Assessing and Reducing Opioid Misuse Among Veterans in VA and Non-VA Systems: Coordination of Fragmented Care

评估和减少退伍军人管理局和非退伍军人管理局系统退伍军人中阿片类药物滥用：分散护理的协调

• 批准号: 10394127
• 负责人: Joel Kupersmith
• 金额: --
• 依托单位: U.S. DEPT/VETS AFFAIRS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2024-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10394127
• 关键词: Address; Administrator; Area; Benzodiazepines; Caring; Clinical; Communication; Communities; Community Health; Consequentialism; Data; Data Analyses; Data Sources; Databases; Diagnosis; District of Columbia; Dose; Electronic Health Record; Ensure; Evaluation; Focus Groups; Goals; Guidelines; Health; Health Insurance; Health Personnel; Healthcare; Healthcare Systems; Information Systems; Injury; Insurance; Interview; Link; Maryland; Medicare; Methods; Mid-Atlantic Region; Musculoskeletal; National Health Interview Survey; Natural Language Processing; Opioid; Pain; Pain management; Patients; Policies; Policy Maker; Prevalence; Privatization; Provider; Recommendation; Reporting; Research; Risk Management; Safety; Statistical Methods; Stratification; Syndrome; System; Toxicant exposure; United States Centers for Medicare and Medicaid Services; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; War; Woman; addiction; care coordination; chronic pain; community center; complex data; deep learning; high risk; improved; informal caregiver; misuse of prescription only drugs; non-opioid analgesic; novel; operation; opioid abuse; opioid epidemic; opioid misuse; opioid overdose; opioid use; opioid use disorder; patient oriented; prescription monitoring program; prescription opioid; prescription opioid misuse; programs; psychiatric comorbidity; suicidal risk; tool; wound

Project Summary The US opioid epidemic has put a significant burden on Veterans and the VA. Veterans often suffer from chronic pain syndromes due to war injuries, toxic exposures, and deployment-related psychiatric comorbidities and are vulnerable to opioid use/misuse. Chronic pain syndromes occur in 65.4% of U.S. veterans, 9.1% of it severe, as against 56 and 6.4% in non-veterans respectively. Both opioid misuse and unrelieved pain have been linked to a higher risk of suicide among Veterans, greater among women. To address the opioid epidemic in the VA, in August 2013, the VA deployed the Opioid Safety Initiative (OSI) to ensure that opioids are used in a safe, effective, and judicious manner and the Stratification Tool for Opioid Risk Management (STORM). Although the implementation of OSI has substantially reduced risky and other opioid prescriptions in VHA and increased use of non-opioid treatments for pain, there remain major gaps in evidence to formulate comprehensive policy as current data is almost exclusively derived from Veterans receiving care within the VHA. This is important as ~80% of the Veterans have private health insurance. It has been reported that Veterans who receive dual VHA and non-VHA care received more opioid prescriptions and more risky prescriptions, that mono VHA users. Also, while opioid overdose rates have been increasing in VHA enrollees VHA Opioid prescriptions in these veterans declined. To address the prescription drug misuse problem, states use Prescription Drug Monitoring Programs (PDMPs), which are electronic databases that collect and track prescription data on controlled substances to reduce their abuse and diversion. However, despite access to these data via Health Information Exchanges (HIE), the guideline-discordant unsafe and concurrent prescriptions and fillings of opioids continue. Also, PDMP data alone are not suitable for policy decisions and practice recommendations as they lack the detailed clinical information necessary to make a comprehensive evaluation of underlying factors associated with non-guideline-concordant prescriptions. Our preliminary data show a decline in Opioid prescriptions with less decline in the diagnosis of Opioid Use Disorder. The absence of community data is also mentioned as a major deficiency in the study and analyses of the opioid misuse crisis in a 2017 VA Office of Inspector General Report. In this VHA HSR&D Merit Review Application we propose to examine factors associated with prescription opioid misuse, specifically the guideline-discordant use of opioids, in 3 Veterans groups, (1) VHA mono-users, (2) VHA paid dual users of both VHA and non-VHA care, and (3) non-VHA paid dual users. We also propose to conduct an interview/focus group study of VA and non-VA community health providers perspectives on: a) barriers and facilitators in providing guideline- concordant care to the dual users, and b) coordination strategies to reduce opioid misuse in the dual user groups. These aims will be achieved by analyzing the complex data using novel deep learning and natural language processing methods in addition to the state-of-the-art statistical methods. The data involved will include the VHA and MedStar Health (largest healthcare system in the Mid-Atlantic region) electronic health record (EHR), the Chesapeake Regional Information System for Patients (CRISP) and Medicare databases. We will also bring together VA and non-VA community health providers, including clinicians, administrators, policy makers, and patients. We have conducted preliminary studies and collected preliminary data to demonstrate the feasibility of the proposed deep learning and natural language processing methods as well as our access to VA and non-VA EHR data. The results of the proposed study will be shared with our VHA and community operational partners. Our ultimate goal is to evaluate and improve care coordination and reduce opioid misuse in Veterans who are dual users of VA and community care.

