ADAPT: Adaptive Decision support for Addiction Treatment

项目摘要 鸦片危机是动态的。为了克服成瘾治疗的障碍，实施研究必须保持 通过更快地适应新出现的证据，与阿片类药物危机不断变化的形势保持同步。临床 决策支持（CDS）提供了一个有希望的实施策略，以更有效地操作和扩展 循证实践。患者在发生哨兵事件后有动力开始成瘾治疗，例如 因阿片类药物过量到急诊科（艾德）就诊。不幸的是，临床医生很少启动成瘾 治疗为此，我们最近进行了EMBED实用集群随机试验。本试验 评估了基于非中断电子健康记录（EHR）的CDS的有效性， 评估和自动化EHR活动，以在常规护理中实施丁丙诺啡的ED启动 阿片类药物使用障碍（OUD）EMBED CDS增加了发起 丁丙诺啡导致EMBED的全国传播。试验后分析发现， 治疗以及增加覆盖面和采用的机会。然而，CDS干预通常 在研究过程中保持不变，传统的评价方法耗时， 错失了取得进展的机会，并拖延了有效干预措施的实施。这些限制必须 为加快实施以证据为基础的解决办法，以解决阿片类药物危机， 全国范围内的EMBED CDS。EHR既可以提供CDS干预，又可以提供非 利用带有自动日志数据的EHR使用测量来大规模研究护理提供的引人注目、严格的方式 捕获.当前定量CDS使用和可用性指标仅限于警报解除率和描述性 CDS特征的测量，但无法评估CDS接口和工作流程，例如 CDS吸收和可用性的粒度评估。因此，我们将采用CDS的最佳做法， OUD患者使用多阶段优化策略（MOST）框架，包括快速、串行 随机测试，通过可扩展的，务实的EHR使用指标来衡量，以实现以下特定目标： (1)完善和验证可重现、可扩展的结局指标，以评估CDS的使用和可用性， 实施丁丙诺啡ED引发OUD和（2）改进和评价多组分CDS 通过增加CDS摄取改善OUD患者中丁丙诺啡ED启动的干预， 可用性和公平性。这些具体目标的实现将为实现可扩展、公平 通过创新数据驱动的适应性方法来干预阿片类药物危机， 为OUD患者提供访问和参与。在急诊医学，成瘾医学， 临床决策支持、实用性评价、生物统计学、健康公平性和数据、测量和 作为实施科学，Melnick博士和ADAPT团队为实现这些目标做好了独一无二的准备。

Project Summary The opioid crisis is dynamic. To overcome barriers to addiction treatment, implementation research must keep pace with the changing landscape of the opioid crisis by more rapidly adapting to emerging evidence. Clinical decision support (CDS) offers a promising implementation strategy to more efficiently operationalize and scale evidence-based practices. Patients are motivated to initiate addiction treatment after sentinel events, such as an emergency department (ED) visit for opioid overdose. Unfortunately, clinicians rarely initiate addiction treatment. To that end, we recently conducted the EMBED pragmatic cluster-randomized trial. This trial evaluated the effectiveness of non-interruptive electronic health record (EHR)-based CDS to facilitate patient assessment and automate EHR activities to implement ED-initiation of buprenorphine in the routine care of people with opioid use disorder (OUD). The EMBED CDS increased the proportion of physicians who initiated buprenorphine leading to national dissemination of EMBED. Post-trial analysis identified disparities in treatment as well as opportunities to increase reach and adoption. However, CDS interventions typically remain unchanged while being studied and traditional methods for evaluation are time-consuming, resulting in missed opportunities for progress and delays in implementing effective interventions. These limitations must be addressed to speed the implementation of evidence-based solutions to the opioid crisis in general and the the nationally scaled EMBED CDS specifically. The EHR can both deliver CDS interventions and offer a non- obtrusive, rigorous way to study care delivery at scale utilizing EHR use measurement with automated log data capture. Current quantitative CDS use and usability metrics are limited to alert dismissal rates and descriptive measures of CDS characteristics but are not capable of evaluating CDS interfaces and workflows such as granular assessment of CDS uptake and usability. Therefore, we will adapt CDS of best practices in the care of people with OUD using a Multiphase Optimization STrategy (MOST) framework including rapid, serial randomized testing, measured by scalable, pragmatic EHR use metrics to achieve the following specific aims: (1) Refine and validate reproducible, scalable outcome measures for assessing CDS uptake and usability to implement ED-initiation of buprenorphine for OUD and (2) Refine and evaluate a multicomponent CDS intervention to improve ED-initiation of buprenorphine in patients with OUD via increased CDS uptake, usability, and equity. Achievement of these specific aims will offer a pathway to scalable, equitable interventions for the opioid crisis by innovating data-driven, adaptive approaches that increase treatment access and engagement for people with OUD. With expertise in emergency medicine, addiction medicine, clinical decision support, pragmatic evaluation, biostatistics, health equity, and data, measurement, and implementation science, Dr. Melnick and the ADAPT team are uniquely poised to achieve these aims.