Table 4.
Summary of qualitative and quantitative findings regarding key hypotheses
| Hypothesis | Quantitative results | Qualitative results | Interpretation |
|---|---|---|---|
| Providers achieve high retention by offering “low-threshold” care. | Supported: higher starting buprenorphine dose and fewer BH visits were more common among treatment episodes achieving retention (Table 1); matched high-retention providers had treatment episodes with fewer BH visits (Supplementary Material 4). | Supported: all low-retention providers used high-threshold practices compared to half of high-retention providers, with the requirement to participate in psychosocial services being the most frequently used high-threshold practice (Table 3). | This hypothesis was supported by our quantitative and qualitative findings. The requirement to participate in psychosocial services appeared especially important in limiting buprenorphine treatment retention. |
| Providers achieve high retention by offering more comprehensive services. | Not supported: in adjusted models, there was no difference in retention between care delivered in office or BH settings (Table 2); matched high retention providers were more often located in office settings, but this difference wasn’t statistically significant (Supplementary Material 4). | Opposed: more low-retention providers reported offering on-site psychological, peer support, or case management services (Table 3). | High-retention providers less frequently offered psychosocial services. This may be explained by the fact that participation in psychosocial services where available was often mandatory, creating a barrier to retention. |
| Providers achieve high retention by offering lower cost care. | Not assessed: the Medicaid claims data we used represent Medicaid payments but do not offer direct insights into out-of-pocket costs for patients. | Equivocal: more low-retention providers accepted Medicaid, but some of these providers required patients pay out-of-pocket for psychosocial services (Table 3); providers generally cited cost as a barrier to treatment retention. | The relationship between cost and retention is confounded by the fact that providers who accepted Medicaid also frequently required participation in services that required out-of-pocket spending. Cost is likely a barrier to retention, as providers generally mentioned it being, but we could not determine that offering lower cost care was reliably employed by providers in our sample to improve retention. |
| Providers achieve high retention because their patients prefer longer treatment. | Not assessed: patient preferences could not be assessed with claims. | Supported: More low-retention providers mentioned that patients at times chose to stop treatment (Table 3). | We could not rule out this hypothesis. However, we believe that low-retention providers’ use of burdensome high-threshold practices likely explains why they more often reported that their patients stopped treatment. |
| Providers achieve high retention through better therapeutic relationships. | Not assessed: the quality of therapeutic relationships could not be assessed with claims. | Not assessed: the quality of therapeutic relationships could not be directly assessed but more low-retention providers mentioned conflicts with patients (Table 3). | We could not directly assess this hypothesis, but low-retention providers more often mentioned conflicts with patients. This may be because these providers used more high-threshold practices that led to conflicts with patients, or because these providers were otherwise unable to form as therapeutic relationships with patients. |
| Providers achieve high retention by selecting more stable patients. | Not supported: sicker patients had lower retention in adjusted models (Table 2) but coarsened exact matching balanced groups on measures of OUD severity and comorbidity (Supplementary Material 4). | Not supported: the same number of high- and low-retention providers indicated selecting for more stable patients (Table 3). | We could not rule out that this practice takes place out of our sample, but we did not find evidence to support this hypothesis among our matched group of providers. |
For each hypothesis of how providers may achieve high retention, the table summarizes whether quantitative and qualitative methods did not assess, did not support, supported, were equivocal, or opposed the hypothesis. “Opposed” is used to designated findings that suggest an opposite relationship than the hypothesis, in contrast to “not supported,” which merely designates absence of support.