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显著恶化， 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 拥有强大社会安全网的国家(丹麦、挪威、瑞典和芬兰)。 可预防的死亡率很难降低，原因有很多，包括许多决定因素 个人、人际、社区和社会层面。然而，基于以下原因，我们有一些乐观的理由 在个人层面上，行动杠杆的效力。在社会经济地位和种族/族裔相关的健康差距中 在美国，有11种可预防的疾病导致了50%的死亡。此外，我们的初步建模工作表明 只需要9个预防目标就能从这11种情况中实现40%的死亡率下降，从而导致 由于相互依赖和共同的途径，死亡率总体上降低了20%。例如，酒精 使用障碍和/或大量饮酒不仅影响肝功能衰竭，还会影响行为后果，如 性行为冒险和用药不依从。 然而，要实现20%的死亡率下降，就需要对预防保健进行根本性变革，例如 我们的建议侧重于个性化、导航和补偿。个性化手段 通过调整筛查强度、筛查频率和筛查强度来最大化个人层面的利益 或反应的持续时间；导航意味着减少因卫生和社会问题支离破碎造成的障碍 补偿意味着抵消受抚养人的护理、时间成本和旅行成本。 R34之后的目标是N=15,000个5年期RCT，它将有足够的能力来检验20%的假设 通过个性化、导航和补偿降低死亡率。这项拟议的R34是为 这一目标，并特别关注酒精使用障碍和酗酒、艾滋病毒风险和 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.