Can a radical transformation of preventive care reduce mortality by 20% in low SES populations? Preparatory work focusing on AUD/heavy alcohol use, HIV risk, and cardiovascular risk

在美国和其他地方，与社会经济地位（SES）相关的健康差距正在大幅恶化， 包括加拿大、澳大利亚、新西兰、日本、韩国、香港，甚至平等主义的北欧国家 拥有健全社会安全网的国家（丹麦、挪威、瑞典和芬兰）。 由于多种原因，包括许多决定因素， 个人、人际、社区和社会层面。然而，有一些乐观的理由， 行动杠杆在个人层面上的效力。在与社会经济地位和种族/族裔有关的健康差距中， 美国，11种可预防的疾病导致>50%的死亡率。此外，我们的初步建模工作表明， 仅需9项预防目标即可将这11种疾病的死亡率降低40%， 由于相互依赖和共同途径，总体死亡率降低20%。例如醇 使用障碍和/或大量饮酒不仅影响肝功能衰竭，还影响行为后果， 性冒险和药物治疗不依从。 然而，要实现死亡率降低20%的目标，就需要对预防保健进行根本性的改革，例如： 我们的建议，侧重于个性化，导航和补偿。个性化意味着 通过调整筛查强度、筛查频率和筛查强度， 导航意味着减少卫生和社会服务分散造成的障碍， 补偿意味着抵消依赖性护理、时间成本和旅行成本。 R34后目标是一项N= 15，000的5年RCT，具有足够的把握度来检验20%的假设 通过个性化、导航和补偿降低死亡率。R34是一种准备 这一目标，并特别侧重于酒精使用障碍和大量饮酒，艾滋病毒的风险， 心血管疾病

Socioeconomic status (SES)-related health disparities are worsening substantially in the U.S. and elsewhere, including Canada, Australia, New Zealand, Japan, Korea, Hong Kong, and even egalitarian Nordic European countries with robust social safety nets (Denmark, Norway, Sweden, and Finland). Preventable mortality is difficult to mitigate for a multitude of reasons, including numerous determinants at individual, interpersonal, community, and societal levels. However, there is some cause for optimism based on the potency of action levers at the individual level. Among SES- and race/ethnicity-related health disparities in the U.S., 11 preventable conditions cause >50% of mortality. Further, our preliminary modeling work suggests that only 9 prevention goals are required to attain 40% mortality reduction from these 11 conditions, resulting in 20% mortality reduction overall, because of interdependencies and common pathways. For example, alcohol use disorder and/or heavy drinking impacts not only liver failure, but also behavioral consequences such as sexual risk-taking and medication nonadherence. However, attaining 20% mortality reduction would require a radical transformation of preventive care, such as what we propose, focused on personalization, navigation, and compensation. Personalization means maximizing individual-level benefit by modulating intensity of screening, frequency of screening; and intensity or duration of response; navigation means reducing barriers posed by fragmentation of health and social systems; and compensation means offsetting dependent care, time costs, and travel costs. The post-R34-goal is a N=15,000 5-year RCT which would have adequate power to test the hypothesis of 20% mortality reduction from personalization, navigation, and compensation. This proposed R34 is preparatory for that goal, and focuses especially on alcohol use disorder and heavy drinking, HIV risk, and risk for cardiovascular disease.