Implementing alcohol use disorder pharmacotherapy in primary care settings: a qualitative analysis of provider-identified barriers and impact on implementation outcomes

Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements

BACKGROUND

Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites.

OBJECTIVE

To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites.

DESIGN

This was a qualitative evaluation based on semi-structured video-based focus groups.

PARTICIPANTS

Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA.

APPROACH

Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes.

KEY RESULTS

Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum.

CONCLUSIONS

Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

Care Practices of Mental Health Clinical Pharmacist Practitioners Within an Interdisciplinary Primary Care Model for Patients With Substance Use Disorders

BACKGROUND

Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings.

OBJECTIVES

We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities.

METHODS

We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019.

RESULTS

CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients.

CONCLUSION

CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.

Unhealthy alcohol use and brief intervention rates among high and low complexity veterans seeking primary care services in the Veterans Health Administration

INTRODUCTION

Brief intervention (BI) is recommended for all primary care (PC) patients who screen positive for unhealthy alcohol use; however, patients with multiple chronic health conditions who are at high-risk of hospitalization (i.e., "high complexity" patients) may face disparities in receiving BIs in PC. The current study investigated whether high complexity and low complexity patients in the Veterans Health Administration (VHA) differed regarding screening positive for unhealthy alcohol use, alcohol-use severity, and receipt of BI for those with unhealthy alcohol use.

METHODS

Patients were veterans receiving PC services at the VHA in a mid-Atlantic region of the United States. The study extracted VHA administrative and clinical data for a total of 282,242 patients who had ≥1 PC visits between 1/1/2014 and 12/31/2014, during which they were screened for unhealthy alcohol use by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). The study defined high complexity patients as those within and above the 90th percentile of risk for hospitalization per the VHA's Care Assessment Need Score. Logistic regression models assessed if being a high complexity patient was associated with screening positive for unhealthy alcohol use (AUDIT-C ≥ 5), severity of unhealthy alcohol use in those who screened positive (AUDIT-C score range 5-12), and receipt of BI in those who screened positive.

RESULTS

Our sample was 94.5% male, 83% White, 13% Black, 4% other race, and 1.7% Hispanic. A total of 10,813 (3.8%) patients screened positive for unhealthy alcohol use from which we identified 569 (5.3%) high complexity and 10,128 (93.6%) low complexity patients (n = 116 removed due to missing complexity data). Relative to low complexity patients, high complexity patients were less likely to screen positive for unhealthy alcohol use (3.3% vs. 4.1%, AOR = 0.59, p < .001); however, in patients who screened positive, high complexity patients had higher AUDIT-C scores (Mean AUDIT-C = 7.75 vs. 6.87, AOR = 1.46, p < .001) and were less likely to receive a BI (78.0% vs. 92.6%, AOR = 0.42, p < .001).

CONCLUSIONS

Disparities in BI exist for highly complex patients despite having more severe unhealthy alcohol use. Future research should examine the specific patient- and/or clinic-level factors impeding BI delivery for complex patients.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms

BACKGROUND

In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options.

METHODS/DESIGN

Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective.

DISCUSSION

Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05023317.

Relationship Between Primary Care Providers' Perceptions of Alcohol Use Disorder And Pharmacotherapy Prescribing Rates

AIMS

Acamprosate, naltrexone and disulfiram are underprescribed for alcohol use disorder (AUD) with marked variability among primary care providers (PCPs). We aimed to identify differences between high and low prescribers of medications for AUD (MAUD) with regard to knowledge, experiences, prioritization and attitudes.

METHODS

We surveyed PCPs from a large healthcare system with at least 20 patients with AUD. Prescribing rates were obtained from the electronic health record (EHR). Survey responses were scored from strongly disagree (1) to strongly agree (5). Multiple imputation was used to generate attitude scores for 7 missing subjects. PCPs were divided into groups by the median prescribing rate and attitude. Comparisons were made using Wilcoxon rank-sum and regression.

