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

Study Objective: 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.

Methods: 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.

Results: 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.

Conclusion: 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.