Title: Improving Hospital Opiate Substitution Therapy (iHOST): implementation and assessment of an intervention to reduce late presentations, discharges against medical advice and repeat admissions among people who use opiates
Funder: Department of Health and Social Care

Abstract: Healthcare services can be inaccessible for people who use drugs such as heroin. Issues such as stigma mean that people in this group often seek help later than other patients. This leads to high use of accident and emergency (A&E) services and hospital admission for preventable conditions. When people who use heroin and other opiates are admitted to hospital, they usually need prompt medication e.g. opioid substitution therapy (OST) to prevent drug withdrawal. Our research finds that delays in OST provision lead to unsafe situations such as use of illicit drugs in hospital and self-discharge. Self-discharge is associated with emergency readmission within 28 days. This can cost over 50% more for each patient than if their initial treatment was completed._x000D_ _x000D_ There are an estimated 261,000 people who use illicit opiates in the UK, of whom 140,000 receive OST in the community. It is important to improve continuity of OST care in hospital settings. This should: a) help people feel supported to seek care early, b) reduce self-discharge, c) improve health outcomes and d) reduce repeat A&E attendance and readmission. In 2019, we requested policies on OST from all hospital trusts and conducted ten workshops with people who use drugs, doctors, nurses, pharmacists, charity and drug treatment staff, to understand the problem and identify solutions. With these stakeholders, we developed the iHOST (Improving Hospital Opioid Substitution Therapy) intervention._x000D_ _x000D_ iHOST consists of 5 components: _x000D_ 1. A ‘My Meds’ card for people on OST, with prescription information for hospital staff and advice for patients._x000D_ 2. A patient advocacy and information helpline. _x000D_ 3. Online training for hospital staff._x000D_ 4. A ‘best practice’ hospital OST policy template_x000D_ 5. A local iHOST ‘champion’_x000D_ _x000D_ iHOST is designed to improve and standardise OST management in hospital settings. Over 3 years this study will test and implement iHOST in 3 hospital settings (rural and urban) and linked drug treatment services. We will: 1st yr) work with London patients and providers to finalise, test and adapt iHOST; 2nd yr) implement iHOST and assess its acceptability, quality and impact at Staffordshire and Leeds hospitals; 3rd yr): refine and disseminate iHOST, develop protocols to help services adapt and use iHOST, and to inform future research._x000D_ _x000D_ We will measure intervention success with quantitative and qualitative methods. We will interview patients and providers to understand iHOST acceptability, uptake, and impact on practice. We will compare patient records at the sites before and after the intervention to assess the difference in discharge against medical advice and emergency readmission within 28 days. We will analyse NHS Hospital Episode Statistics (HES) data for these outcomes to provide a national comparison to the intervention sites. We will cost iHOST and assess its benefits to analyse its value for money._x000D_ _x000D_ We are a multi-disciplinary team with expertise in working to improve health care for marginalised populations. Two team members have personal experience of opioid dependency and OST. We will involve patients and service users throughout and work with them to ensure this project is inclusive and that outcomes are widely disseminated. iHOST is expected to make the hospital a more welcoming environment for people who use opioids. This promises patient benefits beyond physical health outcomes, with potential impact on self-esteem, linkage to care and substance use.

Lay abstract: Research question: Does the iHOST toolkit reduce delays in opioid substitution therapy (OST) administration in two hospitals compared to historical local data, and does this lead to reduced discharge against medical advice (DAMA) and emergency readmission of people who use opioids (PWUO) compared to historical local rates and a national comparator cohort?_x000D_ _x000D_ Background: OST is associated with improved health and social outcomes for PWUO. Continuity of community OST prescribing in hospital settings can be poor, resulting in negative patient experiences, DAMA, and increased costs. There are over 261,000 PWUO in England, of whom 140,000 receive OST. This is an aging population with complex health problems who disproportionately access accident and emergency (A&E) services. _x000D_ _x000D_ The team's research and international evidence show that fear of opioid withdrawal and delayed OST provision in A&E and hospital wards is a primary barrier to timely presentation and completion of care for PWUO. This leads to poor outcomes as well as complex, expensive, and avoidable healthcare. In 2019 we conducted workshops with service users and treatment providers to understand how to address these problems. The outcome of the workshops was the iHOST concept. iHOST consists of: 1) a patient advocacy card; 2) a helpline; 3) hospital staff training; 4) a policy template; and 5) an iHOST ‘champion’. _x000D_ _x000D_ Aims and objectives: We aim to optimise OST management in hospital settings nationally to reduce delayed presentation, DAMA and emergency readmission among PWUO. We will:_x000D_ _x000D_ 1. Optimise iHOST components and test feasibility in a London hospital._x000D_ 2. Evaluate intervention acceptability, fidelity, reach, costs and impact in a rural and urban hospital._x000D_ 3. Develop and disseminate toolkits for national implementation._x000D_ _x000D_ Methods: Quasi-experimental design. Our primary outcomes: DAMA; emergency readmission within 28 days of discharge, will be measured through a difference-in-difference analysis of routinely collected clinical data at two iHOST evaluation sites. Hospital Episode Statistics (HES) will provide national comparator data for a controlled analysis of the primary outcomes. A qualitative process evaluation, involving in-depth interviews, focus groups and site observations with PWUO and healthcare providers, will assess iHOST acceptability, implementation barriers and facilitators, and contextual factors impacting outcomes._x000D_ _x000D_ This is a 4-phase study, involving three geographic sites. Systematic iHOST optimisation (phase 1) and feasibility testing (phase 2) will be carried out in collaboration with University College London Hospital providers, PWUO, and linked drug treatment services. Mixed-method evaluation (phase 3) will take place at Staffordshire and Leeds hospitals and linked drug treatment services. Co-development of outputs and dissemination strategy (phase 4) will involve PWUO and providers at all sites._x000D_ _x000D_ Timelines: We will deliver this project over 36 months: Optimisation Phase 1, months 1-8; Feasibility Phase 2, months 9-14; Evaluation Phase 3, months 15-28; Dissemination Phase 4, months 29 - 36._x000D_ _x000D_ Anticipated impact: This timely and innovative study aims to optimise and scale a toolkit that will enable hospitals to implement and embed evidence-based practice for optimal management of OST. The intervention is very low cost and has the potential to make a significant high value impact on the care and treatment outcomes for PWUO nationally.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE