Improving Outcomes among Medical/Surgical Inpatients with Alcohol Use Disorders

在2014财年，超过57，000名被诊断患有酒精使用障碍（AUD）的退伍军人接受了VHA住院治疗。 医疗外科服务。这可能低估了退伍军人住院患者中AUD的患病率， 因为这些情况在住院期间往往得不到诊断。AUD的高患病率 VHA内外科住院患者是关键问题，因为AUD和医疗条件加剧了一个 另一个是，它们的同时发生增加了昂贵的保健服务的使用。然而，没有证据表明 通过增加利用率来改善该患者群体的结果的策略（起始， （一）服务质量。我们已经确定了饮酒的选择：动机，共同决定， 远程监护（DO-MoST）作为一个潜在的解决方案，以满足基于证据的战略的关键需求。 该项目将评估DO-MoST作为一种新的创新干预措施，以促进从 住院医疗手术护理到初级和专科护理环境中的AUD治疗，从而改善 退伍军人的AUD和医疗结果。DO-Most需要使用动机访谈和决策辅助工具 在住院期间，以促进出院后饮酒选择和资源的知情选择， 帮助改变饮酒，如果需要的话，然后与患者通电话，继续激励和 支持决策。除了确定DO-MoST的有效性外，该项目还包括一个过程， 评估-也就是说，将收集信息，从供应商和病人对DO-MoST的实施， 两个项目地点-告知VA的潜在广泛实施DO-MoST与医疗外科 患者AUD。 使用有效性/实施混合1型设计，结合随机对照 为了促进未来的实施，该项目有三个具体目标。 目标1：调整在非VA初级保健环境中对AUD患者实施的决策辅助， 适用于在内科-外科住院环境中患有AUD的退伍军人。有了这个原型，我们将进行 与患者和提供者进行alpha测试，并调整和试点决策辅助工具，以最终确定其在RCT中使用。 目标2：在两个VA机构（安阿伯和帕洛阿尔托）进行DO-MoST并评估其有效性。 主要假设是：与常规治疗（UC）患者相比，DO-MoST患者更有可能 （1）利用AUD帮助（发起，参与），（2）有更好的AUD（更少的大量饮酒日）和医疗 （身体状况）结果，和（3）有更少和更多的延迟急性护理事件（紧急 部门访问，再住院）。患者将在基线和治疗后3、6和12个月进行评估。 出院，用于结局和非VA医疗保健;将使用VA数据库评估VA医疗保健。GLMM 将进行分析，以比较UC和DO-MoST组的结局。 目标3：进行定性过程评价，为更广泛地实施DO-MoST提供信息， RE-AIM（Reach，Effectiveness，Adoption，Implementation，Maintenance）框架。目的是提供 指导VA设施在未来更广泛地采用DO-MoST，包括其可能的适应性， 退伍军人的不同亚群，例如患有精神健康诊断的患者（例如，PTSD）。 总之，本项目将开发一个决策辅助工具，并全面审查DO-MoST， 一种新颖的、开创性的方法，为住院医疗-外科治疗和 AUD治疗。决策辅助工具已在许多情况下成功使用，但从未用于医疗- AUD住院患者。我们来自VHA心理健康服务和医疗服务的运营合作伙伴致力于 直接解决退伍军人获得住院医疗手术服务的危险，昂贵的模式 但没有得到他们需要的AUD治疗。该项目的重点是VA蓝图中的优先事项， 卓越，HSR&D服务，和PI的HSR&D创新中心。

In FY2014, over 57,000 Veterans with diagnosed alcohol use disorders (AUDs) received VHA inpatient medical-surgical services. This likely underrepresents the prevalence of AUDs among Veteran inpatients, because these conditions often go undiagnosed during hospital stays. The high prevalence of AUDs among VHA medical-surgical inpatients is of critical concern because AUDs and medical conditions exacerbate one another, and their co-occurrence increases the use of costly health services. Yet, there are no evidence-based strategies that improve outcomes in this patient population by means of increased utilization (initiation, engagement) of AUD treatment services. We have identified Drinking Options: Motivate, Shared Decisions, Telemonitor (DO-MoST) as a potential solution to the critical need for evidence-based strategies. This project will evaluate DO-MoST as a new and innovative intervention to facilitate the transition from inpatient medical-surgical care to AUD treatment in primary and specialty care settings, thereby improving Veterans' AUD and medical outcomes. DO-MoST entails use of motivational interviewing and a decision aid during the inpatient stay to facilitate informed choices about post-discharge drinking options and resources for help to change drinking, if desired, followed by telephone calls with the patient to continue to motivate and support decisions. In addition to determining the effectiveness of DO-MoST, this project includes a process evaluation – that is, will gather information from providers and patients on DO-MoST's implementation at the two project sites – to inform VA's potential widespread implementation of DO-MoST with medical-surgical patients with AUDs. Using an effectiveness/implementation Hybrid Type 1 design, incorporating a randomized controlled trial (RCT) and process evaluation to facilitate future implementation, this project has three Specific Aims. Aim 1: Adapt a decision aid being implemented with AUD patients in non-VA primary care settings to be appropriate for Veterans with AUDs in medical-surgical inpatient settings. With this prototype, we will conduct alpha testing with patients and providers, and adapt and pilot the decision aid to finalize it for use in the RCT. Aim 2: Conduct DO-MoST at two VA facilities (Ann Arbor and Palo Alto) and evaluate its effectiveness. The primary hypotheses are: Patients in DO-MoST, compared to patients in usual care (UC), will be more likely to (1) utilize AUD help (initiate, engage), (2) have better AUD (fewer heavy drinking days) and medical (physical status) outcomes, and (3) have fewer and more delayed acute care episodes (Emergency Department visits, rehospitalizations). Patients will be assessed at baseline, and 3, 6, and 12 months post- discharge, for outcomes and non-VA health care; VA health care will be assessed with VA databases. GLMM analyses will be conducted to compare the UC and DO-MoST groups on course of outcomes. Aim 3: Conduct a qualitative process evaluation to inform the wider implementation of DO-MoST, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The purpose is to provide guidance for VA facilities' broader adoption of DO-MoST in the future, including its possible adaptation for diverse subpopulations of Veterans, such as patients with mental health diagnoses (e.g., PTSD). In summary, this project will develop a decision aid and comprehensively examine DO-MoST as a novel and groundbreaking approach to providing a bridge between inpatient medical-surgical treatment and AUD treatment. Decision Aids have been used successfully in a number of contexts, but never with medical- AUD inpatients. Our operations partners from VHA Mental Health Services and Medical Service are committed to directly addressing the dangerous, costly pattern of Veterans obtaining inpatient medical-surgical services but not receiving the AUD treatment they need. The project is focused on priorities in the VA Blueprint for Excellence, of HSR&D Service, and of the PIs' HSR&D Centers of Innovation.