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

描述（由申请人提供）：尽管由于最近最高法院的决定，其实施可能因州而异，但通过“平价医疗法案”（ACA），预计将通过改变治疗融资和主流医疗保健与SUD治疗的更大整合，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（OUDs）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得到了长足的发展，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艾滋病毒相关服务的研究是有限的。目前尚不清楚ACA将如何影响丁丙诺啡治疗的递送。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，对丁丙诺啡的实施进行纵向研究，将ACA实施的各州变化的多层次数据与丁丙诺啡处方医生的纵向调查相结合。R21阶段的主要目的是确定进行一项整合医生水平和州水平数据收集的纵向研究的可行性，通过与四个里程碑相关的研究程序，包括医生样本的构建，通过定性和认知访谈进行的调查发展，以及为ACA实施的州级数据的纵向收集生成协议。提出的R33研究的三个具体目的是：(1)在各州实施ACA的背景下，估计丁丙诺啡使用的横截面和纵向模型，以及高质量临床实践行为（CPBs）和艾滋病毒相关服务在丁丙诺啡治疗中的实施；(2)研究丁丙诺啡治疗期间患者支付来源（如医疗补助、私人保险或自付）和其他患者特征对医生决策的相对重要性；(3)对ACA的实施与两个州级结果之间的关联进行建模：医疗补助计划中丁丙诺啡的使用情况和持有丁丙诺啡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，每年对全国具有代表性的1200名持有丁丙诺啡x许可证的医生进行4次调查。这种纵向调查设计将支持四个独特的联合分析，每个分析都涉及医生决策的一个关键领域，同时也收集CPBs的数据。数据分析将包括决策的横截面多元模型和CPB采用和实施的多层次纵向分析，以检验理论驱动的假设。通过测量美国丁丙诺啡治疗的质量、可用性和利用率，本研究可以确定治疗差距，从而可以开发干预措施来提高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.