The need for a measurement-based care professional practice guideline.

Professional practice guidelines (PPGs) are intended to promote a high level of professional practice and serve as an educational resource, providing pragmatic guidance in a clinical area for psychologists. Measurement-based care (MBC) is an evidence-based psychological practice with accumulating empirical support and alignment with patient-centered care. In connection with the American Psychological Association's Advisory Committee for Measurement-based Care and the Mental and Behavioral Health Registry, this article outlines various lines of support for the development and implementation of an MBC PPG. In addition to research evidence, we address the demonstrated need of this guideline across three domains: public benefit, professional guidance, and legal and regulatory issues. Consistent with the aspirational spirit of a PPG, this article proposes a draft PPG statement and highlights how an MBC PPG would improve service delivery, facilitate implementation of an evidence-based practice associated with symptom reduction, improved retention, and greater patient satisfaction, as well as create a framework that will better align changes in reimbursement models with patients' and providers' treatment goals. We also identify key future directions and critical gaps in MBC science and implementation that require attention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change.

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

Virtual Behavioral Health for Army Soldiers: Soldier Perspectives and Patterns of Treatment.

Delivery of high-quality behavioral health (BH) care is essential to supporting the readiness of the U.S. armed forces and their families. The coronavirus disease 2019 (COVID-19) pandemic led to a dramatic expansion of virtual behavioral health (VBH) care: remote patient access to BH care using technology such as a computer or cellular phone. The U.S. Army asked RAND Arroyo Center to examine the use of VBH to inform recommendations on the role of VBH care in the future of BH care in the Military Health System. The authors analyzed administrative data on VBH and in-person BH care from prior to the pandemic through March 2022 and surveyed soldiers who received BH care to assess their perceptions of VBH care. Administrative data analyses showed that direct care providers were less likely to deliver VBH care than private-sector providers and relied heavily on audio rather than video VBH. In addition, soldiers who received VBH care typically received a mix of VBH and in-person visits. Survey respondents who used VBH care had similar perceptions of the quality of their care and more-positive views of VBH than respondents who did not use VBH care. Few respondents had declined VBH care in favor of in-person care. Using these findings, the authors make recommendations on the role of VBH care in overall BH delivered by the military.

The Impact of Mindfulness Meditation Programs on Performance-Related Outcomes: Implications for the U.S. Army.

Although studies have suggested that mindfulness-based interventions might be effective in enhancing military readiness and resilience, this has not been rigorously evaluated. This study presents results from a systematic review and meta-analyses of research examining how mindfulness meditation affects 13 performance-related outcomes of interest to the U.S. Army and broader military. The authors supplemented the systematic review by examining how mindfulness meditation could support stress management and exploring characteristics of selected mindfulness programs. The goal was to develop recommendations for mindfulness meditation programs for soldiers, should the Army choose to implement such programs in the future. Findings suggest that mindfulness may improve some aspects of attention and emotion regulation, impulsivity, and work-related morale and social support. The available evidence does not suggest that mindfulness improves other outcomes of interest to the Army. Notably, mindfulness meditation programs reduce stress and may reduce parental stress, which could benefit Army families. Yet more research is needed to identify best practices for implementing mindfulness programs in the military. The authors recommend conducting high-quality evaluations of mindfulness meditation with soldiers and assessing the effect of mindfulness meditation on military families.

Optimizing the Role of Military Behavioral Health Technicians: A Survey of Behavioral Health Technicians and Mental Health Providers.

Behavioral health technicians (BHTs), who are enlisted service members with the technical training to work alongside licensed mental health providers (MHPs), are an important part of the Military Health System (MHS) workforce. However, each service branch has different training requirements for BHTs, making it difficult to identify common qualifications across the BHT workforce and ensure that the MHS is making the best use of their skills. Building on prior RAND research that found inconsistencies in how BHTs were integrated across the force, researchers conducted what might be the largest survey to date of BHTs and MHPs. The results provide insights on BHTs' practice patterns, training and supervisory needs, and job satisfaction, as well as barriers to better integrating BHTs into clinical practice and steps that the MHS could take to optimize BHTs' contributions to the health and readiness of the force. Posing parallel sets of questions to BHTs and MHPs allowed comparisons of these groups' perspectives on these topics. The results revealed differences in views by service branch, time in practice, deployment history, and other characteristics. The researchers drew on these findings and recommendations to identify opportunities to optimize the BHT role.

