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

项目摘要 COVID-19大流行对患有严重共病的脆弱人群产生了重大不利影响， 医疗条件。患有晚期慢性肝病（CLD）的个体是最强烈的 受护理中断的影响，也极易受到SARS-CoV-2相关不良结局的影响 感染了解如何在大流行期间有效管理这些患者至关重要。 肝硬化（CLD的终末期）患病率的上升是CLD发病率和死亡率的重要因素， 在美国，饮酒是主要的危险因素。因此，有效的戒酒干预是一种 高优先级需求。此外，符合已知质量指标的高质量高级CLD 与积极的患者结果相关，对提高生存率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， 相关的健康差异。他们在获得医疗保健方面也有已知的障碍，并且面临高风险， 脱离护理。COVID-19大流行严重扰乱了传统的医疗保健 分娩模式，但对晚期CLD脆弱患者结局的影响目前尚不清楚。 此外，远程医疗作为缓解战略在这些卫生系统内的广泛使用， COVID-19为评估和创新护理提供模式提供了前所未有的机会。 迫切需要更好地了解患者的远程医疗体验及其对结果的影响 建立确保公平获得、可持续性和高质量护理的程序和政策。 为了解决这些关键问题，我们建议评估晚期CLD患者在治疗期间的护理。 在为弱势群体服务的两个可推广的卫生系统中， 公共安全网系统和退伍军人事务部医疗保健系统。此外，我们还将研究 分级护理干预（即，动机访谈和成瘾医生管理）通过 远程医疗作为常规肝病护理辅助治疗酒精使用。我们还将研究COVID-19 结果。我们提出以下目标：1）评估COVID-19大流行对临床的影响 在肝病实践中接受护理的晚期CLD弱势患者的结局， 2）评价患者报告的使用远程医疗应对大流行病的经验， 为晚期CLD患者提供肝病专科护理; 3）进行随机对照试验 评估使用远程医疗对不健康酒精进行分步酒精治疗的有效性和可行性 与常规治疗相比，在接受肝病治疗的酒精相关CLD患者中使用。我们 假设我们将观察到大流行后时期患者不良结局的增加， 患者对远程医疗的体验和满意度作为降低COVID-19风险的缓解策略， 改善，接受阶梯式护理的患者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