项目概要 美国阿片类药物的流行给退伍军人和退伍军人管理局带来了沉重的负担。退伍军人经常遭受 由于战争伤害、有毒物质暴露和与部署相关的精神合并症而导致的慢性疼痛综合征 并且容易受到阿片类药物使用/滥用的影响。 65.4% 的美国退伍军人患有慢性疼痛综合征，其中 9.1% 严重，而非退伍军人中分别为 56% 和 6.4%。阿片类药物滥用和未缓解的疼痛都已 退伍军人自杀风险较高，女性自杀风险较高。解决阿片类药物流行病 在 VA，2013 年 8 月，VA 部署了阿片类药物安全倡议 (OSI)，以确保阿片类药物用于 安全、有效和明智的方式以及阿片类药物风险管理分层工具 (STORM)。 尽管 OSI 的实施大大减少了 VHA 和其他阿片类药物的风险处方 越来越多地使用非阿片类药物治疗疼痛，但在制定证据方面仍存在重大差距 全面的政策，因为当前数据几乎完全来自在该机构内接受护理的退伍军人 维哈。这很重要，因为约 80% 的退伍军人拥有私人健康保险。据报道 接受 VHA 和非 VHA 双重护理的退伍军人收到的阿片类药物处方更多，风险也更大 单 VHA 用户的处方。此外，虽然 VHA 参与者的阿片类药物过量率一直在增加 这些退伍军人的 VHA 阿片类药物处方有所减少。为了解决处方药滥用问题，国家 使用处方药监测计划 (PDMP)，这是收集和跟踪的电子数据库 有关受控物质的处方数据，以减少其滥用和转移。然而，尽管访问 这些数据通过健康信息交换（HIE）进行，与指南不一致，不安全且并发 阿片类药物的处方和填充仍在继续。此外，PDMP 数据本身并不适合政策决策和 实践建议，因为它们缺乏做出全面评估所需的详细临床信息 评估与不符合指南的处方相关的潜在因素。我们的初步数据 显示阿片类药物处方量下降，而阿片类药物使用障碍诊断率下降幅度较小。缺席 社区数据的缺乏也被认为是阿片类药物滥用研究和分析的一个主要缺陷 2017 年 VA 监察长办公室报告中的危机。在此 VHA HSR&D 优异评审申请中，我们 建议检查与处方阿片类药物滥用相关的因素，特别是与指南不一致的因素 在 3 个退伍军人群体中使用阿片类药物，(1) VHA 单一用户，(2) VHA 付费 VHA 和非 VHA 双重用户 护理，以及 (3) 非 VHA 付费双用户。我们还建议对 VA 进行访谈/焦点小组研究 非退伍军人事务部社区卫生服务提供者对以下方面的看法：a) 提供指南的障碍和促进因素 对双重使用者的一致护理，以及 b) 减少双重使用者阿片类药物滥用的协调策略 组。这些目标将通过使用新颖的深度学习和自然分析复杂数据来实现 除了最先进的统计方法之外，还包括语言处理方法。所涉及的数据将 包括 VHA 和 MedStar Health（大西洋中部地区最大的医疗保健系统）电子健康 记录 (EHR)、切萨皮克地区患者信息系统 (CRISP) 和医疗保险数据库。 我们还将汇集 VA 和非 VA 社区卫生服务提供者，包括临床医生、管理人员、 政策制定者和患者。我们进行了初步研究并收集了初步数据 证明所提出的深度学习和自然语言处理方法的可行性以及 我们对 VA 和非 VA EHR 数据的访问。拟议研究的结果将与我们的 VHA 和 社区运营伙伴。我们的最终目标是评估和改善护理协调并减少 退伍军人管理局和社区护理双重使用者的退伍军人滥用阿片类药物。