Addictions treatment organizational response to COVID-19: impact on disparities in quality of care

项目概要 COVID-19突发公共卫生事件给SUD治疗带来了非同寻常的外源性冲击 组织，迫使他们快速改变提供护理的方式。在 COVID-19 之前，治疗模式依赖于 大量依靠实体诊所提供面对面的医疗护理和心理社会治疗，包括 通过医疗办公室提供的专业门诊成瘾治疗 (SOAT) 和药物治疗 成瘾治疗（OBAT）。由于政府要求保持身体距离并放松限制 SOAT 和 OBAT 提供商迅速从根本上改变了使用远程医疗的限制 工作流程，包括：新形式的医疗筛查和药物管理；更大的灵活性 允许患者在家自行服药；通过个性化和小组会议进行治疗 远程医疗；减少对吸毒筛查的依赖；以及治疗参与的新策略。这些 变化将对治疗保留、成瘾药物治疗的使用以及长期治疗产生未知的影响。 期限结果。门诊治疗系统对这些外部因素的反应（包括暂时的和持久的） 冲击将采取多种形式，具体取决于项目所在的组织和环境背景 操作。人们担心黑人/非裔美国人和拉丁裔患者更有可能接受护理 在资源匮乏的项目中，获得电子卫生技术的机会较少——将获得较差的质量 护理和更糟糕的结果。我们将采用社会生态框架来研究以下条件： 纽约州的门诊治疗适应了外源性冲击并分析了关系 新临床实践（例如，使用远程医疗）和近端临床实践（例如，保留、使用药物治疗）之间 以及患者结果的远端（例如用药过量、急诊科就诊）标记。此外，我们将 检查可能表明护理以及组织和社区方面差异的种族/民族差异 可能造成差异的因素。我们提出了一种解释性顺序混合方法设计来研究 治疗服务和结果的短期和长期变化。我们将首先使用行政 数据——通过医疗补助加入 SUD 治疗事件的州登记处——以研究治疗的变化 545 个 SOAT 诊所和 3100 个 OBAT 提供者的实践。我们将检查治疗实践的变化： 临床交付（例如，使用远程医疗、团体咨询与个人咨询的混合）、药物治疗的使用 （例如，远程诱导、美沙酮自我给药的更大灵活性）和保留。我们随后将 检查这些实践改变与治疗结果之间的关联，例如药物过量、 与物质相关的急诊就诊和住院治疗。我们将采用定性方法 通过检查项目的组织特征来了解定量结果 代表那些具有最佳保留和治疗结果的项目以及执行的项目 这些措施最糟糕。研究结果将为治疗系统改革的临床和政策决策提供信息。

Project Summary The COVID-19 public health emergency gave an extraordinary exogenous shock to SUD treatment organizations, forcing rapid changes in how they provide care. Before COVID-19, the treatment model relied heavily on brick-and-mortar clinics to provide in-person medical care and psychosocial treatment, including specialty outpatient addictions treatment (SOAT) and pharmacotherapy provided through medical office-based addictions treatment (OBAT). Due to government mandates for physical distancing and relaxation of restrictions for using telehealth, both SOAT and OBAT providers quickly and fundamentally changed their workflows, including: new forms of medical screening and medication management; greater flexibility in allowing patient self-dosing of medication at home; treatment through individualized and group meetings via telehealth; reduced reliance on drug use screening; and new strategies for treatment engagement. These changes will have unknown effects on treatment retention, use of pharmacotherapy for addictions, and longer- term outcomes. The outpatient treatment system responses—both temporary and enduring—to these external shocks will take many forms depending on the organizational and environmental context in which programs operate. There is concern that Black/African American and Latinx patients—who are more likely to receive care in more poorly resourced programs and have lower access to eHealth technology—will receive poorer quality care and worse outcomes. We will employ a social-ecological framework to examine the conditions under which outpatient treatment across New York State adapted to the exogenous shock and analyze relationships between new clinical practices (e.g., use of telehealth) and proximal (e.g., retention, use of pharmacotherapy) and distal (e.g., overdoses, emergency department visits) markers of patient outcomes. Further, we will examine racial/ethnic variation that may indicate disparities in care as well as organizational and community factors that may account for disparities. We propose an explanatory sequential mixed-methods design to study both short term and longer-term changes to treatment services and outcomes. We will first use administrative data—joining a state registry of SUD treatment episodes with Medicaid—to study variation in treatment practices across 545 SOAT clinics and 3100 OBAT providers. We will examine changes to treatment practice: clinical delivery (e.g., use of telehealth, mix of group versus individual counseling), use of pharmacotherapy (e.g., remote induction, greater flexibility in methadone self-administration), and retention. We will then examine the association between these practice changes and treatment outcomes, such as overdoses, substance-related emergency department visits, and hospitalizations. We will employ qualitative methods to develop an understanding of the quantitative findings by examining organizational characteristics of programs representative of those that have best retention and treatment outcomes as well as programs that performed worst on these measures. The findings will inform clinical and policy decisions on treatment system reforms.