TY - JOUR
T1 - Nurse Care Management for Opioid Use Disorder Treatment
T2 - The PROUD Cluster Randomized Clinical Trial
AU - Wartko, Paige D.
AU - Bobb, Jennifer F.
AU - Boudreau, Denise M.
AU - Matthews, Abigail G.
AU - McCormack, Jennifer
AU - Lee, Amy K.
AU - Qiu, Hongxiang
AU - Yu, Onchee
AU - Hyun, Noorie
AU - Idu, Abisola E.
AU - Campbell, Cynthia I.
AU - Saxon, Andrew J.
AU - Liu, David S.
AU - Altschuler, Andrea
AU - Samet, Jeffrey H.
AU - Labelle, Colleen T.
AU - Zare-Mehrjerdi, Mohammad
AU - Stotts, Angela L.
AU - Braciszewski, Jordan M.
AU - Murphy, Mark T.
AU - Dryden, Douglas
AU - Arnsten, Julia H.
AU - Cunningham, Chinazo O.
AU - Horigian, Viviana E.
AU - Szapocznik, José
AU - Glass, Joseph E.
AU - Caldeiro, Ryan M.
AU - Phillips, Rebecca C.
AU - Shea, Mary
AU - Bart, Gavin
AU - Schwartz, Robert P.
AU - McNeely, Jennifer
AU - Liebschutz, Jane M.
AU - Tsui, Judith I.
AU - Merrill, Joseph O.
AU - Lapham, Gwen T.
AU - Addis, Megan
AU - Bradley, Katharine A.
AU - Ghiroli, Megan M.
AU - Hamilton, Leah K.
AU - Hu, Yong
AU - Lahue, Jennifer S.
AU - Loree, Amy M.
AU - Murphy, Sean M.
AU - Northrup, Thomas F.
AU - Shmueli-Blumberg, Dikla
AU - Silva, Angela J.
AU - Weinstein, Zoe M.
AU - Wong, Mark Tinfook
AU - Burganowski, Rachael P.
N1 - Publisher Copyright:
© 2023 American Medical Association. All rights reserved.
PY - 2023/12/4
Y1 - 2023/12/4
N2 - Importance: Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective: To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants: The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention: The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures: The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results: During the baseline period, a total of 130623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10000 PC patients compared with UC clinics (P =.002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P =.70). Conclusions and Relevance: The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration: ClinicalTrials.gov Identifier: NCT03407638.
AB - Importance: Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective: To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants: The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention: The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures: The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results: During the baseline period, a total of 130623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10000 PC patients compared with UC clinics (P =.002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P =.70). Conclusions and Relevance: The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration: ClinicalTrials.gov Identifier: NCT03407638.
UR - http://www.scopus.com/inward/record.url?scp=85178614970&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85178614970&partnerID=8YFLogxK
U2 - 10.1001/jamainternmed.2023.5701
DO - 10.1001/jamainternmed.2023.5701
M3 - Article
C2 - 37902748
AN - SCOPUS:85178614970
SN - 2168-6106
VL - 183
SP - 1343
EP - 1354
JO - JAMA internal medicine
JF - JAMA internal medicine
IS - 12
ER -