DAT- Implementing routine screening for cannabis and other drug use disorders in primary care: impact on diagnosis and treatment in a randomized pragmatic trial in 22 clinics

项目摘要 DAT 18 -06美国物质使用障碍（SUD）的个人、社会和公共卫生负担 阿片类药物的流行以及娱乐和医用大麻的合法化使各州的情况更加复杂 使用.传统上，医疗保健系统将SUD患者转诊给专家。尽管SUD治疗 与改善的结果相关，大多数SUD患者仍然未被识别和治疗。的 未满足需求的规模导致专家建议将SUD的筛查和评估纳入其中 纳入常规初级保健（PC），以提高SUD的诊断和治疗率。尽管进行了广泛 观察性研究，据我们所知，没有随机对照试验评估了 基于PC的新SUD治疗筛查和评估计划。该研究建议采取 一个独特的和偶然的机会，以评估PC程序的筛选和 SUD新诊断和治疗的SUD评估。持续的以病人为中心的酒精 2018年7月完成的相关护理（Related Care，简称CART）试验是一项严格设计的随机实施方案。 试验测试一种多方面的方法来改善对不健康的酒精使用的护理。然而，应 实施该计划的Kaiser Permanente华盛顿（KPWA）的临床负责人， 阿片类药物、大麻和其他药物使用障碍的常规筛查和评估（CUD、OUD和DUD， 在22家KPWA PC诊所开展试验之前，分别添加了这些药物。因此， 实施方案包括实践指导、电子健康记录（EHR）支持 绩效监控和反馈以及提供商培训-也是针对SUD的。卫生系统数据 监测报告表明，该试验实现了高的，持续的SUD筛查率，超过了目标 80%的患者接受了PC访问。然而，这项试验只被资助评估酒精相关的 结果。这项拟议的研究将严格评估该计划对临床的影响。 在初级保健访视后90天内新SUD治疗的有意义的主要结局（目标1）。到 阐明SUD护理质量（目标2）的潜在持续差距，我们将使用自然语言处理 (NLP)提取并量化原因：1）报告≥4个DSM-5 SUD症状的患者未接受 OUD、CUD或DUD的正式编码诊断，以及2）为什么新诊断OUD、CUD和DUD的患者 DUD未接受治疗。大多数患有OUD、CUD和其他DUD的人从未接受过治疗。一个 据估计，2.5-3.9%的美国成年人有去年的SUD，近90%的人报告没有SUD治疗。然而，>84% 的美国成年人每年都有门诊就诊，其中一半以上是在PC中。如果提出的创新 一项研究表明，PC中的筛查和评估增加了SUD治疗，它将为以下方面提供支持： 一个得到广泛认可但以前未经检验的方法，以解决质量方面的一个至关重要的差距， 照顾SUD。

PROJECT SUMMARY DAT18-06 The personal, social, and public health burdens of substance use disorders (SUDs) in the United States have been compounded by the opioid epidemic and legalization of recreational and medical cannabis use. Traditionally, healthcare systems have referred patients with SUDs to specialists. Although SUD treatment is associated with improved outcomes, most people with SUDs remain unidentified and untreated. The magnitude of unmet need has led experts to recommend incorporating screening and assessment for SUDs into routine primary care (PC), to increase rates of diagnosis and treatment of SUDs. Despite extensive observational research, to our knowledge no randomized controlled trial has evaluated the impact of PC-based programs of screening and assessment on new SUD treatment. The proposed study takes advantage of a unique and fortuitous opportunity to evaluate the impact of a PC program of screening and assessment for SUDs on new diagnosis and treatment of SUDs. The Sustained Patient-centered Alcohol Related Care (SPARC) trial, completed in July 2018, was a rigorously-designed randomized implementation trial testing a multifaceted approach to improving care for unhealthy alcohol use. However, at the request of clinical leaders at Kaiser Permanente Washington (KPWA) where the SPARC program was implemented, routine screening and assessment for opioid, cannabis, and other drug use disorders (CUD, OUD, and DUD, respectively) were added before the trial was launched in 22 KPWA PC clinics. As a result, the SPARC trial's implementation program—consisting of practice coaching, electronic health record (EHR) support, performance monitoring and feedback, and provider training—also targeted SUDs. Data from health system monitoring reports indicate the trial achieved high, sustained rates of screening for SUDs, exceeding the target of 80% of patients with PC visits. However, the SPARC trial was only funded to evaluate alcohol-related outcomes. The proposed study will rigorously evaluate the SPARC program's impact on the clinically meaningful primary outcome of new SUD treatment within 90 days of a primary care visit (Aim 1). To illuminate potential continued gaps in the quality of SUD care (Aim 2), we will use natural language processing (NLP) to extract and quantify reasons why: 1) patients reporting ≥4 DSM-5 symptoms of SUDs do not receive formal coded diagnoses of OUD, CUD, or DUD, and 2) why patients with newly diagnosed OUDs, CUDs, and DUDs do not received treatment. Most people with OUDs, CUDs, and other DUDs are never treated. An estimated 2.5-3.9% of US adults have past-year SUDs, and nearly 90% report no SUD treatment. Yet >84% of US adults have outpatient visits annually, and over half of these visits are in PC. If the proposed innovative study demonstrates that screening and assessment in PC increase SUD treatment, it would provide support for a widely endorsed yet previously untested approach to addressing a critically important gap in the quality of care for SUDs.