This is the first study, to our knowledge, to assess changes over time in commonly-reported barriers to providing MOUD associated with a large scale implementation of MOUD delivery in non-SUD specialty VA outpatient settings [12]. Contrary to our hypothesis, improvement was not shown in ratings of most implementation-related factors, despite SCOUTT consisting of multiple discrete implementation strategies. Further, respondents’ lower ratings on MOUD filling an important gap in care at follow-up relative to baseline was the only statistically significant difference between ratings. Consistent with our hypothesis, we found no changes in perceptions of MOUD as time-consuming. Provider-reported barriers included lack of support in diagnosing and treating OUD, time needed for MOUD, and delays in credentialing waivered prescribers. Among provider ratings, leadership behavior and culture and measurement were the lowest scored among Inner Setting CFIR constructs.
Despite the lack of differences from baseline to follow-up in providers’ perceptions of commonly -cited barriers to MOUD provision, findings from the current study, as guided by the CFIR, have implications for further implementation efforts to ensure that patients with OUD receive low-barrier, effective treatment. Below we summarize implications of findings with respect to the CFIR domains of interest.
Intervention characteristics
Similar to findings from prior studies, providers had positive and stable views on the evidence, importance, and life-saving impact of MOUD [30]. In contrast to prior studies, few providers had concerns about patients diverting medications to treat OUD or about provision of MOUD detracting from or competing with other clinical duties [31, 32]. Further, providers’ views on these factors were consistent across survey administrations, suggesting that their experiences implementing MOUD did little to diminish the positive views reported at baseline.
Despite the SCOUTT initiative’s emphasis on assembling a team to deliver MOUD care, 1 in 3 providers had concerns about the time required to deliver MOUD, a barrier often reported by primary care providers in the literature [12, 19, 20, 30, 33]. Providers’ persistent views of the time demands of delivering MOUD suggest that increased experience with the intervention does not necessarily promote more efficient delivery, consistent with previous work [33]. Allowing for longer and/or more frequent visits, reducing caseloads of providers delivering MOUD, or adding case managers to teams may be necessary to address this barrier [30, 34]. It is also possible that participants endorsing this view were from teams that did not function cohesively or collaborate with each other to provide efficient care. More work is needed to understand if high functioning teams were able to address the time barrier often reported by providers delivering MOUD care.
Providers also reported delays in completion of credentialing and privileging processes required by each facility. As indicated on Table 1, the percentage of DEA waivered providers increased from 81% at baseline to 96% at follow-up; however, timely completion of these processes was among the most common barriers providers chose to report. Regulatory steps needed to obtain a waiver to prescribe buprenorphine are often identified as a barrier, with some advocating for eliminating this regulation [34, 35]. Perhaps, because waiver trainings were among the implementation strategies deployed, obtaining an x-waiver was not an identified barrier – rather, it is facility-specific policies on credentialing and privileging that delayed providers from delivering MOUD. Regardless, policy context strategies (i.e., one of two implementation strategy domains not directly addressed by SCOUTT) may be necessary. For example, standardizing credentialing and privileging across VA facilities may reduce delays in MOUD delivery. Because facilities are part of the VA healthcare system and expected to adhere the same clinical policies and guidelines, differences in facility-level prescribing policies were not anticipated. Assessing outer setting components that may influence successful implementation will be critical in future phases of the SCOUTT initiative.
Based on barriers of time and credentialing and privileging processes in the VA identified in part through interactions with SCOUTT teams, shortly after the initial year of SCOUTT, the VA distributed recommendations encouraging facilities to consider incentives (e.g., reduced panel sizes, financial remuneration) to promote the quality and timeliness of MOUD [36]. The recommendations also suggested eliminating credentialing and privileging barriers to MOUD implementation and affirmed that MOUD can be prescribed in all clinical environments. In addition, there have been calls to deregulate prescribing of buprenorphine for OUD to eliminate training requirements, X-waiver applications, and DEA audits, which deter prescribers from offering MOUD [34, 35]. Effective April 28, 2021, prescribers may apply for an X-waiver without completing training requirements that will allow them to prescribe buprenorphine to up to 30 patients [37].
Individual characteristics
The literature is sparse regarding job satisfaction, perceived support, and job-related self-esteem of providers delivering MOUD, and what is available is limited to primary care prescribers [30, 33, 38, 39]. Consistent with a prior study, our respondents from multiple disciplines reported high satisfaction with treating patients with OUD [38]. Further, providers reported positive views of their effectiveness and comfort working with patients who use opioids, as well as their knowledge of opioid use and related consequences, and ability to access support from colleagues. Although prior work has reported lack of prescriber/staff knowledge as a barrier to MOUD delivery [13, 19, 20, 26, 40, 41], respondents to the survey reported high ratings of OUD knowledge at baseline. This suggests that providers received adequate training prior to their involvement in SCOUTT and/or the early SCOUTT trainings provided them with knowledge needed to deliver MOUD. Alternatively, it may be that implementation teams at facilities were selected by regional network leadership based on their baseline knowledge of and experience with delivering MOUD. Contrary to expectations, knowledge ratings did not improve over time, despite several strategies focused on educating providers (e.g., monthly virtual educational trainings, community of practice meetings, access to consultation with local experts). Given the high mean score at baseline, the lack of improvement in knowledge may be due to a ceiling effect. Most of the prescribers who completed the survey at baseline had their DEA waiver to prescribe buprenorphine and over one-half had prescribed it to treat OUD in the 12 months prior to SCOUTT implementation, suggesting a knowledgeable and relatively experienced group of prescribers. Nonetheless, the multi-strategy intervention used in SCOUTT was sufficient for maintaining but not improving positive individual characteristics.
