Methods
This project received a QI designation from the Office of PBM Academic Detailing Service Institutional Review Board at the Edward Hines, Jr. Veterans Affairs Hospital VA Medical Center (VAMC). This designation was reviewed and approved by the Rocky Mountain Regional VAMC Research and Development service. In addition, we received national union approval to disseminate this survey nationally across all VA Integrated Service Networks (VISNs).
Survey
We worked with VHA subject matter experts, key stakeholders, and the VA Collaborative Evaluation Center (VACE) to develop the survey. Subject matter experts and stakeholders included VHA emergency medicine leadership, ADS leadership, and mental health and substance treatment providers. VACE is an interdisciplinary group of mixed-method researchers. The survey questions aimed to capture perceptions and experiences regarding naloxone distribution and new MAT initiation of VHA ED/UCC providers.
We used a variety of survey question formats. Close-ended questions with a predefined list of answer options were used to capture discrete domains, such as demographic information, comfort level, and experience level. To capture health care provider (HCP) perceptions on barriers and facilitators, we used multiple-answer multiple-choice questions. Built into this question format was a free-response option, which allowed respondents to offer additional barriers or facilitators. Respondents also had the option of not answering individual questions.
We identified physicians, nurse practitioners (NPs), and physician assistants (PAs) who saw at least 100 patients in the ED or UCC in at least one 3-month period in the prior year and obtained an email address for each. In total, 2228 ED or UCC providers across 132 facilities were emailed a survey; 1883 (84.5%) were ED providers and 345 (15.5%) were UCC providers.
We used Research Electronic Data Capture (REDCap) software to build and disseminate the survey via email. Surveys were initially disseminated in late January 2019. During the 3-month survey period, recipients received 3 automated email reminders from REDCap to complete the survey. Survey data were exported from REDCap. Results were analyzed using descriptive statistics analyses with Microsoft Excel.
Results
One respondent received the survey in error and was excluded from the analysis. The survey response rate was 16.7%: 372 responses from 103 unique facilities. Each VISN had a mean 20 respondents. The majority of respondents (n = 286, 76.9%) worked in highly complex level 1 facilities characterized by high patient volume and more high-risk patients and were teaching and research facilities. Respondents were asked to describe their most recent ED or UCC role. While 281 respondents (75.5%) were medical doctors, 61 respondents (16.4%) were NPs, 30 (8.1%) were PAs, and 26 (7.0%) were ED/UCC chiefs or medical directors (Table 1). Most respondents (80.4%) reported at least 10 years of health care experience.
The majority of respondents (72.9%) believed that HCPs at their VHA facility should be prescribing naloxone. When asked to specify which HCPs should be prescribing naloxone, most HCP respondents selected pharmacists (76.4%) and substance abuse providers (71.6%). Less than half of respondents (45.0%) felt that VA ED/UCC providers also should be prescribing naloxone. However, 58.1% of most HCP respondents reported being comfortable or very comfortable with prescribing naloxone to a patient in the ED or UCC who already had an existing prescription of opioids. Similarly, 52.7% of respondents reported being comfortable or very comfortable with coprescribing naloxone when discharging a patient with an opioid prescription from the ED/UCC. Notably, while 36.7% of PAs reported being comfortable/very comfortable coprescribing naloxone, 46.7% reported being comfortable/very comfortable prescribing naloxone to a patient with an existing opioid prescription. Physicians and NPs expressed similar levels of comfort with coprescribing and prescribing naloxone.
Respondents across provider types indicated a number of barriers to prescribing naloxone to medically appropriate patients (Table 2). Many respondents indicated prescribing naloxone was beyond the ED/UCC provider scope of practice (35.2%), followed by the perceived stigma associated with naloxone (33.3%), time required to prescribe naloxone (23.9%), and concern with patient’s ability to use naloxone (22.8%).
Facilitators for prescribing naloxone to medically appropriate patients identified by HCP respondents included pharmacist help and education (44.6%), patient knowledge of medication options (31.7%), societal shift away from opioids for pain management (28.0%), facility leadership (26.9%), and patient interest in safe opioid usage (26.6%) (Table 3). In addition, NPs specifically endorsed Computerized Patient Record System prompts for patients prescribed opioids (29.5%).
Less than 6.8% of HCP respondents indicated that they were comfortable using MAT. Meanwhile, 42.1% of respondents reported being aware of MAT but not familiar with it, and 23.5% reported that they were unaware of MAT. Correspondingly, 301 of the 372 (88.5%) HCP respondents indicated that they had not prescribed MAT in the past year. Across HCP types, only 24.1% indicated that it is the role of VA ED or UCC providers to prescribe MAT when medically appropriate and subsequently refer patients to substance abuse treatment for follow-up (just 7.1% of PAs endorsed this). Furthermore, 6.5% and 18.8% of HCP respondents indicated that their facility leadership was very supportive and supportive, respectively, of MAT for OUD prescribing.
Barriers to MAT initiation indicated by HCP respondents included limited scope of ED and UCC practice (53.2%), unclear follow-up/referral process (50.3%), time (29.8%), and discomfort (28.2%). Nearly one-third of NPs (27.9%) identified patient willingness/ability as a barrier to MAT initiation (Table 4).
Facilitators of MAT initiation in the ED or UCC included VHA same-day treatment options (34.9%), patient desire (32.5%), pharmacist help/education (27.4%), and psychiatric social workers in the ED or UCC (25.3%). Some NPs (23.0%) and PAs (26.7%) also indicated that having time to educate veterans about the medication would be a facilitator (Table 5). Facility leadership support was considered a facilitator by 30% of PAs.