Integrating Addiction and Infectious Diseases Services into Primary Care in Rural Settings

将成瘾和传染病服务纳入农村地区的初级保健

基本信息

批准号：
10670120
负责人：
FREDERICK LEWIS ALTICE
金额：
$ 115.52万
依托单位：
YALE UNIVERSITY
依托单位国家：
美国
项目类别：
财政年份：
2021
资助国家：
美国
起止时间：
2021-08-01 至 2027-05-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10670120
关键词：
AIDS prevention Academy Address Administrator Adopted Adoption Caring Clinic Clinical Clinical Skills Communicable Diseases County Disease Outbreaks Education Electronic Health Record Elements Epidemic Evaluation Evidence based practice Evidence based treatment HIV HIV Infections HIV/HCV Health Health Benefit Healthcare Hepatitis C Therapy Hepatitis C virus Hybrids Indiana Individual Infection Injecting drug user International Knowledge Learning Link Measures Mediator Medicine Modeling Modification Nature Needle-Exchange Programs Outcome Overdose Perception Performance Pharmaceutical Preparations Policies Policy Maker Predisposition Prevention Primary Care Process Promoting Action on Research Implementation in Health Services framework Public Health Recommendation Reporting Reproducibility Rural Services Testing Training Translating Ukraine Volatilization West Virginia addiction alcohol misuse behavioral health brief intervention dashboard design effective therapy effectiveness outcome efficacy outcomes experience flexibility implementation framework implementation outcomes implementation trial improved innovation integrated care medical specialties medication for opioid use disorder opioid epidemic opioid use disorder pre-exposure prophylaxis prevent primary care clinic primary care provider primary outcome provider factors response rural counties rural setting scale up screening screening, brief intervention, referral, and treatment service delivery success syndemic systematic review tool treatment as prevention

项目摘要

Abstract The US strategy to End the HIV Epidemic calls for expanded prevention of new infections and more effective responses to HIV outbreaks. These outbreaks often occur in counties and states that share a disproportional burden of HIV, but the co-occurring and syndemic nature with opioid use disorder (OUD) leaves hundreds of additional counties and regions highly susceptible to new HIV (and HCV) outbreaks. West Virginia (WV) is one such mostly rural setting with an explosive opioid epidemic manifest by the highest per capita rate of overdoses and 5 counties with recent HIV outbreaks. Evidence-based practices to prevent and control HIV in clinical settings include medications for OUD (MOUD), ART treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). Treatment with these medications, however, first requires screening and evaluation, followed by treatment (SET). Adoption of SET processes may in turn translate to better health outcomes if adequately facilitated. Most rural settings are poorly equipped to provide specialty HIV/HCV/OUD services – an important lesson from Scott County, Indiana. Yet rural settings rely mostly on primary care clinics (PCC) with inadequate expertise to provide these services. To overcome adoption barriers of SET processes for HIV/HCV/OUD, effective facilitation is key and the NIATx treatment improvement strategy combined with ongoing clinical education and support provided by Project ECHO has the potential to increase adoption to integrate specialty HIV/HCV/OUD services into PCCs. Using the i-PARiHS implementation framework, we propose to address this unmet need by first identifying barriers to adoption and scale-up of HIV/HCV/OUD services. Then we will facilitate practice transformation by integrating clinical prompts in the electronic health record (EHR) to screen for HIV/HCV/OUD, followed by treatment prompts. Treatment will be supported by Project ECHO that provides ongoing clinical support to inspire confidence in treatment, alongside a clinical dashboard embedded within the EHR as part of the quality performance improvement activities to sustain integrating HIV/HCV/OUD services into PCCs. We then propose to conduct a stepped wedge, Type 3, hybrid implementation trial to assess the extent to which clinicians adopt and sustain SET processes to integrate care at 20 PCCs that is facilitated by rapid cycle change projects using NIATx. Adoption of SET processes are the primary outcome and a composite quality health indicator (QHI) that combines QHIs for primary care, HIV, HCV and MOUD are secondary efficacy outcomes. Organizational and clinician factors, along with engagement in facilitation activities (NIATx, ECHO sessions) will be explored as potential mediators and moderators. Significance is high for the rural WV context where a volatile opioid epidemic has ignited HIV/HCV outbreaks. Innovation is high by integrating HIV/HCV/OUD services into PCCs using a framework and strategy we successfully used in urban international settings. Public health benefits are high given the lack of knowledge known about integrating services into rural PCCs. Feasibility is high based on the track record of an experienced team with interdisciplinary expertise and prior in WV.

抽象的美国结束艾滋病毒流行呼吁扩大预防新感染和更有效的战略对艾滋病毒爆发的反应。这些爆发通常发生在共享不变的县和州艾滋病毒的负担，但与阿片类药物使用障碍（OUD）的同时发生和联合性性质留下了数百个其他县和地区非常容易受到新的艾滋病毒（和HCV）暴发的影响。西弗吉尼亚州（WV）是一个这样的粗糙环境，具有爆炸性阿片类药物流行病，人均过量速率最高还有5个县，最近发生了艾滋病毒爆发。在临床环境中预防和控制艾滋病毒的循证实践包括OUD（MOUD）的药物，预防艺术治疗（TASP）和暴露前预防（准备）。但是，使用这些药物治疗，首先需要筛查和评估，然后需要治疗（集合）。如果适当的话，采用设定流程可能会转化为更好的健康结果便利。大多数粗糙的设置相当于提供特殊的HIV/HCV/OUD服务 - 重要的来自印第安纳州斯科特县的教训。然而，粗糙的环境主要依靠不充分的初级保健诊所（PCC）提供这些服务的专业知识。为了克服艾滋病毒/hcv/oud的设定过程的采用障碍，有效促进是关键，NIATX治疗改进策略与持续的临床相结合 Echo项目提供的教育和支持有可能增加采用以整合专业 HIV/HCV/OUD服务到PCC。使用I-Parihs实施框架，我们建议解决这个问题首先确定艾滋病毒/HCV/OUD服务的采用和扩展障碍，无法满足。然后我们将促进通过在电子健康记录（EHR）中集成临床提示来筛选练习转换 HIV/HCV/OUD，然后是治疗提示。治疗将由提供的项目Echo支持正在进行的临床支持以激发对治疗的信心，并嵌入了临床仪表板 EHR作为质量绩效改进活动的一部分，以维持艾滋病毒/hcv/oud服务 PCC。然后，我们建议进行阶梯楔形，3型混合实施试验，以评估范围临床医生采用并维持设定的流程以整合由快速周期制备的20个PCC的护理使用NIATX更改项目。采用设定过程是主要结果和复合质量结合了初级保健，HIV，HCV和MOUD的QHIS的健康指标（QHI）是次要效率结果。组织和临床因素，以及参与设施活动（NIATX，ECHO 会议）将作为潜在的调解人和主持人探讨。对于粗糙的WV环境而言，意义很高挥发性阿片类药物流行引发了HIV/HCV暴发。通过整合HIV/HCV/OUD，创新很高使用我们在城市国际环境中成功使用的框架和策略向PCC提供服务。民众鉴于缺乏将服务集成到粗糙的PCC中的知识，健康益处很高。可行性根据具有跨学科专业知识和先验在WV的经验丰富的团队的往绩。