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

项目摘要/摘要 扩大使用远程医疗来开丁丙诺啡处方可能会减少丁丙诺啡处方者的障碍。 然而，要求处方医生进行面对面医疗评估以引导患者的联邦法规 丁丙诺啡，并将维护访问限制为实时、双向、交互式视听通信(即， 远程保健)阻碍了对扩大远程保健对丁丙诺啡处方的潜在作用的研究。 2020年3月，美国新冠肺炎案件最初激增，促使联邦机构缓解了面对面的 评估要求，允许提供者使用远程医疗或仅限电话访问进行医疗评估 让病人开始服用丁丙诺啡。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的法规的重要临床和政策问题 丁丙诺啡在退伍军人管理局(VA)患者中的启动和治疗服务约500万，000,000 每年，我们将利用退伍军人管理局的电子健康记录数据回答三个重要的临床和 政策问题。(1)放宽丁丙诺啡处方指南对丁丙诺啡有何影响 在新冠肺炎大流行期间，治疗率在总体上和治疗阶段发生变化(新患者与长期患者 (2)更灵活的远程医疗法规对治疗结果有什么影响？ 开始丁丙诺啡治疗的患者？(3)远程保健的使用对治疗结果有什么影响 长期接受丁丙诺啡治疗的患者(在≥护理6个月)？我们将分三个阶段回答这些问题 步骤：(1)我们将使用时间序列方法对丁丙诺啡治疗的VA患者的月计数进行建模 2020年3月前治疗，预测2020年4月至12月每月治疗次数并进行比较 它以观察计数来量化丁丙诺啡治疗率的变化，与之相关的更灵活 治疗规则；(2)测试：(A)丁丙诺啡患者是否通过以下途径获得临床治疗结果 远程保健后的政策变化不同于在疫情爆发前一年开始治疗的患者，以及(B) 调查政策对临床治疗结果的影响的个人、设施和地区层面的修饰者；以及 (3)在长期患者中：(A)检查远程保健使用与临床治疗之间的关系 结果和(B)确定在远程保健丁丙诺啡治疗中的个人、设施和地区水平的差异。 确定更灵活的远程医疗法规的影响将提供有关潜在政策的关键信息 杠杆，以增加获得关键的挽救生命的药物。补充性培训计划 包括正式课程、工作坊、定向阅读和体验式学习将使我发展 作为一名物质使用流行病学家开始我的职业生涯的技能和专业知识，并为我成功地 作为一名独立调查人员争夺R01资金，专注于了解成瘾的原因 以及政策评估，以告知干预措施，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.