C-DIAS RP3: Scaling-out app-based treatments: a multi-level strategy to promote equity across primary care patients with substance use

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C-DIAS RESEARCH PROJECT 3: PROJECT SUMMARY/ABSTRACT At the SUSTAIN phase, C-DIAS Research Project 3 addresses a critical scientific and public health gap: How can we improve equity when offering digital treatments to patients with substance use disorders (SUDs) in primary care? A wide range of effective digital treatments —app or web-based interventions—for SUDs and comorbid conditions are available for use in primary care, and many have been evaluated in diverse populations. Digital treatments for SUDs could potentially reduce inequities, as they: 1) have the potential to reach more people by reducing access barriers; 2) can circumvent SUD stigma; and 3) allow patients to initiate interventions from the comfort and privacy of home. At the same time, digital treatments may also magnify inequities due to factors stemming from the “digital divide.” We will rigorously evaluate an implementation strategy to “scale-out” digital treatments to disadvantaged populations as an approach to potentially improve equity in digital care for people with SUDs, and as a model for how to ethically sustain digital treatments in real-world healthcare. Prior pragmatic trials found that evidence-based practices and other initiatives are hard to sustain without leadership and clinic buy-in, so our multi-level study design and analytic plan focuses on these issues. Our delivery system partners in Kaiser Permanente Washington are committed to collaborating with us to study multi-level strategies for scaling-out existing digital treatments in 32 primary care clinics in Washington State to address expected equity challenges. All clinics will receive a 3-part system-level set of implementation strategies that are suitable for primary care: 1) system-wide audit and feedback; 2) patient stories from members of disadvantaged populations; and, 3) engaging key stakeholders in problem solving to reduce barriers to the use of digital treatments among disadvantaged populations. To test a clinic-level implementation strategy, a subset of 12 clinics will be randomized to receive external facilitation or to a control condition (no facilitation) in a 1:1 parallel-groups design. Equity outcomes will be assessed by comparing reach across subgroups of patients defined by key social determinants (e.g., race/ethnicity). Specific Aims are to: 1) estimate the impact of a multi-level implementation strategy (system- and clinic-level) in increasing equity in the reach of digital treatments among patients with SUD in primary care clinics; and 2) describe the costs of and adherence to the implementation strategies, and examine how contextual determinants can impact equity in implementation and patient outcomes. Research Project 3 leverages a bi-directional relationship with C- DIAS, demonstrated in part by: 1) standardized measures of implementation context, outcomes and procedural details of strategies; 2) PI (Glass)’s role on the C-DIAS Research Core; 3) a close network of collaboration and mentoring among the key project personnel and C-DIAS PI; 4) harmonization of data that can be used for modeling by C-DIAS Research Core experts; 5) data on digital treatment implementation costs for decision- makers; and 6) expanded options for dissemination and impact of study findings through C-DIAS.