Expanding access to medications for opioid use disorder in primary care clinics: an evaluation of common implementation strategies and outcomes

Hannah Cheng; Mark P McGovern; Hélène Chokron Garneau; Brian Hurley; Tammy Fisher; Meaghan Copeland; Daniel Almirall

doi:10.1186/s43058-022-00306-1

Expanding access to medications for opioid use disorder in primary care clinics: an evaluation of common implementation strategies and outcomes

Implement Sci Commun. 2022 Jul 6;3(1):72. doi: 10.1186/s43058-022-00306-1.

Authors

Hannah Cheng¹, Mark P McGovern^{2

3}, Hélène Chokron Garneau², Brian Hurley^{4

5}, Tammy Fisher⁶, Meaghan Copeland⁷, Daniel Almirall^{8

9}

Affiliations

¹ Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA. chenghh@stanford.edu.
² Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
³ Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
⁴ Los Angeles County Department of Public Health, Los Angeles, CA, USA.
⁵ Department of Family Medicine, University of California, Los Angeles, CA, USA.
⁶ Aledade, Inc., Bethesda, MD, USA.
⁷ Center for Care Innovations, Oakland, CA, USA.
⁸ Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
⁹ Department of Statistics, University of Michigan, Ann Arbor, MI, USA.

Abstract

Background: To combat the opioid epidemic in the USA, unprecedented federal funding has been directed to states and territories to expand access to prevention, overdose rescue, and medications for opioid use disorder (MOUD). Similar to other states, California rapidly allocated these funds to increase reach and adoption of MOUD in safety-net, primary care settings such as Federally Qualified Health Centers. Typical of current real-world implementation endeavors, a package of four implementation strategies was offered to all clinics. The present study examines (i) the pre-post effect of the package of strategies, (ii) whether/how this effect differed between new (start-up) versus more established (scale-up) MOUD practices, and (iii) the effect of clinic engagement with each of the four implementation strategies.

Methods: Forty-one primary care clinics were offered access to four implementation strategies: (1) Enhanced Monitoring and Feedback, (2) Learning Collaboratives, (3) External Facilitation, and (4) Didactic Webinars. Using linear mixed effects models, RE-AIM guided outcomes of reach, adoption, and implementation quality were assessed at baseline and at 9 months follow-up.

Results: Of the 41 clinics, 25 (61%) were at MOUD start-up and 16 (39%) were at scale-up phases. Pre-post difference was observed for the primary outcome of percent of patient prescribed MOUD (reach) (β_time = 3.99; 0.73 to 7.26; p = 0.02). The largest magnitude of change occurred in implementation quality (ES = 0.68; 95% CI = 0.66 to 0.70). Baseline MOUD capability moderated the change in reach (start-ups 22.60%, 95% CI = 16.05 to 29.15; scale-ups -4.63%, 95% CI = -7.87 to -1.38). Improvement in adoption and implementation quality were moderately associated with early prescriber engagement in Learning Collaboratives (adoption: ES = 0.61; 95% CI = 0.25 to 0.96; implementation quality: ES = 0.55; 95% CI = 0.41 to 0.69). Improvement in adoption was also associated with early prescriber engagement in Didactic Webinars (adoption: ES = 0.61; 95% CI = 0.20 to 1.05).

Conclusions: Rather than providing an all-clinics-get-all-components package of implementation strategies, these data suggest that it may be more efficient and effective to tailor the provision of implementation strategies based on the needs of clinic. Future implementation endeavors could benefit from (i) greater precision in the provision of implementation strategies based on contextual determinants, and (ii) the inclusion of strategies targeting engagement.

Keywords: Dissemination and implementation science; Implementation science; Implementation strategies; Opioid use disorder; Public health.

Abstract

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