Providing Incentive for Emergency Physician X-Waiver Training: An Evaluation of Program Success and Postintervention Buprenorphine Prescribing

Abstract

Emergency department (ED) initiation of buprenorphine for patients with opioid use disorder increases treatment engagement but remains an uncommon practice. One important barrier to ED-initiated buprenorphine is the additional training requirement (X waiver). Our objective is to evaluate the influence of a financial incentive program on emergency physician completion of X-waiver training. Secondary objectives are to evaluate the program's effect on buprenorphine prescribing and to explore physician attitudes toward the incentive. We conducted a prospective, observational cohort study set in 3 urban academic EDs before and after implementation of a financial incentive program providing $750 for completion of X-waiver training. We describe program participation as well as rates of buprenorphine prescribing per opioid use disorder-related encounter before and after the intervention period, using electronic health record data. We also completed a postintervention physician survey assessing attitudes about the incentive program. Overall, 89% of eligible emergency physicians (56/63) completed the X-waiver training during the 6-week incentive period. In the 5 months after the incentive, buprenorphine prescribing per opioid use disorder-related encounter increased from 0.5% to 16% (Δ 15%; 95% confidence interval 10.6% to 19.9%), with substantial variability across sites (range 8% to 22% of opioid use disorder-related encounters). In a postintervention survey, 67% of participating physicians indicated that they would have completed the training for a lower amount. A financial incentive paying approximately half the clinical rate was effective in promoting emergency physician X-waiver training. The effect on ED-based buprenorphine prescribing was positive but variable across sites, and likely dependent on the availability of additional supports.