Buprenorphine Treatment and Health Reform: Availability, Utilization, and Quality

描述(由申请人提供)：尽管由于最高法院最近的裁决，其实施情况可能在各州有所不同，但《平价医疗法案》(ACA)的通过预计将通过改变治疗资金以及更多地整合主流医疗保健和SUD治疗，极大地影响物质使用障碍(SUD)治疗的提供。丁丙诺啡治疗阿片类药物使用障碍(ODS)的不断发展的系统是整合的一个主要例子。虽然这一系统在过去十年中有了很大的增长，但关于医生如何实施这种挽救生命的治疗以及他们是否提供与艾滋病毒相关的服务的研究有限。目前尚不清楚ACA将如何影响丁丙诺啡治疗的交付。拟议的研究寻求1年的R21支持以确定研究的可行性，并寻求4年的R33支持以进行丁丙诺啡实施的纵向研究，该研究将ACA实施的州水平差异的多水平数据与对丁丙诺啡处方医生的纵向调查相结合。R21阶段的主要目标是通过与4个里程碑相关的研究程序确定进行纵向研究的可行性，该纵向研究整合了医生层面和州层面的数据收集，包括构建医生样本，通过定性和认知访谈进行调查开发，以及制定关于ACA实施情况的州层面数据纵向收集方案。拟议的R33研究的三个具体目标是：(1)评估丁丙诺啡使用的横断面和纵向模型，以及在各州实施ACA的背景下丁丙诺啡治疗中高质量临床实践行为(CPB)和艾滋病毒相关服务的实施情况；(2)检查患者支付来源(例如，医疗补助、私人保险或自付)和其他患者特征对丁丙诺啡治疗期间医生决策的相对重要性；以及(3)模拟ACA的实施与两个州级结果之间的州级关联：医疗补助中丁丙诺啡的使用情况和持有丁丙诺啡处方X许可证的医生数量。这些目标将通过持续收集州一级的政策和行政数据来实现，对持有丁丙诺啡处方X许可证的1200名具有全国代表性的医生进行4次年度调查。这种纵向调查设计将支持现场四个独特的联合分析，每个分析都针对医生决策的一个关键领域，同时还收集了一段时间内的CPB数据。数据分析将包括决策的横截面多变量模型和CPB采用和实施的多层次纵向分析，以检验理论驱动的假设。通过衡量美国丁丙诺啡治疗的质量、可获得性和利用率，这项研究可以确定可以开发干预措施的治疗缺口，以提高OUD的治疗质量，同时有助于了解ACA对美国治疗服务的影响。

DESCRIPTION (provided by applicant): Although its implementation is likely to vary across states due to the recent Supreme Court decision, passage of the Affordable Care Act (ACA) is expected to dramatically impact the delivery of substance use disorder (SUD) treatment through changes to treatment financing and greater integration of mainstream health care and SUD treatment. The evolving system of buprenorphine treatment for opioid use disorders (OUDs) is a prime example of integration. While this system has grown substantially in the past decade, research is limited regarding how physicians are implementing this lifesaving treatment and whether they are delivering HIV- related services. It is unknown how the ACA will impact the delivery of buprenorphine treatment. The proposed study seeks 1 year of R21 support to establish study feasibility and 4 years of R33 support to conduct a longitudinal study of buprenorphine implementation that integrates multi-level data on state-level variations in ACA implementation with longitudinal surveys of buprenorphine-prescribing physicians. The primary aim of the R21 phase is to determine the feasibility of conducting a longitudinal study that integrates physician-level and state-level data collection, through research procedures linked to 4 milestones encompassing the construction of the physician sample, survey development through qualitative and cognitive interviews, and generation of a protocol for longitudinal collection of state-level data on ACA implementation. The three specific aims of the proposed R33 study are: (1) To estimate cross-sectional and longitudinal models of buprenorphine utilization as well as the implementation of high-quality clinical practice behaviors (CPBs) and HIV-related services in buprenorphine treatment in the context of states' implementation of the ACA; (2) To examine the relative importance of patient payment source (e.g., Medicaid, private insurance, or out-of-pocket) and other patient characteristics on physician decision-making during buprenorphine treatment; and (3) To model the state-level associations between the implementation of the ACA and two state-level outcomes: utilization of buprenorphine within Medicaid and the number of physicians holding the X-license for prescribing buprenorphine. These aims will be accomplished through ongoing collection of policy and administrative data at the state-level with 4 annual surveys of a nationally representative sample of 1,200 physicians who hold the X-license to prescribe buprenorphine. This longitudinal survey design will support fielding four unique conjoint analyses, each addressing a key domain of physician decision-making, while also collecting data on CPBs over time. Data analysis will include cross-sectional multivariate models of decision-making and multi-level longitudinal analyses of CPB adoption and implementation to test theory-driven hypotheses. By measuring the quality, availability, and utilization of buprenorphine treatment in the US, this research may identify treatment gaps for which interventions may be developed to improve treatment quality for OUDs while contributing to scientific knowledge regarding the impact of the ACA on US treatment services.