Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066, USA; Division of General Internal Medicine, University of Colorado School of Medicine 12631 E. 17(th) Ave., Academic Office One, Campus Box B180, Aurora, CO 80045, USA.
J Subst Abuse Treat. 2018 Dec;95:43-47. doi: 10.1016/j.jsat.2018.09.006. Epub 2018 Oct 2.
The U.S. is facing an opioid epidemic, but despite mandates for pharmacotherapy for opioid use disorder to be available at Veterans Health Administration (VHA) facilities, the majority of veterans with opioid use disorder do not receive these medications. In implementation research, facilities are often targeted for qualitative inquiry or quality improvement efforts based on quality measure performance during a one-year period. However, sites that experience quality performance changes from one year to the next may be highly informative because mechanisms that impact facility change may be more discoverable. The current study examined changes in receipt of pharmacotherapy for opioid use disorder in a national healthcare system to determine the extent to which sites fluctuated in performance over a two-year period and illustrate how changes in quality measures over time may be useful for implementation research and healthcare surveillance of quality measures.
Using national VHA data from Fiscal Years (FY) 2016 and 2017, we calculated quality measure performance as the number of patients who received pharmacotherapy for opioid use disorder (i.e., methadone, buprenorphine, and naltrexone) divided by the number of patients with a current non-remitted opioid use disorder diagnosis for each FY at each facility (n = 129) and examined change from FY16 to FY17.
The mean rate of receipt of pharmacotherapy for opioid use disorder was 38% (facility range = 3% to 74%) in FY16 and 41% (facility range = 2% to 76%) in FY17. The average facility-level change in performance was 3% and ranged from -19% to 26%. There were 32 facilities that decreased in provision of pharmacotherapy, 12 facilities with no change, and 85 facilities that increased.
For facilities with average or high performance, it was difficult to maintain their performance over time. Identifying and learning from facilities with recent fluctuations may be more informative to guide the design of future quality improvement efforts than studying facilities with stable high or low performance.
美国正面临阿片类药物泛滥的问题，但尽管美国退伍军人事务部（VHA）的规定要求提供阿片类药物使用障碍的药物治疗，但大多数阿片类药物使用障碍患者并未接受这些药物治疗。在实施研究中，通常根据一年内的质量指标表现，对设施进行定性调查或质量改进工作。然而，那些在一年内经历质量绩效变化的站点可能具有重要的参考价值，因为影响设施变化的机制可能更容易被发现。本研究调查了全国医疗系统中接受阿片类药物使用障碍药物治疗的情况，以确定在两年内站点绩效波动的程度，并说明随着时间的推移质量指标的变化如何有助于实施研究和医疗保健对质量指标的监测。
使用 2016 财年（FY）和 2017 财年的全国 VHA 数据，我们将每个 FY 每个设施的接受阿片类药物使用障碍药物治疗（即美沙酮、丁丙诺啡和纳曲酮）的患者人数除以当前非缓解性阿片类药物使用障碍诊断的患者人数，计算出质量指标的表现（n=129），并检查 FY16 到 FY17 的变化。
2016 财年接受阿片类药物使用障碍药物治疗的比例为 38%（设施范围为 3%至 74%），2017 财年为 41%（设施范围为 2%至 76%）。绩效的平均设施水平变化为 3%，范围从-19%到 26%。有 32 个设施减少了药物治疗的提供，12 个设施没有变化，85 个设施增加了。
对于绩效处于平均水平或较高水平的设施来说，随着时间的推移，保持其绩效变得困难。与研究绩效稳定的高或低设施相比，识别和从最近波动的设施中吸取经验教训，可能更有助于指导未来质量改进工作的设计。
