iHOST

Research question: Does the iHOST toolkit reduce delays in opioid substitution therapy (OST) administration in two hospitals compared to historical local data, and does this lead to reduced discharge against medical advice (DAMA) and emergency readmission of people who use opioids (PWUO) compared to historical local rates and a national comparator cohort? Background: OST is associated with improved health and social outcomes for PWUO. Continuity of community OST prescribing in hospital settings can be poor, resulting in negative patient experiences, DAMA, and increased costs. There are over 261,000 PWUO in England, of whom 140,000 receive OST. This is an aging population with complex health problems who disproportionately access accident and emergency (A&E) services. The team's research and international evidence show that fear of opioid withdrawal and delayed OST provision in A&E and hospital wards is a primary barrier to timely presentation and completion of care for PWUO. This leads to poor outcomes as well as complex, expensive, and avoidable healthcare. In 2019 we conducted workshops with service users and treatment providers to understand how to address these problems. The outcome of the workshops was the iHOST concept. iHOST consists of: 1) a patient advocacy card; 2) a helpline; 3) hospital staff training; 4) a policy template; and 5) an iHOST 'champion'. Aims and objectives: We aim to optimise OST management in hospital settings nationally to reduce delayed presentation, DAMA and emergency readmission among PWUO. We will: 1. Optimise iHOST components and test feasibility in a London hospital. 2. Evaluate intervention acceptability, fidelity, reach, costs and impact in a rural and urban hospital. 3. Develop and disseminate toolkits for national implementation. Methods: Quasi-experimental design. Our primary outcomes: DAMA; emergency readmission within 28 days of discharge, will be measured through a difference-in-difference analysis of routinely collected clinical data at two iHOST evaluation sites. Hospital Episode Statistics (HES) will provide national comparator data for a controlled analysis of the primary outcomes. A qualitative process evaluation, involving in-depth interviews, focus groups and site observations with PWUO and healthcare providers, will assess iHOST acceptability, implementation barriers and facilitators, and contextual factors impacting outcomes. This is a 4-phase study, involving three geographic sites. Systematic iHOST optimisation (phase 1) and feasibility testing (phase 2) will be carried out in collaboration with University College London Hospital providers, PWUO, and linked drug treatment services. Mixed-method evaluation (phase 3) will take place at Staffordshire and Leeds hospitals and linked drug treatment services. Co-development of outputs and dissemination strategy (phase 4) will involve PWUO and providers at all sites. Timelines: We will deliver this project over 36 months: Optimisation Phase 1, months 1-8; Feasibility Phase 2, months 9-14; Evaluation Phase 3, months 15-28; Dissemination Phase 4, months 29 - 36. Anticipated impact: This timely and innovative study aims to optimise and scale a toolkit that will enable hospitals to implement and embed evidence-based practice for optimal management of OST. The intervention is very low cost and has the potential to make a significant high value impact on the care and treatment outcomes for PWUO nationally.