Digital treatments for opioids and other substance use disorders (DIGITS) in primary care: Observational Analysis of Adaptions to the Intervention

项目摘要 这项拟议的研究解决了一个关键的知识差距：如何最好地实施数字治疗， 初级保健（PC）中的阿片类药物和其他物质使用障碍（SUD）。reSET和reSET-O是 基于智能手机的，FDA批准的治疗教育系统版本，这是一个计算机化的 认知行为治疗我们将研究它们在PC中的实施，以潜在地改善护理 对于SUD患者，并作为如何可持续地将数字治疗应用于现实世界的模型 健康护理数字治疗可以将SUD治疗的范围扩大到更多的人，并可以解决 在PC中开丁丙诺啡处方的重大障碍：缺乏获得心理社会治疗的机会。递送 华盛顿凯撒医疗机构的系统领导人是我们的合作者，他们研究了 在华盛顿州实施reSET和reSET-O，以应对之前实施的挑战 在文献中有记载。在2家诊所试点后，我们将在2x2析因中随机分配最多23家PC诊所 设计有四种方法：（1）“标准实施”，这是一种基于证据的实施战略 以前由我们的交付系统合作伙伴使用;（2）“外部促进的标准实施”， （3）“标准实施与病人教练”，一个面向病人的 使用医疗助理支持患者采用和参与的实施策略;以及（4） “两者的标准实现。”这些实施策略在PC中有一定的证据，但其 尚未评估对数字治疗的现实世界实施的影响。具体目标是（1） 评估面向临床医生（外部促进）和面向患者（患者教练）实施的效果 在PC诊所中增加数字SUD治疗的范围和保真度的策略，以及（2）比较 每个实施战略在增加覆盖面、保真度和 患者的禁欲。这一行政补充将使我们的研究从COVID相关的 延迟和（3）估计的影响：培训非社会工作临床医生规定的reSET和reSET-O， 允许开处方而不需要随访，并集中管理开处方的行政任务。 影响：研究人员和卫生系统不知道如何接触大量OUD患者 其他SUD数字治疗很有前途，但卫生系统缺乏证据来指导实施 数字疗法本研究将评估和比较面向临床医生和面向患者的有效性 实施战略，为卫生系统领导者提供有关如何最好地实施数字化的数据， 治疗。

PROJECT SUMMARY The proposed study addresses a critical knowledge gap: How to best implement digital treatments for opioids and other substance use disorders (SUDs) in primary care (PC). reSET and reSET-O are smartphone-based, FDA-cleared versions of the Therapeutic Educational System, which is a computerized cognitive-behavioral treatment for SUDs. We will study their implementation into PC to potentially improve care for people with SUDs, and as a model for how to sustainably implement digital treatments into real-world healthcare. Digital treatments could extend the reach of SUD therapy to more people and could address a significant barrier to buprenorphine prescribing in PC: the lack of access to psychosocial treatment. Delivery system leaders in Kaiser Permanente Washington are our collaborators for studying strategies for implementing reSET and reSET-O in Washington State to address prior implementation challenges documented in the literature. After piloting in 2 clinics, we will randomize up to 23 PC clinics in a 2x2 factorial design to four approaches: (1) “standard implementation,” which is an evidence-based implementation strategy previously used by our delivery system partners; (2) “standard implementation with external facilitation,” a clinician-facing implementation strategy; (3) “standard implementation with patient coach,” a patient-facing implementation strategy using medical assistants to support patient adoption and engagement; and (4) “standard implementation with both.” These implementation strategies have some evidence in PC, but their impact on real-world implementation of a digital treatment has not been evaluated. Specific Aims are to (1) Estimate the effect of clinician-facing (external facilitation) and patient-facing (patient coach) implementation strategies in increasing the reach and fidelity of a digital SUD treatment in PC clinics, and (2) compare the population-level cost-effectiveness of each implementation strategy in increasing reach, fidelity, and abstinence by patients. This administrative supplement will allow our study to recover from COVID-related delays and (3) estimate the impact of: training non-social work clinicians to prescribe reSET and reSET-O, allowing prescriptions without requiring follow-up visits, and centralizing the administrative tasks of prescribing. IMPACT: Researchers and health systems do not know how to reach large numbers of patients with OUDs and other SUDs. Digital treatments are promising, but health systems lack evidence to guide implementation of digital therapies. This study will estimate and compare the effectiveness of clinician-facing and patient-facing implementation strategies, providing health system leaders with data on how to best implement digital treatments.