Implementation and Clinical Outcomes of Facilitated Telemedicine in Opioid Treatment Programs: A Hybrid Effectiveness-Implementation Analysis

Background Hybrid effectiveness-implementation designs evaluate the effectiveness and implementation of interventions. We retrospectively evaluated the implementation of a stepped-wedge cluster randomized controlled trial (RCT) of a facilitated telemedicine model (experimental) integrated into opioid treatment programs (OTPs) compared to offsite referral (control) for hepatitis C virus (HCV) treatment. We compared organizational and implementation characteristics associated with an HCV cure and with high healthcare delivery satisfaction. Methods We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM)-QuEST framework to guide data collection and evaluation. We evaluated the clinical effectiveness outcome (HCV cure) and patient centered outcomes (changes between in-person and telemedicine patient satisfaction questionnaire subscales: time spent with doctor, interpersonal manner, accessibility and convenience, and general satisfaction). We combined patient and organization-level information to conduct a configurational comparative method of coincidence analysis (CNA) to identify strategy configurations associated with each outcome. We also utilized the random forest method to identify the most important variables and reran the CNA analysis. For contextual interpretation, we discussed stakeholders’ perceptions of the findings through focus group discussions. Results Using RE-AIM-QuEST, in terms of reach, the RCT enrolled 96.5% of the original projected sample. We found that low patient load per provider or counselor, site liaison presence, and approaches that promoted case manager integration into site workflows, were associated with increased clinical effectiveness. When evaluating organization factors associated with high satisfaction with healthcare delivery, we found that approaches that promote communication, patient and staff education, and site liaison presence were important in the facilitated telemedicine arm. In the referral arm, additional important factors identified included the ability of the case manager to explain the referral process and OTP affiliation with a university. In terms of telemedicine implementation, free-standing sites and low patient volume were associated with high satisfaction. In the referral arm, university affiliation was an important factor. Conclusions Factors associated with communication, addressing participants’ concerns, and case manager integration within OTP workflows are important for successful implementation of facilitated telemedicine. Using these combinations may be important for expanding and evaluating HCV treatment uptake and for understanding successful implementation of telemedicine-based interventions in underserved populations. Trial registration Clintrials.gov registration number NCT02933970; Comparison of Telemedicine to Usual Care for HCV Management for Methadone-maintained Individuals - Full Text View - ClinicalTrials.gov