External Links for this Project
NIH ReporterGrant Number: I01HX000784-01A1
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DRA: Substance Use Disorders
DRE: Treatment - Observational
MeSH Terms: none