Telehealth Treatment of Veterans with Alcohol Misuse at Risk for Cardiovascular Disease

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Background: Cardiovascular disease (CVD) is the most common cause of death in Veterans. CVD-related deaths are over twice as likely in patients with comorbid alcohol misuse, due in part to alcohol misuse directly exacerbating several modifiable factors that lead to CVD. No interventions exist targeting both these comorbidities, and current VA/DoD treatment guidelines for comorbid alcohol misuse in primary care are ineffective. Because alcohol misuse is often a recurrent problem, and the dominant driver of treatment recommendations, timely treatment of these Veterans’ CVD risk in conjunction with alcohol misuse treatment in may be critical for developing clinical traction with CVD risk. Dr. Blalock seeks to refine a telehealth intervention and acquire necessary training throughout this CDA-2 proposal to begin his career as an independent VA health services researcher who seeks to improve the effectiveness and reach of behavioral health treatments for Veterans with comorbid behavioral health problems. Significance/Impact: 9-32% of the entire Veteran population has comorbid alcohol misuse and modifiable elevated CVD risk. This high-risk population is entirely preventable, but is undertreated and understudied. The proposed CDA research would be the first to directly target this high-risk population. This research is highly relevant to Veteran health, VHA priorities, and HSR&D priorities because the combined intervention targets and telehealth approaches address critical gaps in treatment timeliness and access. Specific Aims: Aim 1 –Characterize a national cohort of Veterans with alcohol misuse and modifiable CVD risk, their alcohol services utilization, and clinical outcomes. Aim 2 – Qualitatively assess barriers to treatment for Veterans with alcohol misuse and CVD risk across multiple stakeholders. Aim 3 – Use a successive cohort design to iteratively develop an intervention based on patient feedback. Aim 4 – Test the acceptability and feasibility of an intervention to reduce alcohol misuse and CVD risk in Veterans. Innovation: This application is highly innovative in its attempt to address for the first time: 1) perceptions of barriers to treatment in this population, 2) the utility of a combined intervention for alcohol misuse and CVD risk, 3) multimorbid patient preferences for timing of treatments for multiple different targets, and 4) the sustainability of health behavior habits in VA formed by an intervention using “implementation intentions.” Methodology: Aim 1 will use electronic health records to examine the status of key health criteria and services utilization among Veterans with alcohol misuse, both with and without comorbid CVD risk. Aim 2 will use qualitative interviews of both Veterans with comorbid alcohol misuse and elevated modifiable CVD risk, their providers across different settings, and systems-level stakeholders to assess current treatment barriers. Aim 3 will employ a successive cohort design to iteratively test the proposed intervention with rapid and early feedback from multiple Veteran cohorts. Aim 4 will test a refined intervention based on feedback from Aims 2 and 3 to determine the acceptability to Veteran patients, as well as the feasibility of recruitment, randomization, and intervention. Next Steps/Implementation: Beginning in Aim 1, a systems-level advisory board will be convened semi- annually with the goal of eliciting feedback throughout intervention development to aid implementation. By the end of the 3rd year of the CDA-2, an IIR application will be submitted to fund a randomized comparative effectiveness trial of the Aim 3 intervention. Results will also be presented to local Veterans engagement panels associated with “VetREP.” Additional feedback from OCC and OMHSP operations partners, and implementation considerations gleaned from utilization patterns and care settings in Aim 4, will allow rapid development of a post-IIR implementation plan. Additional training in cost effectiveness and implementation science will also give Dr. Blalock the skills to follow through with additional research and implementation.