Leveraging virtual care strategies to improve access and treatment for individuals with alcohol use disorders

项目摘要/摘要 尽管心理治疗有效，但约90%的酒精使用障碍(AUD)患者并没有 这一慢性病需要接受治疗，但在护理方面存在着明显的差距。接触和参与 在有效的AUD护理中，女性、黑人/非裔美国人和来自其他地区的人的比例甚至更低 代表不足的群体。概念上的新虚拟护理方法(电话、视频、门户治疗) 根植于有效的疗法[例如，动机访谈(MI)、认知行为疗法(CBT)]和 理论可以潜在地改善治疗的可及性和吸引力，并减少耻辱。虚拟方法具有 在澳大利亚的护理中使用有限，最近在新冠肺炎中增加使用，以提供持续的护理(电话/视频 针对专科诊所的现有患者)，而治疗启动率仍然较低。有一个未开发的 虚拟方法的潜力，使卫生系统中的个人参与，否则他们不会获得 治疗，但可能会受益。虚拟战略，包括电话和视频会议以及患者门户，是 有希望接触和吸引使用药物的人群，包括代表性不足的个人， 在卫生系统内。使用门户消息传递系统和电话虚拟地让患者参与AUD 在诊所外和他们首选的地点进行治疗是一种创新的治疗模式，可以潜在地 在卫生系统中实施，但必须进行测试，以便更广泛地传播。 我们将使用顺序、多分配随机试验(SMART)来确定关键的适应性 干预(AI)战略，用于虚拟交付的AUD参与和护理模式。成人澳门氏症(50%) 女性，25%的黑人/非裔美国人，5%的拉丁裔美国人)将被随机分为第一阶段饮酒策略 整合AUD护理转诊的减少和AUD护理参与度：1)单一电话MI会话(T- Engage)，或2)为期4周的以MI为重点的门户消息(P-Engage)。4周后，无应答者将 随机进入第二阶段策略：1)升级到视频8会话MI-CBT for AUD(电话交付作为 需要)，或2)继续第一阶段(即，为期4周的更深入的P-Engage，第二次T-Engage会议 建立在第一个基础上)。结果将在4个月、8个月和12个月时进行评估。目标1将比较第一阶段 关于酒精结果和AUD治疗利用的策略(T-Engage与P-Engage)。在AIM 2中，在第一个- 阶段无应答者，我们将确定最有效的第二阶段策略。AIM 3包括一个 实施规划阶段，包括成本措施、主要利益攸关方面谈和定性分析 实施和采用虚拟护理模式的障碍和促进者。次要目标包括： 检查种族/民族和性别对结果的调节作用，给出我们丰富的样本和 检查人工智能的最佳序列。我们建议的项目将通过评估一个 新的虚拟护理模式专注于提高治疗参与度和提供可集成的服务 在卫生系统中，增加非处方药治疗的吸引力和可及性，并帮助解决治疗差距问题。

Project Summary/Abstract Despite the efficacy of psychotherapies, ~90% of people with alcohol use disorder (AUD) do not receive treatment for this chronic condition and there are notable disparities in care. Access to and involvement in efficacious AUD care is even lower for women, Black/African American individuals, and people from other under-represented groups. Novel virtual care approaches (telephone, video, portal therapies) conceptually rooted in efficacious therapies [e.g., motivational interviewing (MI), cognitive behavioral therapy (CBT)] and theory can potentially improve treatment accessibility and appeal and reduce stigma. Virtual approaches have had limited use in AUD care, recently increasing in COVID-19 to provide ongoing care (telephone/video therapy) for current patients in specialty clinics, while treatment initiation remains low. There is an untapped potential for virtual approaches to engage individuals across health systems, who otherwise do not receive treatment, but could benefit. Virtual strategies, including telephone and video sessions and patient portals, are promising for reaching and engaging substance-using populations, including under-represented individuals, within health systems. Using a portal messaging system and phone calls to virtually engage patients in AUD treatment outside of clinics and in their preferred locations is an innovative treatment model that can potentially be implemented in health systems, but must be tested to inform broader dissemination. We will use a sequential, multiple assignment randomized trial (SMART) to identify critical adaptive intervention (AI) strategies for a virtually-delivered AUD engagement and care model. Adults with AUD (50% women, 25% Black/African American, 5% Latinx) will be randomized to a 1st stage strategy for drinking reduction and AUD care engagement integrating referral for AUD care: 1) a single telephone MI session (T- engage), or 2) 4-weeks of a MI-focused portal messaging (P-engage). At 4 weeks, non-responders will be randomized to a 2nd stage strategy: 1) step up to a video 8-session MI-CBT for AUD (phone delivery as needed), or 2) continued 1st stage (i.e., 4 weeks of P-engage with greater depth, a second T-engage session building on the first). Outcomes will be assessed at 4-, 8-, and 12-months. Aim 1 will compare 1st-stage strategies (T-engage vs. P-engage) on alcohol outcomes and AUD treatment utilization. In Aim 2, among 1st- stage non-responders, we will identify the most efficacious 2nd-stage strategy. Aim 3 includes an implementation planning phase, with cost measures, and key stakeholder interviews and qualitative analysis of barriers and facilitators to implementation and adoption of a virtual care model. Secondary aims include: examining the moderating effects of race/ethnicity and sex on outcomes given our enriched sample and examining the best sequence of AIs. Our proposed project will have high public health impact by evaluating a novel virtual care model focused on increasing both treatment engagement and delivery that can be integrated in health systems to increase AUD treatment appeal and accessibility and help address treatment disparities.