Addiction Telemedicine Consultation in Primary Care: Increasing Access to Pharmacotherapy and Specialty Treatment for Alcohol Problems

摘要 酒精使用障碍(AUD)是一个重大的公共卫生问题，对 临床医生、患者和卫生系统。AUDS与严重的医疗状况有关，可能会使病情复杂化 医疗和增加可避免的卫生服务利用率和成本。然而，大多数患者会 受益于循证的AUD治疗，包括药物治疗，不接受这些服务。 尽管纳曲酮、氨基己酸酯和双硫仑等药物对中、重度患者有效 酒精问题，初级保健提供者(PCP)通常不愿开处方，AUD药物仍然存在 没有得到充分利用。需要创新的护理模式，为初级保健医生提供解决AUDS所需的工具 护理环境，但很少有研究审查干预措施，以改善AUD药物输送和专科 关爱启蒙。为了解决证据基础中的这一重大差距，这项务实的整群随机试验 成人初级保健诊所(n=20)在一个种族和社会经济多元化的大型保健系统中，将 检查创新的、多方面干预的有效性：成瘾远程医疗顾问 服务，或“空中交通管制”。ATC提供了一种灵活、高效、集中的方法来带来成瘾药物 将专业知识直接转化为初级保健。PCP可以通过三种途径访问ATC：实时视频或电话 初级保健就诊、异步电子邮件和电话咨询期间的连接。ATC，一家诊所 药剂师可以评估患者，与PCP和患者讨论适当的AUD药物，如果 适当的，通过处方物流指导初级保健医生，或自己启动处方。这个 接受激励性访谈培训的ATC也可能鼓励患者开始专门的成瘾治疗 并促进与本地节目的连接。ATC干预还将提供最初的持续医疗服务 年向所有初级保健医生提供有关AUDS和AUD药物处方的教育培训和持续的技术援助 空管部门。我们会将ATC ARM与常规护理进行比较，其中包括常规酒精筛查，简要 初级保健的干预和转诊治疗(SBIRT)。我们进行了一项试验可行性研究 ATC模型，拟议的试验建立在我们的试验结果、现有文献的基础上，并纳入了 利益相关者在其设计中的反馈。我们将使用在以下过程中收集的电子健康记录数据 定期临床护理，以检查治疗臂对实施结果的影响(AUD药物 处方率和成瘾治疗转诊率)和患者结果(AUD药物填充率， 开始戒酒、饮酒(每周饮酒天数、每周饮酒天数、“重度”饮酒天数#天 (过去90天的4/5/天)，以及两年内的保健服务利用率和费用。如果干预是 有效，这项研究有能力刺激使用安全有效的药物治疗作为AUDS的标准 在初级保健环境中的实践，并深刻地影响我们如何治疗和研究酒精使用的全部范围 有问题。

ABSTRACT Alcohol use disorders (AUDs) are a major public health problem and pose significant challenges to clinicians, patients, and health systems. AUDs are associated with serious medical conditions, can complicate medical treatment and increase avoidable health service utilization and costs. Yet most patients who would benefit from evidence-based AUD treatment, including pharmacotherapy, do not receive these services. Although medications such as naltrexone, acamprosate and disulfiram can be effective for moderate to severe alcohol problems, primary care providers (PCPs) are often reluctant to prescribe, and AUD medications remain underused. Innovative care models are needed to give PCPs the tools they need to address AUDs in primary care settings, but few studies have examined interventions to improve AUD medication delivery and specialty care initiation. To address this substantial gap in the evidence base, this pragmatic, cluster-randomized trial in adult primary care clinics (n=20) in a large, ethnically and socioeconomically diverse healthcare system, will examine the effectiveness of an innovative, multi-faceted intervention: the Addiction Telemedicine Consultant service, or “ATC.” The ATC provides a flexible, efficient, centralized approach to bringing Addiction Medicine expertise directly into primary care. PCPs can access the ATC via three routes: real-time video or telephone connection during primary care visits, asynchronous email, and telephone consultation. The ATC, a clinical pharmacist, may assess the patient, discuss appropriate AUD medications with the PCP and patient, and if appropriate, guide the PCP through prescribing logistics, or initiate the prescription themselves. The motivational interviewing-trained ATC may also encourage the patient to initiate specialty addiction treatment and facilitate connection to a local program. The ATC intervention will also offer initial continuing medical education training on AUDs and AUD medication prescribing, and ongoing technical assistance, to all PCPs in the ATC arm. We will compare the ATC arm to Usual Care, which includes routine alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care. We conducted a pilot feasibility study of the ATC model, and the proposed trial builds on our pilot findings, the extant literature, and incorporates stakeholder feedback in its design. We will use electronic health record data captured during the course of regular clinical care to examine treatment arm effects on implementation outcomes (AUD medication prescription rates and addiction treatment referral rates) and patient outcomes (AUD medication fill rates, addiction treatment initiation, alcohol use (drinking days/week, # drinks/week, # of “heavy” drinking days (4+/5+/day) in past 90 days), and health services utilization and costs, over two years. If the intervention is effective, this study has the capacity to spur the use of safe, effective pharmacotherapy for AUDs as a standard practice in primary care settings and profoundly affect how we treat and study the full spectrum of alcohol use problems.