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Author Notes:

Eric J. Hawkins, PhD, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S Columbian Way, Seattle, WA 98108. Email: eric.hawkins@va.gov

Dr Hawkins and Ms Malte had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Hawkins, Malte, Gordon, Williams, Hagedorn, Drexler, Knoeppel, Danner, Saxon. Acquisition, analysis, or interpretation of data: Hawkins, Malte, Gordon, Williams, Blanchard, Burden, Danner, Lott, Liberto, Saxon. Drafting of the manuscript: Hawkins, Gordon, Williams, Saxon. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Malte. Obtained funding: Hawkins, Williams, Saxon. Administrative, technical, or material support: Hawkins, Malte, Gordon, Williams, Hagedorn, Drexler, Burden, Danner, Lott, Liberto, Saxon. Supervision: Hawkins.

We thank all the clinicians who made the SCOUTT initiative possible.

Dr Hawkins reported receiving grants from the US Department of Veteran Affairs (VA)/VA Health Services Research and Development Quality Enhancement Research Initiative Partnered Evaluation Initiative during the conduct of the study. Dr Gordon reported receiving grants from the VA for work performed during the conduct of the study and grants from the National Institutes of Health and the VA as well as an honorarium and royalty for a chapter in UpToDate outside the submitted work. Dr Williams reported receiving operational/medical dollars to support implementation evaluation from the VA during the conduct of the study. Dr Hagedorn reported receiving grants and partial salary funding from the VA Health Services Research and Development Quality Enhancement Research Initiative during the conduct of the study. Dr Saxon reported serving on the advisory board of Indivior Inc and Alkermes Inc and receiving travel support from Alkermes Inc and royalties from UpToDate outside the submitted work. No other disclosures were reported.


Research Funding:

This work was supported by Partnered Evaluation Initiatives 18-203 (Dr Hawkins, principal investigator) and 19-001 (Dr Gordon, principal investigator) from the VA, Office of Mental Health and Suicide Prevention, Veterans Health Administration, the VA Center of Excellence in Substance Addiction Treatment and Education, and the VA Health Services Research and Development Quality Enhancement Research Initiative.


  • Aged
  • Cohort Studies
  • Female
  • Health Services Accessibility
  • Humans
  • Male
  • Middle Aged
  • Opiate Substitution Treatment
  • Opioid-Related Disorders
  • Primary Health Care
  • United States
  • United States Department of Veterans Affairs
  • Veterans
  • Veterans Health Services

Accessibility to Medication for Opioid Use Disorder after Interventions to Improve Prescribing among Nonaddiction Clinics in the US Veterans Health Care System

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Journal Title:

JAMA Network Open


Volume 4, Number 12


, Pages e2137238-e2137238

Type of Work:

Article | Final Publisher PDF


Importance: With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. Objective: To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. Design, Setting, and Participants: This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. Exposures: The multifaceted implementation intervention included education, external facilitation, and quarterly reports. Main Outcomes and Measures: The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Results: Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). Conclusions and Relevance: A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access. 2021 Hawkins EJ et al.

Copyright information:

2021 Hawkins EJ et al. JAMA Network Open.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/rdf).
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