Andrea Finlay, PhD, Laura Ellerbe, Anna Rubinsky, Shalini Gupta, Tom Bowe, & Alex Sox-Harris Center for Innovation to Implementation (Ci2i) VA Palo Alto Health Care System National Center on Homelessness Among Veterans Department of Veterans Affairs June 26, 2017
Disclosures Employed and funded 100% by the Department of Veterans Affairs. No other disclosures. Funding Sources: Health Services Research & Development (HSR&D) QUERI Rapid Response Project (RRP 12-468) HSR&D Career Development Award (CDA 13-279, PI: Finlay) HSR&D Research Career Scientist (RCS 14-232, PI: Harris) Role of the funding source: The views expressed in this presentation are those of the authors and do not necessarily reflect the position nor policy of the Department of Veterans Affairs (VA) or the United States government.
Alcohol use disorder is common among veterans 6% of VA patients have alcohol use disorder (AUD), representing over 300,000 veterans (Harris et al., 2012) AUD is more prevalent among special populations 33% of veterans exiting prison (Finlay et al., 2015) 57% of veterans exiting jails or in treatment courts (Finlay et al., 2014) 49% of veterans receiving homeless services (Tsai et al., 2014)
VA Residential Treatment For veterans who need intensive treatment and supervision, VA provides residential treatment 63 Substance Use Disorder (SUD) Residential Rehabilitation Treatment Programs (RRTPs) 34 Mental Health Residential Rehabilitation Treatment Programs with an SUD track Pharmacotherapy for AUD - naltrexone, acamprosate, topiramate, and disulfiram – is mandated to be available and considered but use varies widely in residential treatment
Barriers and Facilitators to Pharmacotherapy for AUD Barriers Program treatment philosophy Lack of access to prescribing physicians Lack of training or knowledge about addiction medications Low perceived patient demand Facilitators More education to patients and providers Increased involvement of physicians in alcohol treatment (Harris et al., 2013; Oliva et al., 2011)
Research Question What are the perceived barriers to and facilitators of pharmacotherapy for AUD in VA residential treatment programs?
Conceptual Framework Consolidated Framework for Implementation Research (CFIR) Inner setting - cultural or structural context in which the implementation occurs Outer setting – external policies and incentives, patients needs and resources Characteristics of individuals – knowledge and beliefs about the intervention, other personal attributes, self-efficacy Intervention characteristics – key aspects of intervention that influence success of implementation Process – planning, execution, evaluation of implementation (Damschroeder et al., 2009)
Methods Sample 63 directors, program managers, and/or staff from 44 of 97 VA residential programs Qualitative Interviews Using fiscal year 2012 VA administrative data, a program profile was calculated for each residential program Unique profile was shared with participants at the start of the interview alongside data on the national program average Interviews were audiotaped and transcribed
Methods Interviews Participants from programs with low rates of receipt of pharmacotherapy for AUD were asked about barriers to receipt of these medications Participants from programs with high rates of receipt of pharmacotherapy for AUD were asked about facilitators to receipt of these medications All programs were asked about their overall approach or philosophy to addiction pharmacotherapy Analysis Thematic analysis to identify barriers and facilitators (Braun & Clark, 2006; Vaismoradi et al., 2013) Themes were organized and matched with domains and constructs from the CFIR
Results - Context 15,056 patients admitted to residential SUD treatment programs who were diagnosed with AUD in FY2012 12 to 689 patients per program 12% average rate of receipt of pharmacotherapy for AUD 0% to 50% across programs
Inner Setting Culture – General norms/program philosophy Negative program norms (barrier) Passive openness/interest (facilitator) Active encouragement/promotion (facilitator) Implementation Climate – shared receptivity of prescriber to intervention Negative receptivity to pharmacotherapy (barrier) Passive openness/interest (facilitator) Active encouragement/promotion (facilitator)
Inner Setting Implementation Climate - Learning Climate Prescriber education (facilitator) Program staff education (facilitator) Readiness for Implementation – Available Resources Access to prescribers/specialists (barrier & facilitator) Readiness for Implementation – Leadership Climate Leadership support or lack thereof (barrier & facilitator)
Inner Setting Networks & Communication Initiated by referring programs (facilitator) Care coordination within residential program (barrier & facilitator) Care coordination with outside providers/programs (barrier & facilitator)
Outer Setting Patient needs & resources Perceived patient attitudes/needs/interest (barrier & facilitator) Patient education (facilitator) External policies & incentives Policy restrictions (barrier)
Characteristics of Individuals & Intervention Characteristics Knowledge & belief of intervention Limitations in prescriber/staff knowledge (barrier) Cost Cost restriction (barrier)
Conclusions Education and training for providers and patients Academic detailing improved prescribing of pharmacotherapy for AUD (Harris et al., 2016) Increase care coordination across settings
Questions? Contact information: Andrea Finlay Andrea.Finlay@va.gov 17
References Cited Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77-101 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci, 4 , 50 Finlay, A. K., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., . . . Harris, A. H. S. (2014). U.S. Department of Veterans Affairs Veterans Justice Outreach program: connecting justice-involved veterans with mental health and substance use disorder treatment. Criminal Justice Policy Review, 27 (2), 203-222 Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., . . . Timko, C. (2015). Use of Veterans Health Administration mental health and substance use disorder treatment after exiting prison: the Health Care for Reentry Veterans program. Administration and Policy in Mental Health Harris, A. H. S., Bowe, T., Hagedorn, H., Nevedal, A., Finlay, A. K., Gidwani, R., . . . Christopher, M. M. (2016). Interrupted time-series analysis of a multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder. Addiction Science & Clinical Practice, 11 (1) , 15. Harris, A. H. S., Ellerbe, L., Reeder, R. N., Bowe, T., Gordon, A. J., Hagedorn, H., . . . Trafton, J. A. (2013). Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychol Serv, 10 (4), 410-419. Harris, A. H. S., Oliva, E. M., Bowe, T., Humphreys, K. N., Kivlahan, D. R., & Trafton, J. A. (2012). Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: Patterns of receipt and persistence. Psychiatric Services, 63 (7), 679-685. Oliva, E. M., Maisel, N. C., Gordon, A. J., & Harris, A. H. (2011). Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psychiatry Rep, 13 (5), 374-381. Tsai, J., Kasprow, W. J., & Rosenheck, R. A. (2014). Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes. Addict Behav, 39(2), 455-460. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci, 15 (3), 398-405.
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