Auty Samantha G, Barr Kyle D, Frakt Austin B, Garrido Melissa M, Strombotne Kiersten L
Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
Partnered Evidence-Based Policy Resource Center, Veterans Administration Boston Healthcare System, Boston, MA, USA.
Addiction. 2023 May;118(5):870-879. doi: 10.1111/add.16110. Epub 2023 Jan 12.
The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD).
Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020.
United States VHA facilities were randomized to case review the top 1 or 5% of high-risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation.
All-cause mortality and opioid-related, drug-related, suicide-related and other SAEs within 90 days of OUD diagnosis.
Mandated case review increased the odds of 90-day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients.
Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case review mandate for high-risk patients prescribed opioids.
退伍军人健康管理局（VHA）实施了阿片类药物风险缓解分层工具（STORM），以降低开具阿片类镇痛药患者发生严重不良事件（SAE）的风险。VHA机构被要求对STORM识别为高风险的患者进行病例审查。本研究的目的是衡量这一要求对新诊断为阿片类药物使用障碍（OUD）的VHA患者全因死亡率和SAE的影响。
对2018年至2020年在所有140个VHA机构进行的阶梯楔形整群随机对照试验进行二次分析，以机构作为随机分组单位。
美国VHA机构被随机分配对STORM识别出的开具阿片类镇痛药的前1%或5%高风险患者进行病例审查。共有28251名患者在试验期间被诊断为OUD，并根据他们接受OUD诊断的机构状态被视为对照或治疗组。对诊断前90天内至少有一张阿片类镇痛药处方的患者进行事后分析，然后根据诊断后90天内是否接受处方进行分层，以评估结果对阿片类药物停用的敏感性。
OUD诊断后90天内的全因死亡率以及与阿片类药物相关、与药物相关、与自杀相关和其他SAE。
强制病例审查增加了90天死亡率的几率[优势比（OR）=1.74，95%置信区间（CI）=1.06，2.87]，但未显著改变SAE的几率。在OUD诊断前但诊断后未接受阿片类药物处方的患者中，90天内全因死亡率的几率相对于对照患者为5.87（95%CI=1.85，18.58）。
新诊断为阿片类药物使用障碍的退伍军人健康管理局患者在扩大对开具阿片类药物的高风险患者的病例审查要求后，全因死亡率增加。