RESULTS

Of the 182 eligible PCPs, 68 (37.4%) completed the survey. Most indicated willingness to attend an educational course (57.4%). Compared with low prescribers, high prescribers viewed the effectiveness of medications more favorably (short term 4.0 vs 3.7, P = 0.02; long term 3.5 vs 3.2, P = 0.04) and were more likely to view prescribing as part of their job (3.9 vs 3.4, P = 0.04). PCPs with positive attitudes (72.4%, CI 60.9-83.8%) had a prescribing rate of 5.0% (CI 3.5-6.5%) compared to 1.9% (CI 0.5-3.4%) among those with negative attitudes (P = 0.028). When stratified by attitude, belief in effectiveness was associated with higher prescribing among PCPs with positive attitudes but not those with negative attitudes.

CONCLUSIONS

PCPs indicated an interest in learning to prescribe MAUD. However, education alone may not be effective unless physicians have positive attitudes towards patients with AUD.

Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review

BACKGROUND

Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone).

METHODS

The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme.

RESULTS

The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD.

CONCLUSIONS

The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.

A scoping review of implementation of health-focused interventions in vulnerable populations

Vulnerable populations face significant challenges in getting the healthcare they need. A growing body of implementation science literature has examined factors, including facilitators and barriers, relevant to accessing healthcare in these populations. The purpose of this scoping review was to identify themes relevant for improving implementation of healthcare practices and programs for vulnerable populations. This scoping review relied on the methodological framework set forth by Arksey and O’Malley, and the Consolidated Framework for Implementation Research (CFIR) to evaluate and structure our findings. A framework analytic approach was used to code studies. Of the five CFIR Domains, the Inner Setting and Outer Setting were the most frequently examined in the 81 studies included. Themes that were pertinent to each domain are as follows—Inner Setting: organizational culture, leadership engagement, and integration of the intervention; Outer Setting: networks, external policies, and patients’ needs and resources; Characteristics of the Individual: knowledge and beliefs about the intervention, self-efficacy, as well as stigma (i.e., other attributes); Intervention Characteristics: complexities with staffing, cost, and adaptations; and Process: staff and patient engagement, planning, and ongoing reflection and evaluation. Key themes, including barriers and facilitators, are highlighted here as relevant to implementation of practices for vulnerable populations. These findings can inform tailoring of implementation strategies and health policies for vulnerable populations, thereby supporting more equitable healthcare.

Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms

Background

The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms.

Methods

The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers.

Results

Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship.

Conclusion

Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.

The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness

Background

In the United States, eighty percent of the adult homeless population smokes cigarettes compared to 15 percent of the general population. In 2017 Power to Quit 2 (PTQ2), a randomized clinical trial, was implemented in two urban homeless shelters in the Upper Midwest to address concurrent smoking cessation and alcohol treatment among people experiencing homelessness. A subset of this study population were interviewed to assess their experiences of study intervention. The objective of this study was to use participants’ experiences with the intervention to inform future implementation efforts of combined smoking cessation and alcohol abstinence interventions, guided by the Consolidated Framework for Implementation Research (CFIR).

Methods

Qualitative semi-structured interviews were conducted with 40 PTQ2 participants between 2016–2017 and analyzed in 2019. Interviews were audio-recorded, transcribed, and analyzed using a socially constructivist approach to grounded theory.

Results

Participants described the PTQ2 intervention in positive terms. Participants valued the opportunity to obtain both counseling and nicotine-replacement therapy products (intervention characteristics) and described forming a bond with the PTQ2 staff and reliance on them for emotional support and encouragement (characteristics of individuals). However, the culture of alcohol use and cigarette smoking around the shelter environment presented a serious challenge (outer setting). The study setting and the multiple competing needs of participants were reported as the most challenging barriers to implementation (implementation process).

Conclusion

There are unique challenges in addressing smoking cessation with people experiencing homelessness. For those in shelters there can be the difficulty of pro-smoking norms in and around the shelter itself. Considering pairing cessation with policy level interventions targeting smoke-free spaces, or pairing cessation with housing support efforts may be worthwhile.. Participants described a discord in their personal goals of reduction compared with the study goals of complete abstinence, which may pose a challenge to the ways in which success is defined for people experiencing homelessness.

Trial registration

Clinicaltrials.gov, NCT01932996, registered 08/30/2013.

Alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) trial: Impact on identified barriers to implementation

Background: A minority of individuals meeting diagnostic criteria for alcohol use disorders (AUD) receive any type of formal treatment. Developing options for AUD treatment within primary care settings is imperative to increase treatment access. A multi-faceted implementation intervention including provider and patient education, clinician reminders, development of local champions and ongoing facilitation was designed to enhance access to AUD pharmacotherapy in primary care settings at three large Veterans Health Administration (VHA) facilities. This qualitative study compared pre-implementation barriers to post-implementation barriers identified via provider interviews to identify those barriers addressed and not addressed by the intervention to better understand the limited impact of the intervention. Methods: Following the nine-month implementation period, primary care providers at the three participating facilities took part in qualitative interviews to collect perceptions regarding which pre-implementation barriers had and had not been successfully addressed by the intervention. Participants included 20 primary care providers from three large VHA facilities. Interviews were coded using common coding techniques for qualitative data using the Consolidated Framework for Implementation Research (CFIR) codebook. Summary reports were created for each CFIR construct for each facility and the impact of each CFIR construct on implementation was coded as positive, neutral, or negative. Results: Some barriers identified during pre-implementation interviews were no longer identified as barriers in the post-implementation interviews. These included Relative Advantage, Relative Priority, and Knowledge & Beliefs about the Innovation. However, Compatibility, Design Quality & Packaging, and Available Resources remained barriers at the end of the implementation period. No substantial new barriers were identified. Conclusions: The implementation intervention appears to have been successful at addressing barriers that could be mitigated with traditional educational approaches. However, the intervention did not adequately address structural and organizational barriers to implementation. Recommendations for enhancing future interventions are provided.

Clinicians' perspectives and perceived barriers to caring for patients with alcohol use disorder and cirrhosis

Background

Alcohol use disorder (AUD) is one of the leading etiologies for liver cirrhosis and liver transplantation. Few individuals with AUD receive guideline-based care in the form of screening, brief intervention, referral to treatment, or prescription of pharmacotherapy for relapse prevention. We interviewed clinicians across Alberta to assess the current experience and perceived barriers to managing AUD in people who have cirrhosis. The aim of this paper is to summarize these findings to inform the development of an educational intervention.

Methods

We used a qualitative descriptive approach to explore the experiences of clinicians who care for patients with cirrhosis and AUD in Alberta. We conducted semi-structured interviews directed by an interview guide. Interviews were recorded and transcribed verbatim. We used an inductive thematic analysis approach whereby transcripts were coded, with codes grouped into larger categories, then themes.

Results

Sixteen clinicians participated in this study. Many participants acknowledged that they do not use a standardized approach to screening, brief intervention, and referral to treatment. Through thematic analysis we identified four themes surrounding barriers to managing AUD in patients with cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and system challenges, (iii) Balancing the complexity of cirrhosis and AUD, and (iv) Acknowledging the influence of provider perceptions on care.

Conclusion

This article presents the perspectives of clinicians who care for people who have AUD and cirrhosis. Significant barriers exist, including limited knowledge and resources, systemic challenges, and patient complexity. The information gathered will be used to develop an educational intervention that will delve deeper into these issues in order to have the greatest impact on clinicians who routinely interface with this patient population.

Assessing Naltrexone Prescribing and Barriers to Initiation for Alcohol Use Disorder: A Multidisciplinary, Multisite Survey

OBJECTIVE

To survey barriers in prescribing naltrexone for alcohol use disorder.

METHODS

A 12-question survey related to naltrexone prescribing patterns, perceptions, and knowledge was sent to 770 prescribers in the departments of internal medicine, family medicine, and psychiatry across a health system with sites in Arizona, Florida, and Minnesota.

RESULTS

Responses were obtained and included for 146/770 prescribers (19.0% response rate). Most respondents were in the department of internal medicine (n = 94, 64.4%), but the departments of psychiatry (n = 22, 15.1%) and family medicine (n = 30, 20.5%) were also represented. Only 34 (23.3%) respondents indicated they had prescribed naltrexone in the previous 3 months. The most common reasons for not prescribing naltrexone were "unfamiliarity with naltrexone for treatment of alcohol use disorder" and "patients do not have appropriate follow-up or are not in a formal treatment program." Compared with those representing internal/family medicine, psychiatry respondents were more likely to prescribe naltrexone and answer knowledge questions correctly.

CONCLUSION

In this survey among primarily non-addiction-trained prescribers, a disparity was shown for prescribing naltrexone and in knowledge barriers between staff in internal/family medicine and psychiatry. There exist opportunities for education and quality improvement that promote the prescribing of naltrexone for alcohol use disorder by non-addiction specialists.

