Impact of the COVID-19 pandemic on patient outcomes, telehealth care delivery, and treatment for unhealthy alcohol use in vulnerable patients with advanced liver disease across two healthcare systems

项目总结 新冠肺炎大流行对弱势群体产生了重大不利影响，并伴有严重并发症 医疗条件。患有晚期慢性肝病(CLD)的人是最强烈的 受护理中断的影响，也非常容易受到与SARS-CoV-2相关的不良结局的影响 感染。了解如何在大流行期间有效管理这些患者是至关重要的。 慢性肝病的终末期 美国和酒精的使用是一个主要的风险因素。因此，对戒酒的有效干预是一种 高优先级需求。此外，符合已知质量指标的高质量高级CLD是 与积极的患者结局相关，对提高生存和生活质量至关重要。弱势群体 包括退伍军人和那些在安全网系统中接受护理的人患肝脏和新冠肺炎的风险很大 相关的健康差距。他们在获得医疗保健方面也存在已知的障碍，并面临着 从照料中解脱。新冠肺炎疫情极大地扰乱了传统医疗保健 分娩模式，但对晚期CLD患者预后的影响目前尚不清楚。 此外，由于以下原因，在这些卫生系统中广泛使用远程医疗作为缓解战略 新冠肺炎为关怀提供模式的评估和创新提供了前所未有的机遇。 迫切需要更好地了解患者使用远程医疗的经历及其对预后的影响 建立流程和政策，确保公平、可持续和高质量的医疗服务提供。 为了解决这些关键问题，我们建议评估晚期慢性阻塞性肺疾病患者在 在服务于弱势人群的两个可概括的卫生系统中，肝病实践中的大流行 公共安全网系统和退伍军人事务医疗保健系统。此外，我们还将研究 阶梯式护理干预(即，激励性访谈和成瘾医生管理) 远程医疗将酒精使用作为常规肝病护理的辅助手段。我们还将研究新冠肺炎 结果。我们提出以下目标：1)评估新冠肺炎大流行对临床的影响 在肝科实践中接受治疗的晚期慢性肝病患者的转归 实验；2)评估患者报告的使用远程医疗应对大流行的经验 为晚期慢性肝病患者提供肝科专科护理；3)进行随机对照试验 远程医疗阶梯式酒精治疗不健康酒精的疗效和可行性评价 在接受肝科护理的酒精相关性慢性肝病患者中使用，与常规护理相比。我们 假设我们将在大流行后观察到不良患者结局的增加，即 患者体验和对远程医疗作为降低新冠肺炎风险的缓解策略的满意度将 改善，接受分级护理的患者将更有可能减少或戒酒。 1

PROJECT SUMMARY The COVID-19 pandemic has had a significant adverse impact on vulnerable populations with serious comorbid medical conditions. Individuals with advanced chronic liver disease (CLD) are among those most strongly affected by disruptions in care and are also highly susceptible to poor outcomes associated with SARS-CoV-2 infection. It is critical to understand how to effectively manage these patients during the course of the pandemic. The rising prevalence of cirrhosis, an end-stage of CLD, is a significant contributor to morbidity and mortality in the United States and alcohol use is a major risk factor. Thus, effective intervention for alcohol cessation is a high-priority need. In addition, high quality advanced CLD with adherence to known quality indicators is associated with positive patient outcomes, critical to enhanced survival, and quality of life. Vulnerable populations including veterans and those receiving care in safety net systems are at significant risk for liver and COVID-19 related health disparities. They also have known barriers to healthcare access and are at high risk for disengagement from care. The COVID-19 pandemic has significantly disrupted the traditional health care delivery models, but the impact on outcomes of vulnerable patients with advanced CLD is currently unknown. Moreover, the widespread use of telemedicine as a mitigation strategy within these health systems due to COVID-19 has provided an unprecedented opportunity for evaluation and innovation of care delivery models. Better understanding of patients' experience with telemedicine and impact on their outcomes is urgently needed to establish processes and polices that ensure equity in access, sustainability, and high-quality care delivery. To address these critical issues, we propose to evaluate the care of patients with advanced CLD during the pandemic within hepatology practices in two generalizable health systems serving vulnerable populations, a public safety net system and Veterans Affairs healthcare systems. Furthermore, we will examine the efficacy of a stepped care intervention (i.e., motivational interviewing and addiction physician management) via telemedicine to treat alcohol use as an adjunct to usual hepatology care. We will also examine COVID-19 outcomes. We propose the following aims: 1) Evaluate the impact of the COVID-19 pandemic on clinical outcomes of vulnerable patients with advanced CLD receiving care in hepatology practices, in a natural experiment; 2) Evaluate patient-reported experiences with use of telemedicine in response to the pandemic to deliver hepatology specialty care in those with advanced CLD; and 3) Conduct a randomized controlled trial evaluating the efficacy and feasibility of a stepped alcohol treatment using telemedicine on unhealthy alcohol use in patients with alcohol-related CLD receiving care in hepatology practices, compared with usual care. We hypothesize that we will observe an increase in adverse patient outcomes in the post-pandemic period, that the patient experience and satisfaction with telemedicine as a mitigation strategy to reduce COVID-19 risk will improve, and that patients receiving stepped care will be more likely to reduce or abstain from alcohol use. 1