Assessing the Quality of Outpatient Pain Care and Opioid Prescribing in the Military Health System.

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions. RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members.

Readiness of Soldiers and Adult Family Members Who Receive Behavioral Health Care: Identifying Promising Outcome Metrics.

Behavioral health (BH) conditions-such as posttraumatic stress disorder, depression, and anxiety-are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Military Behavioral Health Staff Perspectives on Telehealth Following the Onset of the COVID-19 Pandemic.

The COVID-19 pandemic prompted sweeping changes to behavioral health care delivery in the Military Health System (MHS), which turned to telehealth to minimize disruptions and ensure continuity of care for service members. Four to seven months into the pandemic, MHS behavioral health staff at ten military treatment facilities shared their experiences using telehealth and their perspectives on its utility, barriers to its wider integration in the MHS, and concerns about its use in the post-pandemic future. Telehealth use was previously low across the MHS, but it increased dramatically with the onset of the pandemic. At the time they were interviewed, nearly all providers who treated service members with posttraumatic stress disorder, depression, or substance use disorders were using audio-only telehealth in some capacity. Although most were not using video telehealth, three-quarters expressed an openness to using it in the future. However, the widespread integration of telehealth in the MHS will need to include efforts to overcome technical and administrative barriers and to address provider concerns about telehealth modalities for behavioral health care delivery-for example, the need for clinical guidance on using telehealth with specific types of patients, and provider and patient orientation on using telehealth technology.

Improving Behavioral Health Care for U.S. Army Personnel: Identifying Predictors of Treatment Outcomes.

This article identifies factors associated with changes in outcomes for soldiers who received Army behavioral health (BH) specialty care and provides recommendations to improve BH care and outcomes. RAND researchers identified three samples of soldiers who received Army BH care with diagnoses of posttraumatic stress disorder (PTSD), depression, or anxiety and whose symptoms were assessed during their care. Multivariate analyses included 141 patient and treatment variables to identify factors associated with symptom improvement. Analyses also examined patterns in how the symptoms changed over time. Analyses suggest that the Behavioral Health Data Portal, an online system that allows for collection of multiple patient- and clinician-reported measures, is widely used to track symptoms of PTSD, depression, and anxiety, but there are opportunities to expand symptom tracking. Two treatment factors-therapeutic alliance and receipt of benzodiazepines-were associated with treatment outcomes. Specifically, a stronger therapeutic relationship or alliance with providers, as reported by soldiers, was associated with improved PTSD, depression, and anxiety outcomes. Further, receipt of more than a 30-day supply of benzodiazepines was associated with poorer PTSD, depression, and anxiety outcomes. Many soldiers' trajectories of symptom change did not demonstrate improvement. Recommendations include providing feedback and guidance to providers on how to strengthen alliance with their patients, expanding tracking and feedback on benzodiazepine prescribing, and increasing provider use of measurement-based BH care.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads.

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.

A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health.

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use.

BACKGROUND: Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES: To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS: A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES: Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS: The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS: This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.

Assessing Brief Intervention for Unhealthy Alcohol Use: A Comparison of Electronic Health Record Documentation and Patient Self-Report.