The correlates and extent of prescribing of medications for alcohol relapse prevention in England

AIMS

To determine the pattern and extent of prescribing of medications for alcohol relapse prevention (ARP) in England.

DESIGN

Cross-sectional.

SETTING

Specialist drug and alcohol treatment providers in England reporting to the National Drug Treatment Monitoring System.

PARTICIPANTS

Service users aged 18+, with alcohol the primary substance of dependence, completing a treatment journey between April 2013 and March 2016 (n = 188 152).

MEASUREMENTS

Prescription of medications for ARP during a treatment journey. Data on service users' demographics, treatment and clinical characteristics were extracted.

FINDINGS

The rate of prescribing medications for ARP was 2.1% in 2013/14, 6.8% in 2014/15 and 7.8% in 2015/16. A greater likelihood of prescription was associated with treatment journey year [2014/15; adjusted odds ratio (aOR) = 3.269, 95% confidence intervals (CI) = 3.044-3.510, 2015/16; aOR = 3.823, CI = 3.560-4.106], age (25-34; aOR = 1.622, CI = 1.380-1.907, 35-54; aOR = 1.901, CI = 1.628-2.220 or 55+; aOR = 1.700, CI = 1.446-1.999), female gender (aOR = 1.129, CI = 1.077-1.184), white ethnicity (aOR = 1.219, CI = 1.077-1.380), regional prevalence of alcohol dependence (middle rate; aOR = 1.121, CI = 1.024-1.228), severity of alcohol dependence (moderate dependence without complex needs; aOR = 1.329, CI = 1.244-1.419, severe dependence without complex needs; aOR = 1.308, CI = 1.188-1.441, moderate/severe dependence with complex needs; aOR = 1.131, CI = 1.020-1.255), treatment setting (inpatient; aOR = 10.512, CI = 9.950-11.104, primary care; aOR = 2.264, CI = 2.050-2.500, residential; aOR = 3.216, CI = 2.807-3.685), prior treatment for alcohol dependence (aOR = 1.242, CI = 1.183-1.304), longer treatment journey (aOR = 1.002, CI = 1.002-1.002), more drinking days in the prior 28 days (aOR = 1.021, CI = 1.018-1.024) and drinking a higher number of alcohol units in the prior 28 days (aOR = 1.002 CI = 1.001-1.004). Living in a region of England with the lowest alcohol prevalence was associated with a lower likelihood of prescription of medication for aRP (AOR = 0.491, CI = 0.436-0.552).

CONCLUSIONS

In England, medications for alcohol relapse prevention are rarely prescribed (e.g. 7.8% in 2015/16) and those prescriptions appear to be associated with specific service user demographics, treatment and clinical characteristics.

First-line Medications for the Outpatient Treatment of Alcohol Use Disorder: A Systematic Review of Perceived Barriers

OBJECTIVES

Alcohol use disorder (AUD) is a common illness with significant health and economic consequences. Although three pharmacotherapeutic agents have been shown to decrease heavy drinking days among individuals with AUD, they are vastly underutilized in clinical practice. The objective of this review was to elucidate barriers that may prevent patients from obtaining medication for addiction treatment (MAT) for AUD in an outpatient or residential setting.

METHODS

Electronic searches of Medline and EMBASE were conducted, and reference lists were hand-searched. All study designs which discussed the use of MAT for AUD in an outpatient or residential setting were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible articles, the full texts of which were retrieved and assessed for inclusion.

RESULTS

After eliminating duplicate citations and articles that did not meet eligibility criteria, 23 articles were included in the review. Perceived barriers to obtaining pharmacotherapy for the treatment of AUD in an outpatient or residential setting were grouped into 3 themes: lack of knowledge and concerns about efficacy and complexity of prescribing; treatment philosophy and stigma; medication accessibility including formulary restrictions, geographical and socioeconomic barriers.

CONCLUSIONS

Although evidence-based pharmacotherapeutics have been approved for the treatment of AUD, our findings suggest patients continue to experience barriers to the use of these medications. Efforts should be made to increase rates of prescribing by providers and the use of medications by patients. More research is needed to further elucidate perceived barriers to MAT use, along with strategies to overcome them.

Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada's annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used.

