Literature Collection

BACKGROUND: Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here. METHODS: PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16-90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims ("electronic health records," [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization. DISCUSSION: The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings. Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&ra….

BACKGROUND: Given a marked expansion in the work of primary care in recent decades, it is critical to have an accurate understanding of the time involved in managing a primary care panel and the determinants of this time. OBJECTIVE: To estimate the yearly work effort involved for primary care physicians (PCPs) in caring for a patient panel, explore how work effort varies by clinical full-time equivalent (cFTE) status, and identify patient panel factors associated with differential time expenditure. DESIGN: Cross-sectional, observational study using electronic health record and administrative data scaled by a literature-based estimate of activities inadequately captured by these data sources. SETTING: 33 clinics in the Mass General Brigham health system. PARTICIPANTS: 406 attending PCPs who delivered care for at least 9 months in 2021. MEASUREMENTS: Total yearly time expenditure per patient and full-time PCP. RESULTS: The median work effort for a full-time PCP was 2844.3 yearly hours (IQR, 2324.9 to 3478.9 yearly hours), or 61.8 weekly hours (IQR, 50.5 to 75.6 weekly hours), for a 1.0-cFTE physician assuming a 46-week work year. This translates to a median of 1.7 hours (IQR, 1.4 to 2.2 hours) per patient per year. Part-time PCPs spent more time per patient on average than full-time PCPs. Patient medical advice request volume and certain panel characteristics, including greater average age, medical complexity, and percentage of patients with Medicaid, were associated with greater yearly PCP time expenditure per patient. LIMITATION: Derivation of data from a single integrated health system and lack of information about practice structures and staff supports for PCPs. CONCLUSION: Primary care physicians spend a median of 62 weekly hours caring for a patient panel. Panel characteristics and patient message volume are associated with time expenditure. These findings provide valuable insights for designing sustainable primary care roles and adjusting panel size expectations. PRIMARY FUNDING SOURCE: The Physicians Foundation.