Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh, Pittsburgh, PA, USA.
Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA, USA.
Implement Sci. 2019 Jan 18;14(1):5. doi: 10.1186/s13012-019-0852-z.
Mitigating the risks of adverse outcomes from opioids is critical. Thus, the Veterans Affairs (VA) Healthcare System developed the Stratification Tool for Opioid Risk Management (STORM), a dashboard to assist clinicians with opioid risk evaluation and mitigation. Updated daily, STORM calculates a "risk score" of adverse outcomes (e.g., suicide-related events, overdoses, overdose death) from variables in the VA medical record for all patients with an opioid prescription and displays this information along with documentation of recommended risk mitigation strategies and non-opioid pain treatments. In March 2018, the VA issued a policy notice requiring VA Medical Centers (VAMCs) to complete case reviews for patients whom STORM identifies as very high-risk (i.e., top 1% of STORM risk scores). Half of VAMCs were randomly assigned notices that also stated that additional support and oversight would be required for VAMCs that failed to meet an established percentage of case reviews. Using a stepped-wedge cluster randomized design, VAMCs will be further randomized to conduct case reviews for an expanded pool of patients (top 5% of STORM risk scores vs. 1%) starting either 9 or 15 months after the notice was released, creating four natural arms. VA commissioned an evaluation to understand the implementation strategies and factors associated with case review completion rates, whose protocol is described in this report.
This mixed-method study will include an online survey of all VAMCs to identify implementation strategies and interviews at a subset of facilities to identify implementation barriers and facilitators. The survey is based on the Expert Recommendations for Implementing Change (ERIC) project, which engaged experts to create consensus on 73 implementation strategies. We will use regression models to compare the number and types of implementation strategies across arms and their association with case review completion rates. Using questions from the Consolidated Framework for Implementation Research, we will interview stakeholders at 40 VAMCs with the highest and lowest adherence to opioid therapy guidelines.
By identifying which implementation strategies, barriers, and facilitators influence case reviews to reduce opioid-related adverse outcomes, this unique implementation evaluation will enable the VA to improve the design of future opioid safety initiatives.
This project is registered at the ISRCTN Registry with number ISRCTN16012111 . The trial was first registered on 5/3/2017.
减轻阿片类药物不良后果的风险至关重要。因此，退伍军人事务部（VA）医疗保健系统开发了 Stratification Tool for Opioid Risk Management（STORM），这是一个仪表板，可帮助临床医生评估和减轻阿片类药物风险。STORM 每天都会更新，根据 VA 医疗记录中的变量计算出“风险评分”（例如，自杀相关事件、过量用药、过量用药死亡），并显示这些信息，以及建议的风险缓解策略和非阿片类药物疼痛治疗的文件。2018 年 3 月，VA 发布了一份政策通知，要求 VA 医疗中心（VAMC）完成 STORM 确定为高风险（即 STORM 风险评分最高的 1%）的患者的病例审查。VAMC 随机被分配到通知，通知称，如果未能达到既定的病例审查百分比，将需要额外的支持和监督。使用逐步楔形集群随机设计，VAMC 将进一步随机选择扩大患者群体（STORM 风险评分前 5%与前 1%）进行病例审查，从通知发布后 9 或 15 个月开始，共创建四个自然臂。VA 委托进行评估，以了解与病例审查完成率相关的实施策略和因素，本报告介绍了其方案。
这项混合方法研究将包括对所有 VAMC 进行在线调查，以确定实施策略，并在部分设施进行访谈，以确定实施障碍和促进因素。该调查基于专家推荐实施变革（ERIC）项目，该项目邀请专家就 73 项实施策略达成共识。我们将使用回归模型比较各臂之间实施策略的数量和类型及其与病例审查完成率的关系。我们将使用实施研究综合框架的问题，在对阿片类药物治疗指南的依从性最高和最低的 40 个 VAMC 进行利益相关者访谈。
通过确定影响减少阿片类药物相关不良后果的病例审查的实施策略、障碍和促进因素，这项独特的实施评估将使 VA 能够改进未来阿片类药物安全计划的设计。
该项目在 ISRCTN 注册处注册，注册号为 ISRCTN63100411 。该试验于 2017 年 5 月 3 日首次注册。
