Telehealth Treatment of Veterans with Alcohol Misuse at Risk for Cardiovascular Disease

背景：心血管疾病（CVD）是退伍军人最常见的死亡原因。cvd相关 合并酒精滥用的患者死亡的可能性超过两倍，部分原因是酒精滥用 直接加剧了导致CVD的几个可变因素。没有针对这两个方面的干预措施 这些合并症，以及目前VA/DoD在初级保健中合并酒精滥用的治疗指南 是无效的。因为酒精滥用通常是一个反复出现的问题， 建议，及时治疗这些退伍军人的心血管疾病风险与酒精滥用 治疗可能是发展与CVD风险的临床牵引的关键。巴诺克博士试图完善一个 远程医疗干预，并在整个CDA-2提案中获得必要的培训，以开始他的职业生涯 作为一个独立的VA卫生服务研究人员谁寻求提高有效性和覆盖面 行为健康治疗与共病行为健康问题的退伍军人。 意义/影响：整个退伍军人人群中有9-32%患有合并酒精滥用和可改变的 CVD风险增加。这一高危人群是完全可以预防的，但治疗和研究不足。 拟议的CDA研究将是第一个直接针对这一高风险人群的研究。本研究是 与退伍军人健康、VHA优先事项和HSR&D优先事项高度相关，因为综合干预 目标和远程保健办法解决了及时治疗和获得治疗方面的重大差距。 具体目标：目标1 -描述一个全国性的酗酒和可改变的心血管疾病退伍军人队列 风险，他们的酒精服务利用和临床结果。目标2 -质量评估障碍， 为有酒精滥用和心血管疾病风险的退伍军人提供多个利益相关者的治疗。目标3 -使用 连续队列设计以基于患者反馈迭代地开发干预。目标4 -测试 一项旨在减少退伍军人酒精滥用和心血管疾病风险的干预措施的可接受性和可行性。 创新：该应用程序在首次尝试解决以下问题方面具有高度创新性：1） 这一人群的治疗障碍，2）酒精滥用和CVD联合干预的效用 风险，3）多病患者对多个不同目标的治疗时机的偏好，以及4） VA健康行为习惯的可持续性通过使用“实施意图”的干预形成。 方法：目标1将使用电子健康记录来检查关键健康标准的状况， 服务利用与酒精滥用的退伍军人，无论有和没有共病CVD风险。目的2 我将使用定性访谈的退伍军人与共病酒精滥用和升高的可变心血管疾病 风险，他们的供应商在不同的设置，和系统级的利益相关者，以评估当前的治疗 隔栏.目标3将采用连续队列设计，反复测试拟议的干预措施， 来自多个退伍军人群体的快速和早期反馈。目标4将测试一种基于以下方面的改进干预措施： 目标2和3的反馈，以确定退伍军人患者的可接受性，以及 招募、随机化和干预。 后续步骤/实施：从目标1开始，将召开一个系统级咨询委员会会议， 每年进行一次，目的是在制定干预措施的整个过程中征求反馈意见，以帮助实施。通过 在CDA-2的第三年结束时，将提交IIR申请，以资助一项随机比较研究。 目标3干预的有效性试验。结果也将提交给当地退伍军人参与 与“VetREP”相关的面板。OCC和OMHSP运营合作伙伴的其他反馈，以及 从目标4的利用模式和护理环境中收集的实施考虑因素，将允许快速 制定一项后IIR执行计划。成本效益和实施方面的额外培训 科学也将给予Blalock博士继续进行更多研究和实施的技能。

Background: Cardiovascular disease (CVD) is the most common cause of death in Veterans. CVD-related deaths are over twice as likely in patients with comorbid alcohol misuse, due in part to alcohol misuse directly exacerbating several modifiable factors that lead to CVD. No interventions exist targeting both these comorbidities, and current VA/DoD treatment guidelines for comorbid alcohol misuse in primary care are ineffective. Because alcohol misuse is often a recurrent problem, and the dominant driver of treatment recommendations, timely treatment of these Veterans’ CVD risk in conjunction with alcohol misuse treatment in may be critical for developing clinical traction with CVD risk. Dr. Blalock seeks to refine a telehealth intervention and acquire necessary training throughout this CDA-2 proposal to begin his career as an independent VA health services researcher who seeks to improve the effectiveness and reach of behavioral health treatments for Veterans with comorbid behavioral health problems. Significance/Impact: 9-32% of the entire Veteran population has comorbid alcohol misuse and modifiable elevated CVD risk. This high-risk population is entirely preventable, but is undertreated and understudied. The proposed CDA research would be the first to directly target this high-risk population. This research is highly relevant to Veteran health, VHA priorities, and HSR&D priorities because the combined intervention targets and telehealth approaches address critical gaps in treatment timeliness and access. Specific Aims: Aim 1 –Characterize a national cohort of Veterans with alcohol misuse and modifiable CVD risk, their alcohol services utilization, and clinical outcomes. Aim 2 – Qualitatively assess barriers to treatment for Veterans with alcohol misuse and CVD risk across multiple stakeholders. Aim 3 – Use a successive cohort design to iteratively develop an intervention based on patient feedback. Aim 4 – Test the acceptability and feasibility of an intervention to reduce alcohol misuse and CVD risk in Veterans. Innovation: This application is highly innovative in its attempt to address for the first time: 1) perceptions of barriers to treatment in this population, 2) the utility of a combined intervention for alcohol misuse and CVD risk, 3) multimorbid patient preferences for timing of treatments for multiple different targets, and 4) the sustainability of health behavior habits in VA formed by an intervention using “implementation intentions.” Methodology: Aim 1 will use electronic health records to examine the status of key health criteria and services utilization among Veterans with alcohol misuse, both with and without comorbid CVD risk. Aim 2 will use qualitative interviews of both Veterans with comorbid alcohol misuse and elevated modifiable CVD risk, their providers across different settings, and systems-level stakeholders to assess current treatment barriers. Aim 3 will employ a successive cohort design to iteratively test the proposed intervention with rapid and early feedback from multiple Veteran cohorts. Aim 4 will test a refined intervention based on feedback from Aims 2 and 3 to determine the acceptability to Veteran patients, as well as the feasibility of recruitment, randomization, and intervention. Next Steps/Implementation: Beginning in Aim 1, a systems-level advisory board will be convened semi- annually with the goal of eliciting feedback throughout intervention development to aid implementation. By the end of the 3rd year of the CDA-2, an IIR application will be submitted to fund a randomized comparative effectiveness trial of the Aim 3 intervention. Results will also be presented to local Veterans engagement panels associated with “VetREP.” Additional feedback from OCC and OMHSP operations partners, and implementation considerations gleaned from utilization patterns and care settings in Aim 4, will allow rapid development of a post-IIR implementation plan. Additional training in cost effectiveness and implementation science will also give Dr. Blalock the skills to follow through with additional research and implementation.