(63) Addressing Gaps in Buprenorphine Treatment Among Black and Non-English-Speaking Patients

Background &

Introduction: Despite a 10% decrease in overdose deaths across Massachusetts in 2023, the death rate increased over the same time period among Black residents. These inequities in overdose mortality mirror national trends. Buprenorphine is an effective medication for opioid use disorder (OUD) shown to reduce mortality by more than 50%, yet studies have shown it is prescribed less often to individuals who are Black, Hispanic, or speak a language other than English.
In 2021, Mass General Brigham (MGB), an integrated academic healthcare system, set a goal to eliminate racial and ethnic inequities in substance use disorder (SUD) treatment and outcomes. To achieve this, we developed a structure, process, outcome framework for process improvement. The first two years focused on structural changes to expand access to SUD care through the establishment of low barrier bridge clinics, with the idea that they would lead to measurable improvements in treatment initiation and retention in care, and ultimately improvements in health, quality of life and reductions in overdose mortality. In 2023 focus shifted to the process step of targeting buprenorphine treatment with a goal of reducing the gap between Black and white patients and English speaking and those with limited English proficiency by 50%.

Methods: The buprenorphine treatment rate was defined as patients who had an encounter between October 2022 and September 2023 in an MGB care setting associated with a diagnosis for OUD or opioid overdose based on ICD codes who were prescribed or administered buprenorphine. Data was extracted from the electronic health record to determine baseline treatment rates and equity gaps. A dashboard was created which was updated monthly with trends in buprenorphine treatment by race and language and to assess progress in closing the equity gaps. Monthly performance was monitored and provided to site leaders. Monthly discussions were scheduled with site leaders to review the data and discuss process improvement.

Process improvement interventions in addition to regularly sharing data with site leaders, included developing clinical decision support (CDS) within the electronic health record to nudge providers to consider buprenorphine prescription and referral to a bridge clinic for patients with untreated OUD. In addition, an education campaign for providers and patients was launched with videos and printed material providing information about buprenorphine and challenging common myths.

Results: The baseline treatment rate in September 2023 was 39.28% for Black patients and 47.19% for white patients, with a gap of 7.9%. The baseline treatment rate was 28.04% for limited English proficient (LEP) patients and 46.67% for English proficient (EP) patients, with a gap of 18.6%. A 50% relative reduction of the gap between Black and White and EP and LEP patients was set as a target. In September 2024, the treatment gap was reduced by 24% to a gap of 6% between Black (40.8%) and White (46.8%) patients. In September 2024, the treatment gap for LEP and EP patients increased by 9.7% to a gap of 20.4% between English (25.9%) and non-English (46.3%) patients.

The CDS tool within the electronic health record launched in May 2024. Since launching, the CDS resulted in 190 emergency room providers opening the suggested order set and placed orders 7.5% of the time. These orders included 11 medication orders to treat OUD and 12 referrals to an MGB bridge clinic for follow up care. Forty-one inpatient providers placed orders 4.9% of the time including one MGB bridge clinic referral and one medication order. Additionally, 368 outpatient providers placed orders 1.4% of the time. These included four MGB bridge clinic referrals and one medication order.

MGB conducted a campaign in September 2024 focusing on medication hesitancy from the provider and patient perspective. The campaign disseminated printed material and informational videos throughout hospital settings as well as public facing impressions throughout the Boston and North Shore areas of Massachusetts. Materials and video included information specific to MOUD medication, breaking down the myths of prescribing, and information on how to access treatment. From this campaign there were 7,269,647 impressions, resulting in 1,094 visits to the MGB SUD website.

Conclusion &

Discussion: A multipronged process improvement effort to reduce racial and language inequity in buprenorphine treatment rates which included regular sharing of performance data with leadership, development of a CDS tool, and an educational campaign had a modest effect on reducing the racial inequity in buprenorphine treatment for Black patients but no impact on reducing inequity by language. More tailored interventions are needed to further reduce racial inequity in buprenorphine treatment and to begin to reduce inequity by language.

References:
1. DPH report: Massachusetts opioid-related overdose deaths decreased 10 percent in 2023. DPH report: Massachusetts opioid-related overdose deaths decreased 10 percent in 2023 | Mass.gov
2. Wakeman SE, Lambert E, Kung S, et al. Trends in Buprenorphine Treatment Disparities during the COVID Pandemic in Massachusetts. Substance Abuse. 2022;43(1):1317-1321. doi:10.1080/08897077.2022.2095077
3. Stevens MA, Tsai J, Savitz ST, et al. Trends and Disparities in Access to Buprenorphine Treatment Following an Opioid-Related Emergency Department Visit Among an Insured Cohort, 2014-2020. JAMA Netw Open. 2022;5(6): e2215287. doi:10.1001/jamanetworkopen.2022.15287
4. Chhabra N, Smith D, Dickinson G, et al. Trends and Disparities in Initiation of Buprenorphine in US Emergency Departments, 2013-2022. JAMA Netw Open. 2024;7(9):e2435603. doi:10.1001/jamanetworkopen.2024.35603
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