OBJECTIVE: Alcohol screening and brief intervention (BI) are recommended preventive health practices. Veterans Health Administration (VA) uses a performance measure to incentivize BI delivery. Concerns have been raised about the validity of the BI performance measure, which relies on electronic health record (EHR) documentation. Our objective was to assess concordance between EHR-based documentation and patient-reported receipt of BI, and to examine correlates of concordance. METHOD: Patients with a documented positive screen for unhealthy alcohol use at VA Greater Los Angeles primary care clinics were surveyed (within 15 days on average) in 2013-2014. Documented BI was indicated by an EHR note that the patient was advised to drink within recommended limits or reduce or abstain from drinking. Patient-reported receipt of BI corresponded to an affirmative response to questions on whether a VA provider advised the patient to drink less or abstain. Patient report and documentation were assessed over the same period. RESULTS: Documented and patient-reported receipt of BI had low concordance. Almost all patients who reported receiving BI had documentation of BI (93%; 95% CI [90%, 95%]), but only 63% [59%, 67%] of patients with documented BI reported receiving it. BI concordance was associated with more severe unhealthy alcohol use and drinking-related consequences, mental health comorbidity, and greater readiness-to-change alcohol use. CONCLUSIONS: Discrepancies between EHR documentation and patient-reported BI raise concerns about performance measure validity. Patient-reported receipt of BI could be an alternative or complementary measure of BI.

Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities.

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This study provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Quality of Care for PTSD and Depression in the Military Health System: Final Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This study is a comprehensive assessment of the quality of care delivered by the MHS in 2013-2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012-2013 and 2013-2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

Does Documented Brief Intervention Predict Decreases in Alcohol Use in Primary Care?

BACKGROUND: Brief intervention (BI) is recommended for patients with unhealthy alcohol use, but the effectiveness of BI in usual care settings remains unclear. OBJECTIVE: We evaluated whether BI predicts decreases in drinking 6 months after a positive screen for unhealthy alcohol use. METHOD: We enrolled patients who recently screened positive for unhealthy alcohol use during a routine screen in Veterans Health Administration primary care. We conducted medical record review to assess whether providers documented advice to reduce or abstain, feedback about risks to health, feedback about how patient drinking compares to norms or recommended limits, and discussion of drinking-related goals. BI elements were coded from 7 days before the date of the positive screen to 60 days after. We conducted baseline and 6-month follow-up telephone interviews to assess change in past 30-day drinking. We fit regression models examining each BI element and another model for the total count of instances of any combination of elements. RESULTS: Of the 327 patients included, 86% had at least one documented instance of receiving advice, 86% had risk feedback, 55% had normative feedback, 38% had goal discussion, and 75% had three or more instances of any combination of elements of BI. None of the individual BI elements, nor the total number of instances, were significantly associated with decreased drinking. CONCLUSIONS: Results suggest that provider documentation of elements of BI and increasing numbers of instances of BI elements were not associated with decreased heavy drinking at 6-month follow-up among patients identified with unhealthy alcohol use.

Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System.

Traumatic brain injury (TBI) is considered a signature injury of modern warfare, though TBIs can also result from training accidents, falls, sports, and motor vehicle accidents. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. Many of these service members receive care through the Military Health System, but the amount, type, and quality of care they receive has been largely unknown. A RAND study, the first to examine the mTBI care of a census of patients in the Military Health System, assessed the number and characteristics (including deployment history and history of TBI) of nondeployed, active-duty service members who received an mTBI diagnosis in 2012, the locations of their diagnoses and next health care visits, the types of care they received in the six months following their mTBI diagnosis, co-occurring conditions, and the duration of their treatment. While the majority of service members with mTBI recover quickly, the study further examined a subset of service members with mTBI who received care for longer than three months following their diagnosis. Diagnosing and treating mTBI can be especially challenging because of variations in symptoms and other factors. The research revealed inconsistencies in the diagnostic coding, as well as areas for improvement in coordinating care across providers and care settings. The results and recommendations provide a foundation to guide future clinical studies to improve the quality of care and subsequent outcomes for service members diagnosed with mTBI.

Association Between Process-Based Quality Indicators and Mortality for Patients With Substance Use Disorders.

