Program Evaluation of Academic Detailing on Naloxone Prescriptions Prescribed in the U.S. Department of Veterans Affairs
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Background The rising incident of opioid overdose mortality has become a national epidemic in the U.S., especially among veterans whose mortality risk is twice that of the general population. The U.S. Department of Veterans Affairs (VA) implemented the Opioid Overdose Education and Naloxone Distribution (OEND) Program to provide education and training to providers and patients on opioid overdose prevention, recognition, response, and proper use of naloxone to reverse opioid-related overdose events. Penetration into the provider section required a partnership with the VA Pharmacy Benefits Management National Academic Detailing Service that delivers educational outreach to providers to align their naloxone prescribing to veterans at risk of an opioid overdose with evidence-based practice. This study focused on the impact of academic detailing on naloxone prescribing by evaluating the impact of the intervention as well as providers’ perception of the program and naloxone use to reverse opioid overdose events. In Aim 1, I evaluated the implementation strength of academic detailing at the VA from October 2014 to December 2017. This was complemented by Aim 2, which explored the providers’ perception of academic detailing and captured facilitators and barriers to naloxone prescribing. Methods In Aim 1, a repeated measures, retrospective cohort design with a fixed effects negative binomial model was used to evaluate the impact of implementation strength (proportion of providers exposed to exposed to academic detailing) on total number of naloxone prescriptions prescribed for each VA station from October 2014 to December 2017. Setting was in the VA system, which consists of 130 stations comprised of VA Medical Centers and their surrounding clinics. I evaluated a closed cohort of primary care providers who wrote a prescription for an opioid. In Aim 2, a mixed methods design was used to explore providers’ perception of academic detailing and naloxone prescribing using a survey and identify barriers and facilitators using semi-structured phone interviews. Online survey was developed based on a conceptual framework using existing theories (Theory of Planned Behavior, Social Marketing Theory, and the Framework for effective implementation), tested for face validity, and deployed to providers using who recently received an OEND-specific academic detailing visit within 2 to 4 weeks across the VA. Semi-structured phone interviews were conducted with providers who finished the survey and agreed to continue their participation. Results In Aim 1, there was a total of 5,452 providers who wrote for an opioid prescription. Increasing the proportion of providers exposed to academic detailing at each VA station from 0% to 100% was associated with a of 5.51 times higher incidence (95% CI: 1.86, 16.27) in the monthly number of naloxone prescriptions prescribed. Alternatively, this was a 9.13 increase in the monthly number of naloxone prescriptions. In Aim 2, 137 (12.2%) providers completed the survey. The average domain score for responders was highest for Satisfaction (6.28) followed by Attitude (6.02), Knowledge (5.96), Social norms (5.64), and Perceived barriers (4.86). Knowledge, Social norms, and Satisfaction domains were similar across the different provider types. However, pain specialists had a higher Attitude score (+0.56, P=0.011) and Perceived barriers score (+0.82, P=0.009) than primary care providers. A total of 11 responders participated in phone interviews. Participants identified limited time, poor data integration, social stigma, and lack of homeless support as barriers to prescribing naloxone. A patient list generated by academic detailers was identified as a facilitator to prescribing naloxone. Conclusions By combining the findings from these different approaches, I was able to develop a deeper understanding of academic detailing’s effectiveness to increase naloxone prescriptions prescribed as its phenomena for augmenting providers’ naloxone prescribing behavior.