DAT- Implementing routine screening for cannabis and other drug use disorders in primary care: impact on diagnosis and treatment in a randomized pragmatic trial in 22 clinics

项目总结 DAT18-06美国物质使用障碍(SODS)的个人、社会和公共卫生负担 各国因阿片类药物流行以及娱乐和医用大麻合法化而雪上加霜。 使用。传统上，医疗系统会将患有肥皂泡的患者转介给专家。虽然SUD治疗 与改善结果相关，大多数肥皂泡患者仍然身份不明，没有得到治疗。这个 大量未得到满足的需求导致专家建议将肥皂泡的筛查和评估纳入其中 纳入常规初级保健(PC)，以提高SUDS的诊断率和治疗率。尽管广泛 观察性研究，据我们所知，没有随机对照试验评估过 基于PC的新的SUD治疗的筛选和评估程序。拟议的研究采取了 利用独特而偶然的机会评估PC筛查和 新诊断和新治疗对肥胖症的评估。持续的以患者为中心的酒精 相关护理(SPARC)试验于2018年7月完成，是一项严格设计的随机实施 试验测试一种多方面的方法，以改善对不健康酒精使用的护理。然而，应美国政府的要求 实施SPARC计划的华盛顿凯撒永久医院(KPWA)的临床负责人， 对阿片类药物、大麻和其他药物使用障碍(CUD、OUD和DUD， 分别)，在22个KPWA PC诊所启动试验之前添加。因此，SPARC试验的 实施计划--包括实践指导、电子健康记录(EHR)支持、 性能监控和反馈，以及提供商培训--也针对SUDS。来自卫生系统的数据 监测报告表明，试验取得了高的、持续的肥皂水筛查率，超过了目标 80%的患者使用PC进行访问。然而，SPARC试验的资金仅用于评估与酒精有关的 结果。这项拟议的研究将严格评估SPARC计划对临床的影响 初级保健就诊后90天内新的SUD治疗的有意义的主要结果(目标1)。至 阐明SUD护理质量的潜在持续差距(目标2)，我们将使用自然语言处理 (NLP)提取和量化原因：1)报告≥4-DSM-5症状的患者没有收到 OUD、CUD或DUD的正式编码诊断，以及2)为什么新诊断的OUD、CUD和 哑巴不接受治疗。大多数患有OUD、CUD和其他哑巴的人从未得到治疗。一个 据估计，2.5%-3.9%的美国成年人在过去一年中患有肥皂泡，近90%的人报告说没有进行肥皂泡治疗。然而&gt；84% 的美国成年人每年都有门诊就诊，其中超过一半的就诊是在个人电脑上。如果提议的创新 研究表明，在PC的筛查和评估中增加SUD的治疗，将为 一种得到广泛认可但之前未经测试的方法，用于解决关键的质量差距 注意肥皂水。

PROJECT SUMMARY DAT18-06 The personal, social, and public health burdens of substance use disorders (SUDs) in the United States have been compounded by the opioid epidemic and legalization of recreational and medical cannabis use. Traditionally, healthcare systems have referred patients with SUDs to specialists. Although SUD treatment is associated with improved outcomes, most people with SUDs remain unidentified and untreated. The magnitude of unmet need has led experts to recommend incorporating screening and assessment for SUDs into routine primary care (PC), to increase rates of diagnosis and treatment of SUDs. Despite extensive observational research, to our knowledge no randomized controlled trial has evaluated the impact of PC-based programs of screening and assessment on new SUD treatment. The proposed study takes advantage of a unique and fortuitous opportunity to evaluate the impact of a PC program of screening and assessment for SUDs on new diagnosis and treatment of SUDs. The Sustained Patient-centered Alcohol Related Care (SPARC) trial, completed in July 2018, was a rigorously-designed randomized implementation trial testing a multifaceted approach to improving care for unhealthy alcohol use. However, at the request of clinical leaders at Kaiser Permanente Washington (KPWA) where the SPARC program was implemented, routine screening and assessment for opioid, cannabis, and other drug use disorders (CUD, OUD, and DUD, respectively) were added before the trial was launched in 22 KPWA PC clinics. As a result, the SPARC trial's implementation program—consisting of practice coaching, electronic health record (EHR) support, performance monitoring and feedback, and provider training—also targeted SUDs. Data from health system monitoring reports indicate the trial achieved high, sustained rates of screening for SUDs, exceeding the target of 80% of patients with PC visits. However, the SPARC trial was only funded to evaluate alcohol-related outcomes. The proposed study will rigorously evaluate the SPARC program's impact on the clinically meaningful primary outcome of new SUD treatment within 90 days of a primary care visit (Aim 1). To illuminate potential continued gaps in the quality of SUD care (Aim 2), we will use natural language processing (NLP) to extract and quantify reasons why: 1) patients reporting ≥4 DSM-5 symptoms of SUDs do not receive formal coded diagnoses of OUD, CUD, or DUD, and 2) why patients with newly diagnosed OUDs, CUDs, and DUDs do not received treatment. Most people with OUDs, CUDs, and other DUDs are never treated. An estimated 2.5-3.9% of US adults have past-year SUDs, and nearly 90% report no SUD treatment. Yet >84% of US adults have outpatient visits annually, and over half of these visits are in PC. If the proposed innovative study demonstrates that screening and assessment in PC increase SUD treatment, it would provide support for a widely endorsed yet previously untested approach to addressing a critically important gap in the quality of care for SUDs.