By Mark Gold, MD
The Stratification Tool for Opioid Risk Management (STORM) is a safety initiative by the VA Healthcare System to help clinicians evaluate and mitigate opioid risks among their patients. VA commissioned an evaluation to understand the implementation strategies and factors associated with case review completion rates. A recently published report describes the evaluation protocol.
Opioid overdose rates have surged to become the number one cause of accidental deaths in the United States. In 2017, approximately 2.1 million people had an opioid use disorder, and 192 people a day died of a fatal overdose. Opioid use disorder is especially prevalent among veteran populations, and ensuring that patients’ pain care is as safe and effective as possible is a priority for the Veterans Affairs (VA) Healthcare System.
Opioid use among veterans
Previous studies conducted in VA Healthcare System and non-VA settings have established a significant association between prescription of higher opioid doses and increased risk of opioid overdose fatality. Studies also found that yearly opioid use prevalence rates are almost seven times greater in veteran patients than in the civilian population. In 2013, over 1 million veterans received opioids at the VA, a figure almost double that of 2001 when 651,000 Veterans received opioids. In 2013, 23% of VA pharmacy users received an opioid, compared to 19% in 2001.
What is STORM?
STORM’s predictive model and web-based dashboard help clinicians identify patients with an opioid prescription who are at high-risk of serious adverse events (SAEs) (such as overdoses, overdose death, or suicide) and target clinical interventions.
Updated daily, the STORM algorithm calculates a “risk score” for serious adverse events (SAEs) for each veteran receiving an opioid prescription, based upon demographic information, previous SAEs, substance use, and mental health history from electronic medical records. The STORM dashboard also highlights an array of risk factors applicable to each patient and tracks upcoming appointments to help practitioners coordinate care.
In March 2018, a national policy notice was issued by the VA requiring VA Medical Centers (VAMCs) to complete case reviews for patients that had been identified as high-risk by STORM. Half of the VAMCs were randomly assigned a policy notice stating that additional oversight and coaching would be required if they did not complete 97% of the necessary case reviews within 6 months.
Study protocol
This report, led by the team at the VA Center for Health Equity Research and Promotion (CHERP), aims to evaluate the implementation of the 2018 policy notice. The number and type of implementation strategies used by all VAMCs will be assessed through an online survey, as will the relationship between implementation strategies and the successful compliance of the STORM policy notice. The researchers will use regression models to compare the number and types of implementation strategies and their respective case review completion rates.
The study will also examine barriers and facilitators to assimilating data-based case reviews into clinical practice through interviews at a subset of facilities. The survey is based upon the Expert Recommendations for Implementing Change (ERIC) project, which engaged experts to come to a consensus on the 73 suggested implementation strategies. Questions from the Consolidated Framework for Implementation Research (CFIR) will be used to interview stakeholders at the 40 VAMCs with the highest and lowest adherence to opioid therapy guidelines.
Why is this important?
VA is the largest integrated healthcare system in the U.S., with a wide array of facilities that vary in size, location, number of patients, resources, services, and organization. Hence, coaching each VAMC to carry out case reviews is not feasible or practical. Instead, the STORM policy notice has enabled VAMCs and individual providers to determine the feasibility of using the STORM dashboard.
The simultaneous tracking of outcomes and how the implementation of this policy varies across VAMCs will further fortify VA’s ability to clarify, design and execute regionally and culturally appropriate protocols for care coordination across services, which will enhance the safety and efficacy of care at a national level.
Additionally, the authors believe that the program evaluation holds the potential to increase facility compliance and advance implementation science by connecting outcomes to specific implementation strategies.
Citation: Chinman, M., Gellad, W. F., McCarthy, S., Gordon, A. J., Rogal, S., Mor, M. K., & Hausmann, L. R. M. (2019). Protocol for evaluating the nationwide implementation of the VA Stratification Tool for Opioid Risk Management (STORM). Implementation Science, 14(1), 5.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.