University of North Carolina School of Medicine, NC, United States.
University of North Carolina Gillings School of Global Public Health, NC, United States.
Int J Drug Policy. 2022 Jul;105:103715. doi: 10.1016/j.drugpo.2022.103715. Epub 2022 May 6.
Low retention is a persistent challenge in the delivery of buprenorphine treatment for opioid use disorder (OUD). The goal of this study was to identify provider factors that could drive differences in treatment retention while accounting for the contribution of patient characteristics to retention.
We developed a novel a mixed-methods approach to explore provider factors that could drive retention while accounting for patient characteristics. We used Medicaid claims data from North Carolina in the United States to identify patient characteristics associated with higher retention. We then identified providers who achieved high and low retention rates. We matched high- and low-retention providers on their patients' characteristics. This matching created high- and low-retention provider groups whose patients had similar characteristics. We then interviewed providers while blinded to which belonged in the high- and low-retention groups on aspects of their practice that could affect retention rates, such as treatment criteria, treatment cost, and services offered.
Less than half of patients achieved 180-day treatment retention with large differences by race and ethnicity. We did not find evidence that providers who achieved higher retention consistently did so by providing more comprehensive services or selecting for more stable patients. Rather, our findings suggest use of "high-threshold" clinical approaches, such as requiring participation in psychosocial services or strictly limiting dosages, explain differences in retention rates between providers whose patients have similar characteristics. All low-retention providers interviewed used a high-threshold practice compared to half of high-retention providers interviewed. Requiring patients to participate in psychosocial services, which were often paid out-of-pocket, appeared to be especially important in limiting retention.
Providers who adopt low-threshold approaches to treatment may achiever higher retention rates than those who adopt high-threshold approaches. Addressing cost barriers and systemic racism are likely also necessary for improving buprenorphine treatment retention.
在提供阿片类药物使用障碍（OUD）的丁丙诺啡治疗时，保留率低一直是一个持续存在的挑战。本研究的目的是确定在考虑患者特征对保留率的贡献的情况下，可能导致治疗保留率差异的提供者因素。
我们开发了一种新的混合方法来探索在考虑患者特征的情况下可能导致保留率差异的提供者因素。我们使用美国北卡罗来纳州的医疗补助索赔数据来确定与更高保留率相关的患者特征。然后，我们确定了实现高保留率和低保留率的提供者。我们根据患者的特征对高保留率和低保留率的提供者进行匹配。这种匹配创建了具有相似特征的高保留率和低保留率提供者组。然后，我们在对哪些提供者属于高保留率和低保留率组不知情的情况下对提供者进行了访谈，讨论了可能影响保留率的实践方面，如治疗标准、治疗成本和提供的服务。
不到一半的患者实现了 180 天的治疗保留率，且种族和民族之间存在很大差异。我们没有发现证据表明，实现更高保留率的提供者始终通过提供更全面的服务或选择更稳定的患者来实现这一目标。相反，我们的研究结果表明，使用“高门槛”临床方法，如要求参加心理社会服务或严格限制剂量，可以解释具有相似特征的患者之间保留率的差异。所有接受采访的低保留率提供者都使用了高门槛实践，而接受采访的高保留率提供者中有一半使用了这种方法。要求患者参加心理社会服务，这些服务往往需要自费，似乎对限制保留率特别重要。
采用低门槛治疗方法的提供者可能比采用高门槛治疗方法的提供者实现更高的保留率。解决成本障碍和系统性种族主义可能也是提高丁丙诺啡治疗保留率所必需的。
