Abstract：
Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor.
We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale.
Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients\' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff.
Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.
We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale.
Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients\' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff.
Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.
摘要：
背景：阿片类药物过量死亡在美国迅速增加。阿片类药物使用障碍（MOUD）是有效的，可以在初级保健中提供，但是农村社区的吸收有限。农村初级保健诊所（TM-MOUD）转诊并与外部远程医疗（TM）供应商进行协调，可能会增加农村患者的MOUD访问，但是我们对关键利益相关者对这种模式的看法知之甚少。作为TM-MOUD可行性研究的一部分，我们探讨了来自7家农村初级保健诊所和一家TM-MOUD供应商的人员和患者对TM-MOUD的可接受性和可行性.
方法：我们与诊所管理员进行了虚拟访谈或焦点小组（n=7次访谈），临床初级保健和行为健康提供者(8组，n=30),其他诊所工作人员(9组，n=37),接受MOUD的患者(n=16次访谈)，TM-MOUD供应商员工(n=4次访谈)，和供应商相关的行为健康和处方提供者(n=17次访谈)。我们询问了MOUD（主要是丁丙诺啡）和远程医疗（TM）以及TM-MOUD转诊和协调模型的经验和可接受性。我们进行了内容分析，以确定主题，参与者以4项量表定量评估TM-MOUD元素的可接受性。
结果：基于供应商的TM-MOUD的感知好处包括减少后勤障碍，更多的隐私和更少的耻辱，以及对本地不可用服务的访问(例如，咨询,疼痛管理)。障碍包括缺乏互联网或患者家中连接不良，TM-MOUD和诊所提供者之间的沟通和信任有限，以及关于TM-MOUD转诊给外部供应商的临床价值的问题。TM-MOUD的可接受性评级普遍较高；他们在一线员工中最低。
结论：农村初级保健诊所人员，TM-MOUD供应商人员,患者通常认为从初级保健转诊到TM-MOUD供应商，从而有可能增加农村社区获得MOUD的机会。提高TM-MOUD的使用率需要员工对TM-MOUD工作流程的认可和理解，提供的TM服务，对患者的要求，相对于诊所提供者的诊所或TM服务的优势，并确定合适的患者。贫穷,伴随着病人开始治疗的犹豫，通常会对MOUD治疗造成实质性障碍；互联网可用性不足会对TM-MOUD造成实质性障碍。
方法：我们与诊所管理员进行了虚拟访谈或焦点小组（n=7次访谈），临床初级保健和行为健康提供者(8组，n=30),其他诊所工作人员(9组，n=37),接受MOUD的患者(n=16次访谈)，TM-MOUD供应商员工(n=4次访谈)，和供应商相关的行为健康和处方提供者(n=17次访谈)。我们询问了MOUD（主要是丁丙诺啡）和远程医疗（TM）以及TM-MOUD转诊和协调模型的经验和可接受性。我们进行了内容分析，以确定主题，参与者以4项量表定量评估TM-MOUD元素的可接受性。
结果：基于供应商的TM-MOUD的感知好处包括减少后勤障碍，更多的隐私和更少的耻辱，以及对本地不可用服务的访问(例如，咨询,疼痛管理)。障碍包括缺乏互联网或患者家中连接不良，TM-MOUD和诊所提供者之间的沟通和信任有限，以及关于TM-MOUD转诊给外部供应商的临床价值的问题。TM-MOUD的可接受性评级普遍较高；他们在一线员工中最低。
结论：农村初级保健诊所人员，TM-MOUD供应商人员,患者通常认为从初级保健转诊到TM-MOUD供应商，从而有可能增加农村社区获得MOUD的机会。提高TM-MOUD的使用率需要员工对TM-MOUD工作流程的认可和理解，提供的TM服务，对患者的要求，相对于诊所提供者的诊所或TM服务的优势，并确定合适的患者。贫穷,伴随着病人开始治疗的犹豫，通常会对MOUD治疗造成实质性障碍；互联网可用性不足会对TM-MOUD造成实质性障碍。
