In a March 13, 2017, Health Affairs Blog post, Arthur Robin Williams, Edward Nunes, and Mark Olfson propose repurposing the "Cascade of Care" framework, once used to combat the HIV/AIDS crisis, to fight the opioid epidemic.
Williams and colleagues propose developing performance measures to track the success of the state grants across the five framework stages:
- Diagnosis among those affected
- Linkage to care among those diagnosed
- Medication initiation among those entering care
- Retention for at least six months among those initiating medication
- Continuous abstinence among those retained
We applaud Williams and colleagues for highlighting the concept of the cascade of care as a useful framework to address the opioid epidemic. To make this vision a reality, there are important steps that need to be taken to develop the framework's quality measures and how to use the measures to guide work with states, managed care organizations, localities, treatment providers, recovery support services, and others to end the opioid crisis.
Drawing On Federal Data Systems
Data for the cascade of care can draw on existing federal data collection systems. For example, the Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health (NSDUH) is the primary source for information on the prevalence of substance use disorders including opioid use disorders. Although federal data systems do not currently capture information on whether an individual with an opioid use disorder was diagnosed by a health professional or told by a professional that he or she had a substance use disorder, the first stage of the Cascade of Care Framework, this question could be added to the NSDUH or other national data sets such as those collected by the Centers for Disease Control and Prevention (CDC). For example, the CDC's National Health and Nutrition Examination Survey (NHANES) determines whether respondents have diabetes using fasting blood glucose levels. The NHANES also asks respondents whether they have ever been told that they have diabetes. Thus, we have a good understanding of the prevalence of undiagnosed diabetes. These data are evaluated to determine the characteristics of populations that need to be targeted for more aggressive screening, assessment, and outreach efforts. For those with substance use disorders, being told by a trusted and nonjudgmental health professional that you have a diagnosable and treatable disorder can be a critical first step of engaging in treatment.
The second stage of the framework—linkage to care among those diagnosed—is currently collected in the NSDUH survey. The NSDUH asks whether individuals received treatment for their substance use in the past year. Thus, one can track the percentage of individuals with addiction who received treatment.
The NSDUH also recently modified the collection of prescription drug information and now collects information on how many people received prescriptions for buprenorphine, one of the three medications approved by the Food and Drug Administration (FDA) to treat opioid use disorders. To our knowledge, federal data systems do not currently collect national data on treatment of opioid use disorders with methadone or long-acting injectable naltrexone, the other medications FDA approved to treat opioid use disorders.
National surveys may not be well suited to track the fourth stage—retention for at least six months among those initiating medication. However, the National Quality Forum recently endorsed a measure—Continuity of Pharmacotherapy for Opioid Use Disorder—that uses insurance claims data to measure the percentage of adults ages 18–64 with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment. Thus, health systems that adopt this measure will be able to track this quality measure. One could capture these data on a larger population level using claims data sets that capture a significant portion of the Medicare, Medicaid, and private insurance market.
Recovery Tracking
Most difficult and lacking from our national data systems is the final stage—continuous abstinence for six months among those retained and other positive outcomes from drug treatment. Substance use is not alone in this critical performance measure gap in health system and population-level outcome measures. Some state systems collect this information as part of their block grant reporting requirements, but these measures and others need additional development and testing before being adopted as a reliable and valid performance measure to track the opioid epidemic. Reaching out to individuals who are in recovery and no longer in active treatment requires that a system and tools be in place that encourage continuous contact with individuals who have received treatment to help them assess with professionals the status of their recovery.
Once a robust data collection system is in place to track performance, the barriers to eliminating the opioid crisis can be systematically targeted and the impacts of these initiatives can be systematically evaluated. These barriers include the lack of health system–wide screening and identification of individuals in need of treatment; poor care coordination to ensure that those identified are referred and admitted to treatment; provider and patient lack of understanding of the effectiveness of opioid use disorder medications, which has resulted in the low use of medications; lack of training about substance use disorders and their treatment among health professionals; lack of administrative and financial support for medical practices implementing medications; and too few providers who are trained and willing to deliver high-quality substance use treatment.
Provider Capacity And Use Of Quality Metrics
The cascade of care will provide a population-level view of the nation's performance in addressing the opioid epidemic. However, in addition to population-level statistics, two other types of data are critical to ensuring success in treating opioid use disorders: 1) data to identify provider and service capacity in states and substate areas and to identify the quality of service delivery, and 2) incentives that encourage providers to use quality measurement tools, to report measures, and to develop quality improvement plans when necessary.
The Centers for Medicare and Medicaid Services Substance Use Disorder Innovator Accelerator Program has been working with a number of state Medicaid directors and their staffs as they apply for 1115 substance use disorder waivers. As part of that effort, states are developing methods to identify provider capacity for delivering substance use disorder treatment services for opioid use disorders. Among the states leading the way are Virginia and Michigan as well as the County of Los Angeles.
Other states are leading the way in implementing a variety of incentives to improve quality of treatment. For example, Pennsylvania is using incentive payments in its integrated care program for incremental improvement on two quality measures; and, Vermont has created a public dashboard that includes comparative reporting on each of its "spokes" (enhanced primary care group practices around the state that provide treatment services to individuals with substance use disorders). In Rhode Island, medical homes sited in opioid treatment programs are required to provide performance data to the state in order to be paid an enhanced rate.
Many of the elements to implement the Cascade of Care Framework exist, in part or total, in various data systems and corners of the country. With the opioid epidemic still ranging, now is the time to pull these elements together into a comprehensive opioid use disorder tracking and delivery system.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2sPZpa6
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