Abstract
BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P =.02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 339-344 |
| Number of pages | 6 |
| Journal | Journal of Hospital Medicine |
| Volume | 16 |
| Issue number | 6 |
| DOIs | |
| State | Published - Jun 2021 |
ASJC Scopus subject areas
- Internal Medicine
- Leadership and Management
- Fundamentals and skills
- Health Policy
- Care Planning
- Assessment and Diagnosis
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In: Journal of Hospital Medicine, Vol. 16, No. 6, 06.2021, p. 339-344.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - A Resident-Led Intervention to Increase Initiation of Buprenorphine Maintenance for Hospitalized Patients With Opioid Use Disorder
AU - Thakrar, Ashish P.
AU - Furfaro, David
AU - Keller, Sara
AU - Graddy, Ryan
AU - Buresh, Megan
AU - Feldman, Leonard
N1 - Funding Information: This study shows how a resident-led intervention comprising clinician education and a team of X-waivered generalists was associated with improved treatment of OUD for hospitalized patients. We encourage residents and all clinicians at other hospitals without addiction medicine consult services to design, implement, and study similar interventions that directly increase the use of buprenorphine or methadone maintenance to treat OUD. Preliminary results from this project were presented at the AMERSA National Conference on November 7, 2019. Disclosures: The authors have nothing to disclose. Funding: This project was supported by R25DA013582 from the National Institute on Drug Abuse and by an award from the Health Resources & Services Administration (HRSA) of the US Department of Health & Human Services (HHS). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government. This study took place from July 2018 to June 2019 at JHH, a large, academic, urban hospital in Baltimore. Prior to the intervention, internal medicine residents at JHH commonly used short courses of buprenorphine to treat withdrawal, but they did not have access to hospital-specific resources to assist with starting maintenance OAT. During the study period, JHH had a Substance Use Disorders team staffed by peer recovery specialists that could be consulted by hospitalists and residents to provide psychosocial support and link admitted patients to treatment after discharge. There were no providers on the team to guide pharmacotherapy or to write discharge buprenorphine prescriptions. The Osler Medical Residency Training Program at JHH has 140 internal medicine residents and 16 combined medicine-pediatrics residents. All residents receive 1 hour of formal education about opioid use disorder annually. In addition, 28 of those 156 residents, those in the Urban Health Primary Care track, spend 1 month on an Addiction Medicine rotation in which they complete the 8-hour training required to receive the X-waiver. Those residents are encouraged to apply for the X-waiver once they obtain a medical license subsidized by a Health Resources & Services Administration (HRSA) grant. Four internal medicine attending physicians on teaching services and one resident had X-waivers prior to the intervention. This study took place from July 2018 to June 2019 at JHH, a large, academic, urban hospital in Baltimore. Prior to the intervention, internal medicine residents at JHH commonly used short courses of buprenorphine to treat withdrawal, but they did not have access to hospital-specific resources to assist with starting maintenance OAT. During the study period, JHH had a Substance Use Disorders team staffed by peer recovery specialists that could be consulted by hospitalists and residents to provide psychosocial support and link admitted patients to treatment after discharge. There were no providers on the team to guide pharmacotherapy or to write discharge buprenorphine prescriptions. The Osler Medical Residency Training Program at JHH has 140 internal medicine residents and 16 combined medicine-pediatrics residents. All residents receive 1 hour of formal education about opioid use disorder annually. In addition, 28 of those 156 residents, those in the Urban Health Primary Care track, spend 1 month on an Addiction Medicine rotation in which they complete the 8-hour training required to receive the X-waiver. Those residents are encouraged to apply for the X-waiver once they obtain a medical license subsidized by a Health Resources & Services Administration (HRSA) grant. Four internal medicine attending physicians on teaching services and one resident had X-waivers prior to the intervention. In November 2018, we administered a survey to residents to identify barriers to starting buprenorphine maintenance and to measure knowledge and confidence with using buprenorphine for OUD (Appendix Figure 1 and Figure 2). We focused on buprenorphine because providers at JHH were familiar with this medication and because Baltimore has widespread access to buprenorphine, with more than 490 local buprenorphine providers.20 Five residents piloted the survey and provided feedback. We then administered the survey to all internal medicine and medicine-pediatrics residents. Based on the results, we developed a targeted educational conference and also created the Buprenorphine Bridge Team (BBT). In January 2019, we presented the educational conference for residents devoted to the use of buprenorphine for OUD and introduced the BBT. The conference started with a patient testimonial and included peer recovery specialists, pharmacists, nurses, and social workers. We summarized the evidence for buprenorphine and offered a practical guide to start treatment in a one-page protocol. This protocol included guidance on selecting patients, shared decision-making around OUD treatment, avoiding precipitated withdrawal, dosing buprenorphine, and establishing follow-up (Appendix Figure 3). We asked for input on this protocol from nursing leadership, social work teams, and peer recovery specialists. Dosing was adapted from the Guidelines from the American Society of Addiction