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

描述（由申请人提供）：虽然由于最近最高法院的决定，其实施可能会因州而异，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和SUD治疗的更大整合来显著影响物质使用障碍（SUD）治疗的提供。丁丙诺啡治疗阿片类药物使用障碍（OUD）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大幅增长，但关于医生如何实施这种拯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有限。目前尚不清楚ACA将如何影响丁丙诺啡治疗的提供。拟议的研究寻求1年的R21支持以确定研究可行性，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实施中州一级变化的多水平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纵向研究的可行性，该研究整合了医生和州一级的数据收集，通过与4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调查开发，以及生成一个关于ACA实施的州一级数据纵向收集协议。拟议的R33研究的三个具体目标是：（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丁丙诺啡治疗中高质量临床实践行为（CPB）和HIV相关服务的实施;（2）检查患者支付来源的相对重要性（例如，医疗补助，私人保险，或自付）和其他患者特征对医生的决策在丁丙诺啡治疗期间;（3）模拟ACA的实施和两个国家级的结果之间的国家级关联：利用医疗补助和丁丙诺啡处方丁丙诺啡持有X执照的医生数量。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1,200名持有丁丙诺啡处方X许可证的医生进行4次全国代表性抽样调查。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，以测试理论驱动的假设。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，可以制定干预措施以提高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.