Improving Outcomes among Medical/Surgical Inpatients with Alcohol Use Disorders

2014财年，超过57,000名确诊为酒精使用障碍(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AUDS的患病率， 因为这些情况在住院期间经常没有得到诊断。AUDS的高发人群 VHA内科外科住院患者受到严重关注，因为AUDS和医疗条件会加剧AUDS 另一种情况是，它们的共同出现增加了昂贵的医疗服务的使用。然而，没有基于证据的 通过增加利用率来改善这一患者群体结果的策略(启动， AUD治疗服务的参与)。我们已经确定了饮酒的选择：激励，共同决定， 远程监控(DO-MOST)作为解决循证战略迫切需要的潜在解决方案。 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-外科护理到初级和专科护理环境中的AUD治疗，从而改善 退伍军人的澳元和医疗结果。DO-MOST需要使用激励性访谈和决策辅助工具 在住院期间，促进有关出院后饮酒选择和资源的知情选择 如果需要，帮助改变饮酒习惯，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，该项目还包括一个流程 评估-也就是说，将从提供者和患者那里收集有关DO-MOST实施的信息 两个项目站点-为退伍军人管理局广泛实施内外科Do-Most提供信息 AUDS患者。 使用有效性/实施混合类型1设计，结合随机对照 为促进今后的实施，该项目有三个具体目标。 目标1：将针对非退伍军人初级保健环境中的AUD患者实施的决策辅助调整为 适合内外科住院的患有AUDS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阿尔法测试，并调整和试点决策援助，以最终确定其在随机对照试验中使用。 目标2：在退伍军人管理局的两个设施(安娜堡和帕洛阿尔托)进行最多工作，并评估其有效性。 主要假设是：与处于常规护理(UC)的患者相比，处于DO-MOST状态的患者更有可能 为了(1)利用AUD帮助(发起、参与)，(2)有更好的AUD(减少酗酒日)和医疗 (身体状况)结果，以及(3)延迟的急性护理事件(紧急情况)越来越少 科室就诊、再住院)。患者将在基线以及3、6和12个月后进行评估。 出院、结果和非退伍军人保健；退伍军人保健将使用退伍军人数据库进行评估。GLMM 将进行分析，以比较UC组和DO-MOST组的结果。 目标3：进行定性过程评估，以便更广泛地实施Do-Most，使用 Re-AIM(REACH，有效性，采用，实施，维护)框架。其目的是提供 指导退伍军人管理局今后更广泛地采用Do-Most，包括其可能适用于 退伍军人的不同亚群，例如有精神健康诊断的患者(例如，创伤后应激障碍)。 总而言之，这个项目将开发一个决策辅助工具，并作为一个 新的突破性方法在住院内外科治疗和治疗之间架起桥梁 AUD治疗。决策辅助已经在许多情况下成功使用，但从未用于医疗- 还有一些住院病人。我们来自VHA精神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内外科服务的危险、昂贵的模式 但没有得到他们所需的澳大利亚大学的治疗。该项目侧重于退伍军人事务部蓝图中的优先事项 卓越，高铁研发服务，以及PIS的高铁研发创新中心。

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.