Medicine, with expert input from physicians from the Addiction Medicine Consult service at Johns Hopkins Bayview Medical Center, also in Baltimore.5 We instructed residents to obtain discharge buprenorphine prescriptions from an X-waivered physician on their team or from the newly established BBT. We asked resident teams to set up a postdischarge appointment for patients with an X-waivered provider, either in a community practice or at the JHH After Care Clinic, a transitional care clinic for discharged patients.21 The BBT is a resident-led group of X-waivered JHH residents and hospitalists who volunteer to write discharge buprenorphine prescriptions for patients. The BBT serves to ensure primary teams have access to an X-waivered prescriber. It is not a consult service. We asked primary teams to contact the BBT after initiating buprenorphine and after securing a follow-up appointment. In response to each request, a member of the BBT reviews the patient chart, confirms the follow-up plan, writes a prescription for buprenorphine along with intranasal naloxone, and leaves a brief note. During the 6-month postintervention period, the team consisted of three residents and three hospitalist attendings. Each week, two members (residents or attendings) staffed the team Monday to Friday, 8 am to 5 pm. Most weeks were staffed by two residents. One resident provided services after hours and during weekends. Resident team members ensured that the buprenorphine plan was discussed with the primary team's attending. For dosing questions beyond the BBT's scope of knowledge, a member of the BBT relayed questions to physicians from the Addiction Medicine Consult team at Johns Hopkins Bayview Medical Center. In May 2019, 5 months after the education session and implementation of the BBT, we administered a follow-up survey. The primary outcome was the percent of inpatients eligible to start OAT who were discharged on buprenorphine maintenance. We obtained data from the electronic medical record. The denominator consisted of patients with OUD not on buprenorphine or methadone maintenance on admission. We identified patients with OUD by an opioid-related International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code or by a standing or as-needed order for buprenorphine or methadone during hospitalization.22 We reviewed admission and discharge documentation to identify patients with OUD who were not in active treatment with buprenorphine or methadone maintenance. As a secondary outcome, we measured engagement in OUD treatment after discharge by calculating the proportion of patients started on buprenorphine who filled a buprenorphine prescription within 30 days after discharge. We chose 30 days based on the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) measure for engagement of treatment for alcohol and other drugs.23 We obtained the data from the Chesapeake Regional Information System for our Patients (CRISP) Prescription Drug Monitoring Program, which monitors all prescriptions for controlled substances dispensed in Maryland and five neighboring states. As a balancing measure, we counted patients newly started on methadone maintenance for OUD before and after the intervention. Additional secondary process outcomes included frequency of BBT requests, the volume of buprenorphine prescriptions written by the team, and time required to complete a BBT request. Clinician-level outcomes, measured with electronically administered pre- and postintervention surveys to residents, included knowledge about and comfort with buprenorphine. Of the 16 questions in the pre- and postimplementation surveys, we analyzed the 6 questions concerning knowledge and comfort that remained identical in the pre- and postintervention surveys and used 5-point Likert scale responses. As an incentive, we randomly distributed three $50 gift cards to survey completers. We used an interrupted time series analysis to evaluate the association between the intervention bundle and a change in the rate that medical teams started patients with OUD on buprenorphine maintenance. This approach allowed us to control for preintervention trends. To evaluate the impact of our interventions, our pre- and postintervention periods include the same residents during the 2018-2019 academic year. Both periods consisted of twelve 2-week intervals (preintervention: July 26, 2019, to January 9, 2019; postintervention: January 10, 2019, to June 26, 2019). To evaluate for changes in engagement in OUD treatment after discharge, we used two-sample t tests. To evaluate for changes in resident-reported comfort and knowledge with initiating buprenorphine maintenance, we used Wilcoxon rank sum tests for survey data and Wilcoxon signed rank tests for paired data. All analyses employed two-sided P values with statistical significance evaluated at the.05 alpha level. We analyzed data using R version 3.6.3 (Foundation for Statistical Computing). The Institutional Review Board at JHH reviewed and approved the study protocol as a quality improvement project (IRB00193365). Funding Information: Funding: This project was supported by R25DA013582 from the National Institute on Drug Abuse and by an award from the Health Resources & Services Administration (HRSA) of the US Department of Health & Human Services (HHS). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government. Publisher Copyright: © 2021 Society of Hospital Medicine.
PY - 2021/6
Y1 - 2021/6
N2 - BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P =.02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.
AB - BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P =.02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.
UR - http://www.scopus.com/inward/record.url?scp=85108246822&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85108246822&partnerID=8YFLogxK
U2 - 10.12788/jhm.3544
DO - 10.12788/jhm.3544
M3 - Article
C2 - 34129484
AN - SCOPUS:85108246822
SN - 1553-5592
VL - 16
SP - 339
EP - 344
JO - Journal of Hospital Medicine
JF - Journal of Hospital Medicine
IS - 6
ER -