Increasing Early Outpatient Goals of Care Conversations: A Sequential Multiple Assignment Randomized Trial (SMART)

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

Early goals of care conversations are recommended by the National Academy of Medicine, preferred by patients and families, and associated with less aggressive medical care at end of life, earlier hospice referral, and better caregiver bereavement adjustment. Conversations aim to explore and establish patients’ underlying values and priorities to guide decisions about specific medical interventions in the present and future. Despite the VA’s intent to increase early conversations in the outpatient setting by implementing the National Center for Ethics in Health Care’s Life Sustaining Treatment Decisions Initiative (LSTDI) in 2017, the majority of conversations still take place in the inpatient setting near end of life, when patients may be critically ill and unable to fully participate. Thus, further implementation strategies are needed. Using a sequential multiple assignment randomized trial (SMART) design, various adaptive strategies will be compared to better understand whether low- or high-intensity patient-facing and/or clinician-facing strategies improve conversations. This will help health care systems decide which approaches to use.

METHODS

This study employs a cluster (clinician-level randomization) SMART design. The primary outcome is number of documented conversations, measured 6 and 12 months after initial randomization. In stage 1, clinicians will receive written materials and one-time training. Their patients will be randomized to no patient strategy or a letter directing them to an interactive website to prepare for conversations. After 6 months, in stage 2, clinicians in either group who do not respond (<4 notes completed) will receive in-person team facilitation and lists of patients potentially appropriate for a conversation. Clinicians’ patients will be randomized to receive the letter or the letter with follow-up phone calls. Clinician and patient implementation strategy success or failure will be evaluated through surveys and semi-structured interviews. Data will be analyzed using quantitative and qualitative methods.

A Protocol for a Pragmatic Pilot Trial Implementing Measurement-Based Care in Community Opioid Treatment Programs

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

The opioid overdose epidemic is a public health emergency in the United States. The majority of drug overdose deaths involve opioids and overdose is a leading cause of death among persons under age 55. Medication for opioid use disorder (MOUD) is the gold standard evidence-based treatment for OUD, however treatment engagement and maintenance in long term recovery are suboptimal. There is a critical need to supplement MOUD with psychosocial interventions, however high patient volume and the need for flexible treatment limits psychosocial treatment use in opioid treatment programs (OTPs). Measurement-based care (MBC), which involves administration, review, and discussion of client self-report data in counseling, is one evidence-based intervention that may enhance OTP engagement and outcomes. This two-phase hybrid implementation-effectiveness pilot trial seeks to evaluate MBC’s potential in OTPs through: 1) mixed method development of an MBC protocol; and 2) pilot implementation of MBC in community OTPs.

METHODS

Phase 1 will employ Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to build community partnerships with OTPs and evaluate factors impacting MBC implementation. RAPICE methodology will include clinical ethnography, cognitive interviews (n = 48), and quantitative surveys (n = 80). The quantitative surveys will evaluate Consolidated Framework for Implementation Research domains including MBC attitudes, MBC characteristics, implementation climate, organizational functioning, and organizational workflow and documentation practices. RAPICE data will be analyzed by a multidisciplinary team to: a) adapt an MBC protocol for use in OTPs; and b) select four OTPs with high implementation potential for Phase 2 participation. Phase 2 OTPs will engage in a collaborative MBC electronic health record (EHR) integration process followed by a one-day MBC training and ongoing monthly consultation for six months. All Phase 2 study outcomes will be drawn from the OTP EHRs. Effectiveness outcome measures will include treatment attendance and opioid abstinence pre- and post-MBC implementation. Implementation outcome measures will include provider MBC exposure (percent of total counseling sessions where MBC administered) and MBC fidelity (MBC administration, review, and discussion).

Using the Contingency Management Tracker as Both an Implementation Strategy and an Implementation Research Tool

Posted on May 7, 2021May 18, 2021 by coprhcon

BACKGROUND

Contingency management (CM) is one of the only behavioral interventions shown to improve patient abstinence from opioids when combined with FDA-approved pharmacotherapy. Nonetheless, the implementation of CM in opioid treatment programs (OTPs) remains low. Furthermore, research suggests that when CM is implemented in real-world treatment settings, it is implemented with poor adherence. The objective of this poster is to describe the development and use of the Contingency Management Tracker, which was developed to serve the dual purpose of a research tool for standardizing the assessment of CM implementation and an implementation strategy (develop and implement tools for quality monitoring) to improve fidelity.

METHODS

Funded by the National Institute on Drug Abuse, Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) is a cluster-randomized type 3 implementation-effectiveness hybrid trial testing strategies for helping OTPs and their staff implement CM. As part of Project MIMIC, the maximum number of CM sessions is 12 and the maximum number of prize draws is 78. Beyond general implementation data, the CM Tracker was designed to collect and store data specific to the escalating prize-based CM protocol being implemented as part of Project MIMIC. By providing simple inputs about CM sessions, staff receive a user-friendly dashboard that provides visual information to support CM implementation with patients.

RESULTS

To date, 47 CM staff across 16 OTPs have used the project’s CM Tracker for documenting CM implementation. Of the project’s 284 patient participants, CM was initiated by 229 (81%). Per data collected in the CM Tracker, there have been 1,486 CM sessions to date. The median number of CM sessions implemented per initiated patient was 6 (out of 12 possible sessions). OTPs varied widely in their implementation, with the number of initiated patients ranging from 0 to 31. Across OTPs with at least one initiated patient (n = 16), the average number of CM sessions per initiated patient ranged from 3.1 to 11.5. Across OTPs with at least one initiated patient, the average number of CM prize draws per initiated patient was 23.7 and ranged from 4.8 to 61.5.