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Hagedorn HJ, Sox-Harris AH, Wisdom J, Myrick D, Dawes M, Brown R, Oliva E. Implementation of Alcohol Dependence Pharmacotherapy and Treatment in Primary Care (ADAPT-PC). Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN.
Research Objective: Despite the high prevalence of alcohol use disorders (AUDs), in a given year, only 12.1% of those meeting diagnostic criteria receive any treatment. Most individuals with AUDs are identified in primary care settings and referred to substance use disorders clinics, however only a minority attend treatment services. Developing options for treatment within primary care settings may increase receipt of services for AUDs. Safe and effective pharmacological treatments exist that could be integrated into primary care settings. The objective of this study is to refine, implement and evaluate an intervention to integrate AUD treatment options, particularly pharmacological options, into primary care settings. Study Design: The implementation strategy targets several different stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local substance use disorders providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive ongoing external facilitation. Primary care providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification and tracking. Veterans with AUD diagnoses receive educational information in the mail and materials targeting patients are posted throughout the medical facilities. Formative evaluation (FE) methods follow Stetler's four-phase FE strategy and include developmental FE (pre-implementation interviews with champions, primary care providers and Veterans), implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions and rates of accessing patient dashboard), progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and substance use disorders specialty care) and interpretive FE (combining data from all phases as well as post-implementation interviews with champions and primary care providers). Analysis of FE data is guided by the Consolidated Framework for Implementation Research (CFIR). Effectiveness of the intervention is evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Population Studied: Three large Veterans Health Administration (VHA) medical facilities. Principal Findings: This paper will present the use of implementation theory to develop implementation and evaluation strategies. The paper will also present the results of the developmental portion of the FE and will demonstrate: 1) the use of CFIR to organize FE results, and 2) the use of developmental FE results to inform refinement of the implementation strategy. Conclusions: Designing an implementation strategy is a daunting task which can be more easily organized using implementation theory and a thorough understanding of the context in which the practice change will take place. Formative evaluation methods allow for monitoring and modification of strategies during the implementation phase to increase chances of successful practice change and to enhance understanding of implementation success or failure. Implications for Policy or Practice: If demonstrated to be successful, this implementation strategy will provide a replicable, feasible and relative low-cost method for integrating AUD treatment services into primary care settings, thereby increasing access to AUD treatment. Ongoing collaboration with VHA policy makers throughout the project, beginning in the planning phase, will foster dissemination of project findings.
