Barriers to use of pharmacotherapy for alcohol dependence in VA primary care

背景：酒精依赖是一种常见的慢性疾病，影响4.2%的VA患者。而 专业成瘾治疗方案对治疗酒精依赖有效，大多数（约66%）VA 有酒精依赖的病人从来没有接受过它。三种药物被食品和药物管理局批准 美国食品药品监督管理局（FDA）的酒精依赖，并认为是标准的治疗酒精依赖的VA， 但约95%的酒精依赖VA患者没有接受这些治疗。因此，增加获得这些 药物治疗是多个VA利益相关者的主要目标。虽然在VA的共同定位和团队为基础的护理 初级保健心理健康整合倡议和VA的患者对齐护理团队可以使初级保健 护理提供者开处方并将这些药物纳入现有的护理系统， 由于吸毒成瘾者护理历来与主流分开， 药物和与酒精有关的耻辱。尽管弗吉尼亚州以前的研究集中在描述障碍， 和促进使用药物治疗酒精依赖的专业成瘾护理提供者， 以前的研究没有描述使用药物治疗酒精依赖的障碍和促进因素， 初级保健.实施的第一步是了解初级保健提供者对 用药物治疗酒精依赖的可行性和障碍。 目的：本研究的具体目标是：1）描述小学生学习的障碍和促进因素 护理提供者使用药物治疗酒精依赖的VA初级保健使用定性，半， 在9个当地初级保健诊所进行结构化访谈，2）开展调查，评估使用 药物治疗酒精依赖之间的VA初级保健提供者的可推广的样本。 研究计划：本研究将对VA初级保健提供者进行定性半结构化访谈， 9个初级保健诊所与一个当地VA医疗机构相关，以描述 在VA初级保健中使用药物治疗酒精依赖，并开展后续调查。所有 具有处方特权的初级保健提供者，每周至少在9个 诊所将有资格。招募策略将采用本研究先前成功使用的方法 团队提供者将通过首先与每个诊所的关键联系点建立沟通来招募 介绍这项研究，并建立在诊所进行访谈的最佳方法， 最大限度地减少对诊所流程和病人护理的干扰。视乎诊所的情况，面试将透过 电子邮件与个别初级保健提供者或通过现场招聘。每一位潜在的参与者都将 要求转介到一个或多个其他供应商（滚雪球抽样）。我们将努力采访 跨工作分类的提供者（即，工作人员医生、住院医生和执业护士）， 那些对酒精依赖治疗的行为改变有潜在不同障碍的人。半- 结构化面试将根据社会营销概念框架，这是重点 识别和消除行为改变的障碍。所有的采访都将被数字化记录， 转录。将使用模板分析（也称为专题编码）以迭代方式分析数据。 代码的初始模板将基于罗宾逊的模型，但该模板将在迭代中进行修改。 时尚.代码模板完成后，两名编码员将对所有面试成绩单进行编码。差异 编码器之间的问题将由研究团队审查并达成共识。然后将内容排序 按领域进行报告;将对每个领域和子域的主要观察结果进行摘要介绍 并用于制定一项调查，将在随后的研究中进行实地调查。

Background: Alcohol dependence is a common, chronic condition affecting 4.2% of VA patients. While specialty addictions treatment programs are effective for treating alcohol dependence, a majority (~66%) of VA patients with alcohol dependence never receive it. Three medications are approved by the Food and Drug Administration (FDA) for alcohol dependence and are considered standard care for alcohol dependence in VA, but ~95% of VA patients with alcohol dependence do not receive them. As such, increasing access to these medications is a major goal of multiple VA stakeholders. While the co-located and team-based care in VA's Primary Care Mental Health Integration Initiative and VA's Patient Aligned Care Teams could enable primary care providers to prescribe and integrate these medications into existing systems of care, there are likely substantial barriers to such integration due to the historic separation of addictions care from mainstream medicine, and alcohol-related stigma. Although previous research in the VA has focused on describing barriers and facilitators to use of medications to treat alcohol dependence among specialty addictions care providers, no previous study has described barriers and facilitators to use of medications to treat alcohol dependence in primary care. An initial step in implementation is to understand primary care providers' perceptions of the feasibility of and barriers to managing alcohol dependence with medications. Objective: The specific aims of the proposed research are to: 1) Describe barriers to and facilitators of primary care providers' use of medications to treat alcohol dependence in VA primary care using qualitative, semi- structured interviews at 9 local primary care clinics, and 2) Develop a survey to assess determinants of use of medications to treat alcohol dependence among a generalizable sample of VA primary care providers. Research Plan: This study will conduct qualitative semi-structured interviews with VA primary care providers at 9 primary care clinics associated with a single local VA medical facility to describe barriers to and facilitators of use of medications to treat alcohol dependence in VA primary care and to develop a subsequent survey. All primary care providers with prescribing privileges who practice at least one half day per week in one of the 9 clinics will be eligible. The recruitment strategy will employ methods previously successfully used by the study team. Providers will be recruited by first establishing communication with a key point-of-contact at each clinic to introduce the study and establish the best method for conducting interviews at the clinic in a way that minimizes the disruption of clinic flow and patient care. Depending on the clinic, interviews will be arranged via email with individual primary care providers or through on-site recruitment. Each potential participant will be asked for referrals to one or more other providers (snowball sampling). An effort will be made to interview providers across job classifications (i.e., staff physicians, resident physicians, and nurse practitioners) and those with potential differing barriers to behavior change regarding treatment of alcohol dependence. Semi- structured interviews will be developed based on a social marketing conceptual framework, which is focused on identifying and removing obstacles to behavior change. All interviews will be digitally recorded and transcribed. Data will be analyzed in an iterative fashion using template analysis (also called thematic coding). The initial template of codes will be based on Robinson's model, but the template will be revised in an iterative fashion. After the template of codes is finalized, two coders will code all interview transcripts. Discrepancies between coders will be reviewed by the study team and resolved with consensus. Content will then be sorted by domain for reporting; key observations in each domain and sub-domain will be abstracted for presentation and used to develop a survey, which will be fielded in a subsequent study.