背景:包括丁丙诺啡在内的阿片类药物使用障碍(MOUD)是有效的,但利用不足。农村患者在获得方面存在明显差异。为了接触农村患者,美国退伍军人事务部(VA)试图将丁丙诺啡的处方扩展到专科范围之外,并扩展到初级保健领域.
目标:尽管挑战依然存在,一些农村VA医疗保健系统已经开始在初级保健中提供丁丙诺啡阿片类药物使用障碍(OUD)治疗.我们采访了临床医生,领导人,和这些系统内的工作人员了解这一结果是如何实现的。
方法:使用来自VACorporateDataWarehouse(CDW)的管理数据,我们发现农村VA医疗保健系统在2015-2020年期间提高了基于初级保健的丁丙诺啡处方率.我们对在这些系统中实施或处方丁丙诺啡的工作人员进行了定性访谈(n=30),以了解促进实施的过程。
方法:临床医生,工作人员,和嵌入在西北部农村VA医疗保健系统中的领导者,西,中西部(2)南,和东北。
方法:使用混合归纳/演绎方法分析了定性访谈。
结果:访谈揭示了丁丙诺啡被纳入初级保健的过程,以及不足以实施变革的进程。实施最初通常是通过有针对性的雇用来催化的。冠军随后与临床医生和领导人一对一地“推销”案件,描述丁丙诺啡处方与现有目标之间的一致性,并描述它们可以提供的支持作用。通过开发新的临床团队和重新设计临床流程,为实施准备了站点。这些过程中的每一个都是由活跃的,领导的工具性支持。
结论:结果表明,寻求改善丁丙诺啡在初级保健中的可及性的农村系统可能需要改变初级保健结构以适应丁丙诺啡处方,无论是通过新员工,团队发展,或临床重新设计。
BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in
access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care.
OBJECTIVE: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved.
METHODS: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation.
METHODS: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast.
METHODS: Qualitative interviews were analyzed using a mixed inductive/deductive approach.
RESULTS: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to \"pitch\" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership.
CONCLUSIONS: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.