Inner setting
Providers endorsed MOUD as compatible with care delivered in their clinics and filling an important gap in care, though agreement with the latter question decreased significantly from baseline to follow-up. Given providers’ strong agreement with the scientific evidence and lifesaving potential of MOUD, this finding is likely not about changing views on the merit, importance, and potential impact of this treatment. Speculatively, it may reflect providers’ perception of low patient demand for MOUD in their clinics, changing perspectives on where care should be delivered, and/or experiencing MOUD delivery as more difficult and complex than anticipated [32, 33, 42].
Our finding that nearly one-half of respondents view their colleagues as lacking motivation or interest to deliver MOUD is a common finding in the literature [12, 30]. However, while ratings were stable across our study, previous qualitative longitudinal work has found that motivation to prescribe MOUD decreases over time [33]. One interpretation is that SCOUTT strategies were sufficient to maintain but not increase motivation from baseline. Financial strategies, which were not used in this project, such as prescriber-directed incentives to obtain an x-waiver and/or prescribe buprenorphine may encourage those with little interest to deliver MOUD [15, 43]. Physician-directed incentives have been associated with increases in physicians completing x-waiver training and the proportion of buprenorphine prescribing among clinical encounters involving an OUD [44].
Respondents’ mostly neutral ratings of leadership readiness to adopt new practices, promote team building, and promote communication persisted over time. Although prevalent in the broader implementation literature, few studies have identified leadership-related barriers in implementation of MOUD in outpatient settings. Among those studies, lack of leadership support was identified as a barrier to MOUD in VA residential facilities and community-based primary care, and lack of leadership support persisted but decreased over implementation phases in a primary care study [33, 45]. As ratings of leadership culture and behaviors were among the lowest of leadership ratings, it may be that the clinic leaders who implementation teams report to (e.g., chief of service or program lead) are influencing team dynamics and contributing to the stability, rather than improvement, of scores over time. Further, the dynamic between top clinical leaders and those at the team and/or clinic-level may have led to the provider-reported barrier of lack of support to diagnose and treat OUD [46]. This finding suggests implementation strategies directly targeting leaders may be necessary to improve implementation of stepped care for OUD. Additional work is needed to further understand how top clinical leaders influence providers' perception of support for MOUD and how leaders' involvement and support of MOUD delivery can be enhanced. Planning strategies that build buy-in from top leaders or involve executive boards with organizational support to prioritize change may influence clinical leaders’ willingness to promote and support MOUD delivery [15]. Further, providing opportunities for clinic-level leaders to communicate with top leaders about the types of support that would be most impactful in supporting providers’ commitment to MOUD implementation may also improve implementation effectiveness. Financial incentives for clinical leaders also may need to be considered to encourage leaders to prioritize provider-wide adoption and sustainment of MOUD delivery.
Because the VA is an integrated health care system with specialty substance use and mental health disorder services with national treatment guidelines, we considered components of the outer setting (e.g., external policies, incentives) to be less important to the SCOUTT initiative and did not include items related to this domain on the survey. However, several findings highlight the importance of this domain to the implementation of MOUD in the VA. The observed variation in the credentialing and privileging policies of x-waivered prescribers across participating facilities indicates that practices and policies can be influenced at the facility-level; changes in national policies and/or mandates may be needed to support implementation. Further, additional funding at the national-level may be needed to support financial incentives to encourage providers to adopt this new practice and facility leaders to commit adequate resources to spread and sustain MOUD at their facilities. As there are possibly other strategies at the external and/or VA organization level that are important to implementation, the lack of specific survey items to assess the outer setting is a limitation of this investigation. Further, implementation processes such as planning, executing plans and evaluating progress are all important components of implementation that were not examined by the survey, and thus represent another limitation of the current investigation. However, they will be addressed by other data collection approaches.
Limitations
Our project has several limitations in addition to those noted above. Although data were obtained from implementation teams from across 18 VA medical centers, these findings may not generalize to other VA or non-VA settings. Because regional leaders could select the implementation clinic location and team members, results may be biased in an unquantifiable manner. This may have been compounded by one regional network not responding to the follow-up survey. The sample size was too small to examine differences by clinic type or prescriber status, and the survey response rate of 50% is low, increasing likelihood of further response bias. There were changes in team memberships between baseline and follow-up, and we do not know how representative responses were of the entire SCOUTT team or how experienced new members were with regards to MOUD delivery. Because participants’ responses were anonymous, we were not able to link participants’ responses across survey administrations. Some survey items were developed specifically for the project and have not been validated. Our findings are limited to provider perceptions and do not examine MOUD outcomes. Although provider perceptions are a consistent barrier to MOUD, future work should examine how changes in perceptions impact rates of MOUD receipt and patient outcomes.
