Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.

OBJECTIVES To evaluate the effects of the U.S. Veterans Health Administration (VA) National Academic Detailing Service alongside the Opioid Overdose Education and Naloxone Distribution (OEND) program on naloxone prescriptions prescribed from October 2014 to September 2016. METHODS A retrospective, repeated measures cohort study was conducted to evaluate the effectiveness of a real-world application of academic detailing (AD) alongside OEND on providers' outpatient naloxone prescribing from October 2014 to September 2016. Outcome was the number of naloxone prescriptions prescribed per month per provider. During the study period, VA providers were aware of OEND, but may not have been exposed to academic detailing. Therefore, providers were categorized as exposed when the first OEND-specific academic detailing session was provided during the study period. Generalized estimating equations were used to estimate the association between exposure to academic detailing and monthly naloxone prescriptions prescribed while taking into account the correlation within each provider. Incident rate ratios with 95% CIs were reported. RESULTS Seven hundred fifty (22.6%) of 3313 providers received at least 1 OEND-specific academic detailing visit. At 1 year, the average number of naloxone prescriptions per month was 3-times greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0-5.3); and at 2 years, the average number of naloxone prescriptions was 7-times greater (95% CI 3.0-17.9). Moreover, the average difference in naloxone prescribing from baseline to 2 years was 7.1% greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0%-12.5%). CONCLUSIONS This preliminary analysis provides the first evidence that academic detailing influenced naloxone prescribing rates in a large, integrated health care system at 1 and 2 years. In addition, AD-exposed providers had a higher average difference in naloxone prescribing rate compared with AD-unexposed providers after 2 years of follow-up.

[1]  Shane R Mueller,et al.  Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff , 2015, Journal of General Internal Medicine.

[2]  Rose A Rudd,et al.  Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014. , 2016, MMWR. Morbidity and mortality weekly report.

[3]  C. Wilder,et al.  A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs , 2014, Journal of addiction medicine.

[4]  I. Ajzen.  The theory of planned behavior , 1991 .

[5]  C. Fox,et al.  Using a Clinical Practice Guideline to Measure Physician Practice: Translating a Guideline for the Management of Heart Failure , 1997, The Journal of the American Board of Family Medicine.

[6]  S. Zeger,et al.  Longitudinal data analysis using generalized linear models , 1986 .

[7]  J. Stock,et al.  Instrumental Variables Regression with Weak Instruments , 1994 .

[8]  M. Goldstein,et al.  Academic detailing to improve antihypertensive prescribing patterns. , 2003, American journal of hypertension.

[9]  S. Galea,et al.  Accidental Poisoning Mortality Among Patients in the Department of Veterans Affairs Health System , 2011, Medical care.

[10]  Benjamin French,et al.  Analysis of longitudinal data to evaluate a policy change , 2008, Statistics in medicine.

[11]  P. Austin.  An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies , 2011, Multivariate behavioral research.

[12]  Corey S Davis,et al.  Patient Perspectives on An Opioid Overdose Education and Naloxone Distribution Program in the U.S. Department of Veterans Affairs , 2016, Substance abuse.

[13]  R. Heimer,et al.  Barriers to Medical Provider Support for Prescription Naloxone As Overdose Antidote for Lay Responders , 2013, Substance use & misuse.

[14]  Shannon C Miller,et al.  Knowledge of and interest in opioid overdose education and naloxone distribution among US veterans on chronic opioids for addiction or pain , 2016 .

[15]  J. Zenilman,et al.  Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach. , 2008, Journal of hospital medicine.

[16]  Gary A. Ballinger,et al.  Using Generalized Estimating Equations for Longitudinal Data Analysis , 2004 .

[17]  D. Wermeling,et al.  Intranasal naloxone administration for treatment of opioid overdose. , 2014, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[18]  David S. Lee,et al.  Regression Discontinuity Designs in Economics , 2009 .

[19]  S. Counsell,et al.  A conceptual model for the process of IT innovation adoption in organizations , 2012 .

[20]  S B Soumerai,et al.  Principles of educational outreach ('academic detailing') to improve clinical decision making. , 1990, JAMA.

[21]  M. Christopher,et al.  VA Academic Detailing Service: Implementation and Lessons Learned. , 2016, Federal practitioner : for the health care professionals of the VA, DoD, and PHS.

[22]  Steven A. Sumner,et al.  Use of Naloxone by Emergency Medical Services during Opioid Drug Overdose Resuscitation Efforts , 2016, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[23]  Alex H. S. Harris,et al.  Multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder: interrupted time series evaluation of effectiveness , 2016, Addiction Science & Clinical Practice.

[24]  Challenges in Measuring Adherence to Clinical Practice Guidelines , 1997, The Journal of the American Board of Family Medicine.

[25]  J. M. Villa.  Simplifying the estimation of difference in differences treatment effects with Stata , 2012 .

[26]  Stephen B. Soumerai,et al.  Improving Drug-Therapy Decisions through Educational Outreach , 1983 .

[27]  R. Kerns,et al.  Trends and Regional Variation in Opioid Overdose Mortality Among Veterans Health Administration Patients, Fiscal Year 2001 to 2009 , 2013, The Clinical journal of pain.

[28]  D. Rubin,et al.  The central role of the propensity score in observational studies for causal effects , 1983 .

[29]  D. Albarracín,et al.  A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. , 2005, Psychological bulletin.

[30]  Al Ozonoff,et al.  Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis , 2013, BMJ.

[31]  S. Greenland.  An introduction To instrumental variables for epidemiologists , 2000, International journal of epidemiology.

[32]  D. Campbell,et al.  Regression-Discontinuity Analysis: An Alternative to the Ex-Post Facto Experiment , 1960 .

[33]  Al Ozonoff,et al.  Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study , 2014, BMC Public Health.

[34]  J. Shaw,et al.  Error reduction: academic detailing as a method to reduce incorrect prescriptions , 2003, European Journal of Clinical Pharmacology.