Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration

• Published in: Implementation science communications 2021-02, Vol.2 (1), p.20-13, Article 20
• Main Authors: Gustavson, Allison M, Wisdom, Jennifer P, Kenny, Marie E, Salameh, Hope A, Ackland, Princess E, Clothier, Barbara, Noorbaloochi, Siamak, Gordon, Adam J, Hagedorn, Hildi J
• Format: Article
• Language: English
• Subjects: Clinics; Drug stores; Drug use; Evidence-based practice; Facilitation; Implementation; Intervention; Interviews; Leadership; Medication treatment; Mental disorders; Mental health; Narcotics; Opioid use disorder; Pain; Patients; Primary care; Substance abuse treatment; Veterans
• ISSN: 2662-2211; 2662-2211
• DOI: 10.1186/s43058-021-00119-8

Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescrib