Nudges and Incentives to Enhance the Opioid Treatment Workforce
Condition: Opioid Abuse (Disorder)
MeSH terms: Opioid-Related Disorders
Study type: Interventional

Summary: 
      This project seeks to examine a critical barrier to optimizing the health care workforce for
      the treatment of opioid use disorders. Without a dramatic increase in the number of primary
      care providers trained and comfortable with the many nuances of prescribing
      medication-assisted treatment (MAT), the staggering increases in opioid overdose deaths will
      continue to skyrocket. However, Drug Addiction Treatment Act (DATA) 2000 waiver training
      alone is not enough to facilitate prescribing for patients who desperately need services; an
      estimated 40% of physicians with waivers do not initiate MAT prescriptions. To address this
      problem, North Carolina developed a learning collaborative framework to promote MAT training.
      Learning collaboratives have been shown to be an efficacious approach to increase utilization
      of MAT, but engagement among providers in North Carolina has been low. To date, the need to
      encourage provider collaborative participation at scale has not been addressed. This is the
      critical problem focused on in this proposal.

      The death rate from accidental opioid overdoses continues to climb at an alarming rate, with
      overdose deaths in 2016 almost five times the number from 1999. The daily death rate from
      opioid overdoses in the U.S. alone is now estimated at 115, so every day that evidence-based
      treatment is not available leads to more preventable deaths. North Carolina is one of the
      states with both an opioid overdose death rate greater than the national average (11.9 vs
      10.4 deaths per 100,000, age-adjusted) and a rate of increase in opioid overdose deaths
      greater than the national average (19% vs. 16%). North Carolina is also one of four states
      with an Agency for Healthcare Research and Quality (AHRQ) funded Extension for Community
      Healthcare Outcomes (ECHO) MAT learning collaborative available to primary care practices,
      but engagement among providers is low. While the main barriers to engagement are incompletely
      understood, recent evidence from provider interviews conducted by the study team in December
      2017 and January 2018 suggest that one substantial barrier is the time required for weekly
      ECHO clinics.
    

Detailed description: 
      This study is designed to assess how to effectively recruit and enroll primary care providers
      into participation into an ECHO MAT learning collaborative. For study participants that
      enroll in the learning collaborative, the study team will track participation over 6 months.

      The study is designed to be implemented in two phases. Phase 1 is the recruitment phase.
      Providers will be randomized to receive recruitment letters and emails from 1 of 4
      conditions. Randomization for this phase will occur at the practice level, as determined by
      provider address.

      Participants that contact the study team and enroll in the study will begin Phase 2 of the
      study. In Phase 2 of the study participants will be randomly assigned to rewards for
      participation in ECHO MAT learning collaborative. Their participation in the learning
      collaborative will be tracked. Phase 2 of the study is a pilot.

      Recruitment:

      Primary care providers will receive recruitment letters, and may receive emails and phone
      calls based on the recruitment condition they are assigned to.

      Informed Consent:

      Since it is not possible to consent before recruitment, participants will complete the
      informed consent process at the beginning of Phase 2 of the study. The consent form will be
      shared with eligible participants when they contact the study team to enroll. Before
      enrolling in the ECHO MAT learning collaborative, participants will be asked to provide
      consent in order to enroll in the study.

      Randomization:

      Phase 1: Primary care providers will be randomized by practice to 1 of 4 study arms.
      Computerized randomization will assign practices to study arms, practices and primary care
      providers will have an equal chance of being randomized to each study arm .

      Phase 2: Eligible participants will be randomized to the Phase 2 study arm upon enrollment in
      the study. Randomization will be assigned using a predetermined randomly ordered list of
      study condition assignments. Upon enrolling in the study, the participants will be assigned
      to the condition that is next on the list. Participants will have an equal chance of being
      randomized to each study arm.

      Assessment:

      Assessment for Phase 1 will occur when participants contact study staff with interest in the
      study or to enroll. Any primary care providers that are sent letters but do not contact study
      staff will be included in study analyses as 'No' for outcomes for Phase 1.

      Assessment for Phase 2 will occur throughout the 6 months after participants enroll in the
      study. Outcomes for this study phase are related to participation in ECHO MAT learning
      collaboratives, which is tracked for each training by study staff.

      Detailed Description of the Intervention:

      Phase 1 recruitment letters are designed in a 2 (prosocial mention of need for primary care
      providers trained in opioid use disorder treatment vs. none) x 2 (mention of additional
      practice supports available for participation in training vs. none). This yields 4 study
      conditions for recruitment letters: 1) Letter including prosocial messages and additional
      mention of practice supports available for participation, 2) Letter including prosocial
      messages but no additional mention of practice support available for participation, 3) Letter
      including an additional mention of practice support available for participation but no
      prosocial messages, and 4) Recruitment as usual letter that does not include prosocial
      messages or an additional mention of practice support available for participation.

      Phase 2 examines participation in the learning community by group. Participants will be
      randomly assigned to 1 of 3 groups. At this time the investigators are not disclosing the
      Phase 2 conditions, and will disclose these at the end of the study, as approved by UNC's
      institutional review board (IRB).
    

Intervention name(s): Phase 1 Condition 1; Phase 1 Condition 2; Phase 1 Condition 3; Phase 1 Condition 4; Phase 2 Condition 1; Phase 2 Condition 2; Phase 2 Condition 3
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): Providers assigned to this condition will be sent recruitment materials that are 'recruitment as usual' (Phase 1 Condition 1). These materials will not include prosocial messaging and will not include an additional mention of financial support available for participation.; Providers assigned to this condition will be sent recruitment materials that include an additional mention of financial support available for participation, but will not include prosocial messaging (Phase 1 Condition 2).; Providers assigned to this condition will be sent recruitment materials that include prosocial messaging, but do not include an additional mention of financial support available for participation (Phase 1 Condition 3).; Providers assigned to this condition will be sent recruitment materials that include prosocial messaging and an additional mention of financial support available for participation (Phase 1 Condition 4).; Providers who enroll in the study and are assigned to this condition will be in this group. Other than the opportunity to participate in a learning collaborative, participants receive no compensation.; Providers who enroll in the study and are assigned to this condition will be in this group. In addition to the opportunity to participate in the learning collaborative, participants receive a reimbursement at 30% of the NC Medicaid rate for a patient visit.; Providers who enroll in the study and are assigned to this condition will be in this group. In addition to the opportunity to participate in the learning collaborative, participants receive a reimbursement at 100 percent of the NC Medicaid rate for a patient visit for their time participating in the learning collaborative.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Opioid Abuse Disorder