OBJECTIVE: Substance use disorders (SUDs) are associated with elevated rates of mortality. Little is known about whether receiving appropriate care is associated with lower mortality for patients with SUDs. This study examined the association between the receipt of care for SUDs and subsequent 12- and 24-month mortality. METHOD: This was a retrospective cohort study of veterans who received care for SUDs paid for by the Veterans Health Administration during October 2006- September 2007 (n = 339,966). Logistic regressions were used to examine the association between quality indicators measuring receipt of care and mortality while controlling for patient characteristics and facility service area. RESULTS: There were four quality indicators: SUD treatment initiation, SUD treatment engagement, SUD-related psychosocial treatment, and SUD-related psychotherapy. Outcomes measured were mortality 12 and 24 months after the end of the observation period, through September 2009. Receipt of indicated care ranged from 26.5% to 58.6%, and 12- and 24-month mortality rates were 3% and 6%, respectively. Adjusted odds ratios [95% CI] of 12-month mortality by indicator were: initiation, 0.86 [0.79, 0.93]; engagement, 0.65 [0.58, 0.74]; psychosocial treatment, 0.88 [0.84, 0.92]; and psychotherapy, 0.84 [0.79, 0.89]. For the 24-month mortality outcome, adjusted odds ratios were: initiation, 0.88 [0.84, 0.93]; engagement, 0.78 [0.71, 0.85]; psychosocial treatment, 0.91 [0.88, 0.94]; and psychotherapy, 0.87 [0.83, 0.91]. Results were similar when controlling for facility service area. CONCLUSIONS: Receiving appropriate care is associated with lower mortality for patients with SUDs. Significant overall and within-facility service area associations of quality indicators and mortality support their use in encouraging providers to deliver the indicated care. These indicators should be prioritized above others lacking comparably strong process-outcome associations.

Association Between Quality Measures and Perceptions of Care Among Patients With Substance Use Disorders.

OBJECTIVE: This study evaluated whether eight quality measures assessing care for patients with a substance use disorder were associated with patient perceptions of their care, including perceived improvement and global rating of behavioral health care. METHODS: Secondary data analyses were conducted of administrative and patient survey data collected as part of a national evaluation of Veterans Health Administration (VHA) mental health and substance use services. Data for patients who received care for substance use disorders during October 2006-September 2007 paid for by the VHA and who participated in a telephone interview about their care (N=2,074) were included. Measures of patient perceptions of care included perceived improvement and global rating of behavioral health care. Eight quality measures based on administrative data assessed initiation and engagement in substance use disorder care, receipt of psychotherapy or psychosocial treatment, and follow-up after hospitalization. Regression models were conducted in which each quality measure predicted each outcome, with analyses adjusting for patient characteristics and functioning. RESULTS: Treatment engagement, two measures of psychotherapy receipt, and psychosocial treatment were significantly associated with perceived improvement, whereas treatment initiation and follow-up after hospitalization (seven and 30 days) were not. Psychotherapy receipt and follow-up after hospitalization (seven and 30 days) were significantly associated with global rating of behavioral health care. CONCLUSIONS: Some quality measures assessing care for substance use disorders were significantly associated with patient perceptions of care. Results provide additional support for these quality measures and suggest that patient perceptions of care are an important outcome in assessing care.

Association between process measures and mortality in individuals with opioid use disorders.

BACKGROUND: Individuals with opioid use disorders have high rates of mortality relative to the general population. The relationship between treatment process and mortality is unknown. AIM: To examine the association between 7 process measures and 12- and 24-month mortality. METHODS: Retrospective cohort study of patients with opioid use disorders who received care from the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 7 patient-level process measures, while risk-adjusting for patient characteristics. Process measures included quarterly physician visits, any opioid use disorder pharmacotherapy, continuous pharmacotherapy, psychosocial treatment, Hepatitis B/C and HIV screening, and no prescriptions for benzodiazepines or opioids. We conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder. RESULTS: Among individuals with opioid use disorders, not being prescribed opioids or benzodiazepines, receipt of any psychosocial treatment and quarterly physician visits were significantly associated with lower mortality at both 12 and 24 months, but Hepatitis and HIV screening, and measures related to opioid use disorder pharmacotherapy were not. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of the confounder, to render these findings non-significant. CONCLUSIONS AND RELEVANCE: This is the first study to show an association between process measures and mortality in patients with opioid use disorders and provides initial evidence for their use as quality measures.