METHODS

A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site.

RESULTS

Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging (key individuals to participate in program implementation), design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead.

CONCLUSIONS

This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.

Characterizing the Variation of Alcohol Cessation Pharmacotherapy in Primary Care

BACKGROUND

Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized.

OBJECTIVE

Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors.

DESIGN

Retrospective cohort using electronic health records from 2010 to 2019.

PARTICIPANTS

Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients.

MAIN MEASURES

Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence.

KEY RESULTS

We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85).

CONCLUSIONS

Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol.

Pre-Implementation of the Age-Friendly Health Systems Evidence-Based 4Ms Framework in a Multi-State Convenient Care Practice

BACKGROUND

Quality issues in the delivery of healthcare services to older adults and changes in societal demographics call for a social movement to improve the care of older adults in a variety of healthcare settings, including ambulatory care and convenient care clinics.

AIMS

To describe the pre-implementation phase to integrate the Age-Friendly Health Systems (AFHS) 4Ms (i.e., What Matters, Medication, Mentation, and Mobility) Framework in 1,100 MinuteClinics (the retail medical clinic of CVS Health) using the Consolidated Framework for Implementation Research (CFIR) and RE-AIM (an evaluation implementation framework).

METHODS

The CFIR and RE-AIM models guided data collection. Data were collected from all stakeholders (patients, healthcare providers, managers, educators, informatics staff, communications staff, and implementation consultants) via observations, surveys, interviews, focus groups, organizational readiness assessment, stakeholder assessment, and workflow mapping during a 15-month period to identify potential barriers, facilitators, and other opportunities for implementation.

RESULTS

The CFIR and RE-AIM implementation frameworks provided a comprehensive approach to guide the pre-implementation phase of the AFHS 4Ms Framework at the MinuteClinic. The baseline assessments guided by the CFIR revealed important insights in the choice of implementation strategies that were developed and tested in the pre-implementation phase, and the RE-AIM guided meaningful components to the development of the logic model.

LINKING ACTION TO EVIDENCE

As more healthcare systems integrate the AFHS 4Ms Framework, the approach reported in this quality improvement project can be used in other settings to facilitate a comprehensive implementation.

A conceptual model to guide research on the activities and effects of innovation champions

Background

The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role.

Methods

The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs.

Results

The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment.

Conclusion

The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research.

Use of Medications for the Treatment of Alcohol Dependence: A Retrospective Study Conducted in 2011-2012

BACKGROUND

Pharmacotherapy for Alcohol Dependence (AD) is underutilized. Barriers preventing the use of AD medications include high prices, lack of access to prescribing physicians, and a limited number of available medications.

OBJECTIVE

The study evaluated the use of AD medications in a sample of Italian outpatients who received these medications free of charge, had access to physicians during office hours, and for whom substitution therapy [gamma-hydroxybutyrate (GHB)] was available. We also evaluated the rate of patients who received a combination of non-pharmacological and pharmacological treatments among participants who were still drinking.

METHODS

SCID for AD and questionnaire were filled by to AD outpatients during a face-to-face interview.

RESULTS & DISCUSSION

345 AD outpatients were interviewed: 58.8% were currently receiving at least one AD medication (GHB: 34.3%, disulfiram: 29.6%, acamprosate: 5.9%; naltrexone: 2.5%; more than one medication: 16.7%). Less than 30% of participants who were still drinking, received a combination of non-pharmacological and pharmacological treatments. Nonetheless, we found higher use of AD medications compared to previous studies conducted in other countries. This higher use of AD medications may be due to access to free medications, prescribing physicians' style, and a larger number of available medications.

CONCLUSION

Our results confirm the underutilization of AD medications, as less than 60% of AD outpatients received medications, and less than 30% of those who were still drinking, received a combination of non-pharmacological and pharmacological treatments. These findings may be useful in improving our knowledge of the barriers that prevent the use of AD medications in clinical practice.

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study

Background

Despite available evidence‐based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's^® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness.

Objective

This study assessed barriers and facilitators to HKTP implementation preparation.

Methods

Interviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis.

Results

Forty‐four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health‐care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders’ focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients’ transplant education needs. Implementation barriers included: stakeholders’ perceptions that Hispanics’ health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion.

Discussion and Conclusions

Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations’ implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.