The Kirby Institute, UNSW, Sydney, Australia.
Centre for Social Research in Health, UNSW, Sydney, Australia.
Implement Sci. 2023 Jun 9;18(1):22. doi: 10.1186/s13012-023-01281-4.
Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic.
Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access.
We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses.
The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.
去实施（deimplementation），即去除或减少潜在危险的医疗方法，是促进健康公平的关键。尽管阿片类激动剂治疗（OAT）的益处已有充分证据，但治疗方法的广泛差异却削弱了积极的结果。在 COVID-19 大流行期间，OAT 服务部门取消了澳大利亚长期以来治疗的核心部分，包括监督剂量、尿液药物检测和频繁的亲自复查。本分析探讨了提供者如何考虑 COVID-19 大流行期间 OAT 限制供应去实施时患者的健康公平问题。
2020 年 8 月至 12 月期间，对澳大利亚的 29 名 OAT 提供者进行了半结构式访谈。根据提供者如何考虑社会不平等问题与去实施的关系，将与客户保留相关的社会决定因素代码进行聚类。然后，使用常规化进程理论（Normalisation Process Theory）根据提供者在 COVID-19 大流行期间的工作情况分析聚类，以了解他们如何应对影响 OAT 获得的系统问题。
我们根据常规化进程理论的构建，基于四个总体主题进行了探讨：适应性执行、认知参与、规范重构和维持。适应性执行的叙述表明了提供者对公平和患者自主权的概念之间的紧张关系。认知参与和规范重构是 OAT 服务中快速和急剧变革的可行性的关键。关键的变革性因素包括实践社区和“思想领袖”，他们长期以来一直支持更人道的护理去实施。在大流行的早期阶段，提供者已经开始考虑如何在这一时期为去实施的维持提供信息。在考虑未来大流行后的时期时，一些提供者对以“证据足够”为操作模式表示不适，并呼吁对不良事件（如过量用药）和专家共识的带走剂量进行严格定义类型的数据。
在实现健康公平方面的可能性受到提供者和接受 OAT 的人的治疗目标分歧的限制。要实现 OAT 供应的强制性方面的持续和公平去实施，需要共同制定治疗目标、以患者为中心的监测和评估，以及为提供者提供支持性的实践社区。
