COVID-19 Pandemic: Natural Experiment in Telehealth on Buprenorphine Treatment in a Large Integrated Healthcare System

项目总结/摘要 扩大使用远程医疗开丁丙诺啡处方可能会减少丁丙诺啡处方者的障碍。 然而，联邦法规要求处方医生进行亲自医疗评估，以引导患者 对丁丙诺啡和限制维护访问实时，双向，交互式视听通信（即， 远程保健）的影响，阻碍了对扩大远程保健对丁丙诺啡处方的潜在作用进行研究。 2020年3月，美国COVID-19病例最初激增，导致联邦机构放松了对 评估要求，允许提供者使用远程医疗或仅电话访问进行医疗评估 给病人用丁丙诺啡我们提出了一项研究，利用这些与COVID相关的监管改革， 回答有关使用远程医疗法规的重要临床和政策问题， 在退伍军人管理局（VA）患者中开始丁丙诺啡治疗。服务量~ 500万 患者每年，我们将利用VA电子健康记录数据来回答三个重要的临床和 政策问题。(1)放松丁丙诺啡处方指南对丁丙诺啡的影响是什么 2019冠状病毒病大流行期间的总体治疗率和各治疗阶段的治疗率（新患者与长期患者） 患者（？(2)更灵活的远程保健条例对治疗结果的影响是什么？ 开始丁丙诺啡治疗的患者(3)使用远程保健对治疗结果的影响是什么？ 长期接受丁丙诺啡治疗的患者（治疗≥6个月）？我们将分三个部分来回答这些问题 步骤：（1）我们将使用时间序列方法来模拟丁丙诺啡中VA患者的月计数 在2020年3月之前接受治疗，预测2020年4月至12月的每月治疗次数，并比较 它以观察计数来量化丁丙诺啡治疗率的变化， （2）测试是否：（a）通过以下途径开始丁丙诺啡治疗的患者的临床治疗结果： 远程医疗政策后的变化与在爆发前一年开始治疗的患者不同，以及（B） 调查政策对临床治疗结果影响的个人、机构和地区层面的修正因素;以及 (3)（a）审查远程保健使用与临床治疗之间的关系 结果和（B）确定远程保健丁丙诺啡治疗中的个体、设施和地区差异。 确定更灵活的远程保健条例的影响将为潜在的政策提供关键信息 杠杆，以增加获得关键的救生药物，为OUD。补充培训计划 包括正式的课程，研讨会，指导性阅读和体验式学习将让我发展 技能和专业知识，开始我的职业生涯作为一个物质使用流行病学家，并准备我成功地 作为一名独立的调查员竞争R 01资金，重点是了解成瘾的原因 和政策评估，为干预措施提供信息，预防和治疗OUD及其相关危害。

PROJECT SUMMARY/ABSTRACT Expanded use of telemedicine for buprenorphine prescribing may reduce barriers to buprenorphine prescribers. However, federal regulations that require prescribers to conduct in-person medical evaluations to induct patients on buprenorphine and limit maintenance visits to real-time, two-way, interactive audio-visual communication (i.e., telehealth) has prevented research on the potential role of expanding telehealth for buprenorphine prescribing. The initial surge of COVID-19 cases in the US in March 2020 led federal agencies to ease the in-person evaluation requirement, allowing providers to use telemedicine or telephone-only visits for medical evaluations to start patients on buprenorphine. We propose a study that leverages these COVID-related regulator reforms to answer important clinical and policy questions regarding the regulations governing the use of telehealth for buprenorphine initiation and treatment among Veterans Administration (VA) patients. Serving ~5,000,000 patients each year, we will leverage the VA electronic health record data to answer three important clinical and policy questions. (1) What was the effect of the relaxed buprenorphine prescribing guidelines on buprenorphine treatment rates change during the COVID-19 pandemic overall and by treatment stage (new patients vs. long- standing patients)? (2) What is the effect on treatment outcomes of more flexible telehealth regulations on patients initiating buprenorphine treatment? (3) What is the effect of telehealth use on treatment outcomes on patients in long-standing buprenorphine treatment (in care ≥6 months)? We will answer these questions in three steps: (1) We will use time-series methods to model the monthly counts of VA patients in buprenorphine treatment prior to March 2020, predict the monthly count in treatment from April to December 2020 and compare it to the observe counts to quantify the change in buprenorphine treatment rates associated with more flexible treatment regulations; (2) Test whether: (a) clinical treatment outcomes in patients initiating buprenorphine via telehealth post-Policy changes differ from patients initiating treatment in the year before the outbreak and (b) Investigate individual, facility, and area-level modifiers of the policy effects on clinical treatment outcomes; and (3) Among long-standing patients: (a) Examine the relationship between telehealth use and clinical treatment outcomes and (b) Determine individual, facility, and area-level differences in telehealth buprenorphine treatment. Determining the effects of more flexible telehealth regulations will provide critical information on a potential policy lever to increase access to critical life-saving medications for OUD. The complementary training program comprising of formal courses, workshops, directed readings, and experiential learning will let me develop the skill and expertise to launch my career as a substance use epidemiologist and prepare me to successfully compete for R01 funding as an independent investigator with a focus on understanding the causes of addiction and policy evaluation to inform interventions, prevent, and treat OUD and its related harms.