Literature Collection

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

BACKGROUND: There are extreme psychosocial, environmental, and behavioral risks to the health and well-being of persons experiencing homelessness. Within this complex and hazardous environment, there is an opportunity to gain clearer perspective into the role of accelerating cardiovascular disease (CVD) progression alongside the aging cohort effect in this population. METHOD: Utilizing 2021 and 2022 data from the Harris County Medical Examiner, investigators analyzed CVD-associated deaths for excess mortality and impact of age-related factors specific to persons experiencing homelessness. All medicolegal deaths involving CVD were examined to determine relative frequencies of secondary causes of death and the influence of age between housed individuals and individuals experiencing homelessness. RESULTS: The examination of the CVD mortality cases among persons experiencing homelessness in 2021 (n = 52) and 2022 (n = 71) revealed important trends. The mean age for CVD deaths for persons experiencing homelessness was 58.6 and 60.6 years in 2021 and 2022, respectively. Despite this slight, recent increase, the average age for CVD death among persons experiencing homelessness is dramatically lower than the housed, medicolegal CVD deaths, and the general population. Top-associated conditions were hypertension and atherosclerosis, regardless of housing status. However, chronic obstructive pulmonary disease and congestive heart failure were more common in CVD deaths of people experiencing homelessness. DISCUSSION: These findings reemphasize the uniqueness and complexity of the risks for premature mortality in people experiencing homelessness. This underscores the call for social services and healthcare systems to be more responsive to the challenges faced by persons experiencing homelessness, with more integrated and targeted health and aging care interventions to address the specific needs of these marginalized individuals.

We describe a quality improvement study to understand clinicians' perspectives on using a clinical decision support tool (CDS) for clinical diagnosis and education (VisualDx™) across an integrated healthcare system. Surveys, interviews, and secondary data were analyzed to understand the patterns of usage, associated barriers, facilitators, and suggestions influencing the CDS's adoption and usability. Overall, the CDS had multidimensional functionality, and outpatient primary care had the highest adoption. Key benefits included assistance in building differential diagnoses, mainly of 'dermatological conditions', which could be used for patients, students, and clinician self-education. Barriers impacting use were retrospectively mapped to the RE-AIM implementation science framework (e.g., "Reach" or tool-related limited awareness; "Adoption "or access challenges; and "Implementation", and "Maintenance" or sub-optimal training). Incorporating end-user (i.e., clinician) perspectives around factors influencing adoption and use of CDS, under a specific context, could lead to a wider and more successful use.

Objective To describe medical, safety, and health care utilization outcomes associated with an early treatment model for neonatal opioid withdrawal. Study Design This is a retrospective review of 117 opioid-exposed infants born in a large regional hospital and treated in the level I nursery with methadone initiated within 48 hours of birth. Results For this cohort, mean length of stay was 8.3 days. Hospital safety events were infrequent; there were no medication errors or deaths. Within 30 days of discharge, 14% of infants visited the emergency department; 7% were readmitted. Per birth, mean hospital charges were $10,946.96; mean costs were $5,908.93. Conclusion This study is the first to describe an early treatment model in a low-acuity nursery to prevent severe neonatal opioid withdrawal. The described model may be safe, effective, low-cost, and feasible for replication.