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

项目总结/摘要 尽管心理治疗有效，但约90%的酒精使用障碍（AUD）患者没有 接受这种慢性病的治疗，在护理方面存在显著差异。接触和参与 在有效的AUD护理中，女性、黑人/非裔美国人和其他人的AUD护理甚至更低。 代表性不足的群体。新的虚拟护理方法（电话，视频，门户疗法）概念 植根于有效的疗法[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，并减少耻辱感。虚拟方法有 在AUD护理中使用有限，最近在COVID-19中增加，以提供持续护理（电话/视频 治疗），而治疗开始仍然很低。有一个尚未开发的 虚拟方法的潜力，以吸引整个卫生系统的个人，否则他们不会得到 治疗，但可以受益。虚拟策略，包括电话和视频会议以及患者门户网站， 有希望接触和吸引吸毒人群，包括代表性不足的个人， 在卫生系统内。使用门户消息系统和电话以AUD虚拟方式与患者互动 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， 在卫生系统中实施，但必须进行测试，以便为更广泛的传播提供信息。 我们将使用一个连续的，多分配随机试验（SMART），以确定关键的适应性 针对虚拟交付的AUD参与和护理模型的干预（AI）策略。持有澳元的成年人（50%） 女性，25%黑人/非裔美国人，5%拉丁裔）将被随机分配至第一阶段饮酒策略 减少和AUD护理参与整合了AUD护理的转诊：1）单一电话MI会话（T- 参与），或2）为期4周的以MI为重点的门户消息传递（P-engage）。4周时，无应答者将 随机分配到第二阶段策略：1）升级到视频8会话MI-CBT，用于AUD（电话交付， 需要），或2）继续第一阶段（即，4周更深入的P-参与，第二次T-参与会议 建立在第一个之上）。将在4、8和12个月时评估结局。目标1将比较第1阶段 策略（T参与与P参与）对酒精结果和AUD治疗利用的影响。在目标2中，在第一- 阶段无应答者，我们将确定最有效的第二阶段策略。目标3包括 执行规划阶段，包括成本计量，与主要利益攸关方进行访谈， 实施和采用虚拟护理模式的障碍和促进因素。次要目标包括： 根据我们丰富的样本，检查种族/民族和性别对结果的调节作用， 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 一种新的虚拟护理模式，重点是增加治疗参与和交付， 提高AUD治疗的吸引力和可及性，并帮助解决治疗差异。

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.