Background and significance: To mitigate the risks of adverse outcomes of opioid therapy, the VA Office of Mental Health Operations (OMHO) and the National Pain Management Program developed a tool to estimate and display the risk of adverse outcomes among patients prescribed opioids. Known as the Stratification Tool for Opioid Risk Management (STORM), the data dashboard displays individual patients? level of risk, specific clinical risk factors, use of recommended risk mitigation strategies, and pain treatments. STORM is available for use by the field, but there is uncertainty about how to achieve consistent utilization across VA Medical Centers (VAMCs) and maximize its effectiveness in reducing opioid-related adverse events. The overall objective of this service-directed project is to perform, in collaboration with OMHO and the Partnered Evidence-Based Policy Resource Center (PEPReC), a randomized program evaluation that will allow the VA to randomize VAMCs to different STORM rollout conditions using a stepped-wedge design. This innovative feature will allow the VA to evaluate the impact of different rollout conditions on STORM uptake and clinical impact. Methodology and expected results: All VAMCs will receive a policy memorandum mandating STORM-facilitated case reviews of patients at high risk for opioid-related adverse events. VAMCS will be randomized to a policy that has consequences for not meeting target case review completion rates versus a policy without consequences. Subsequently, facilities will be randomized to perform case reviews on patients at the top 1% versus 5% of STORM risk scores in a stepped-wedge fashion. In this partnered evaluation, PEPReC will use VA administrative and clinical data to examine the effects of the randomized rollout on patient-level clinical outcomes. In parallel, a team of investigators from the Center for Health Research and Promotion (CHERP) will conduct facility-level quantitative and qualitative analyses to identify strategies used to implement STORM-facilitated case reviews across VAMCs nationally, as well as implementation barriers and facilitators at a subset of facilities. The CHERP evaluation consists of two overall aims.
Aim 1 a is to describe the number and type of strategies VAMCs used to implement the STORM policy and compare implementation strategies across the consequences and no consequences rollout arms.
Aim 1 b is to examine whether the number and type of STORM implementation strategies used by VAMCs predict achievement of the target case-review completion rate outlined in the STORM policy.
These Aims will be achieved by conducting an online survey of implementation strategies used across all VAMCs. Regression techniques will be used to compare the number and types of strategies across rollout arms (Aim 1a) and examine their associations with case review completion rates (Aim 1b).
Aim 2 is to identify barriers and facilitators to implementing the STORM policy and compare these barriers and facilitators across facilities in each STORM rollout arm. This will be achieved by interviewing key stakeholders at 40 VAMCs nationally using structured interview questions guided by the Consolidated Framework for Implementation Research. This randomized program evaluation provides a unique opportunity to identify the effect of STORM rollout variations and implementation strategies on STORM utilization and outcomes. The evaluation led by CHERP will yield critical insights that will enable OMHO and VA to refine policy implementation, and, synergistic with PEPReC?s evaluation, increase STORM?s clinical impact in accordance with VA priorities for a learning healthcare system.
Identifying patients at risk for adverse outcomes from prescription opioid therapy is an essential priority for VA, as it balances risks of opioid therapy with the need to appropriately treat pain. To address this need, the VA developed a predictive model ? known as STORM ? that estimates the risk of adverse outcomes, like overdoses, among patients who were prescribed opioids. To test whether use of STORM is effective, and to understand how this tool is being used, the VA will roll out a policy to VA facilities that requires use of STORM in a randomized fashion. Using a detailed national survey and in-depth interviews, our evaluation of this rollout will provide insights for the VA on how best to design policies to improve quality and safety for Veterans and how best to implement STORM across facilities to reduce opioid- related adverse events and improve the safe treatment of pain.
