Impact of the COVID-19 pandemic on patient outcomes, telehealth care delivery, and treatment for unhealthy alcohol use in vulnerable patients with advanced liver disease across two healthcare systems

COVID-19 大流行对两个医疗系统中晚期肝病弱势患者的患者治疗结果、远程医疗保健服务以及不健康饮酒治疗的影响

• 批准号: 10581644
• 负责人: Mandana Khalili
• 金额: $ 69.89万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-06-01 至 2026-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10581644
• 关键词: 2019-nCoV; Address; Adherence; Affect; Alcohol consumption; Alcoholic Liver Diseases; Alcohols; Ascites; Biological Models; COVID-19; COVID-19 impact; COVID-19 pandemic; COVID-19 pandemic effects; COVID-19 risk; COVID-19 susceptibility; Cardiovascular Diseases; Caring; Cause of Death; Chronic; Chronic Disease; Chronic Kidney Failure; Cirrhosis; Clinic; Clinical; Communities; Complex; Computerized Medical Record; Counseling; Data; Deterioration; Diabetes Mellitus; Diagnostic Services; Disease; Disease Management; Disease Outcome; Disparity; Dissemination and Implementation; Encephalopathies; Ensure; Equity; Esophageal Varix; Evaluation; Fibrosis; Gastrointestinal Hemorrhage; Goals; Health; Health system; Healthcare Systems; Hepatology; High Prevalence; Individual; Intervention; Laboratories; Liver; Liver Cirrhosis; Liver diseases; Medical; Mental disorders; Modeling; Monitor; Morbidity - disease rate; Natural experiment; Outcome; Patient Care; Patient-Focused Outcomes; Patients; Persons; Physicians; Police; Population; Predisposition; Prevalence; Prevention; Preventive measure; Primary Care; Primary carcinoma of the liver cells; Process; Psychological Impact; Quality Indicator; Quality of Care; Quality of life; Randomized, Controlled Trials; Recovery; Reporting; Risk; Risk Factors; SARS-CoV-2 infection; Sampling; Service delivery model; Services; Site; Social isolation; Substance Use Disorder; Surveys; System; Telemedicine; Testing; Time; United States; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; Vulnerable Populations; acute liver disease; addiction; alcohol abstinence; alcohol abuse therapy; alcohol intervention; alcohol misuse; barrier to care; care delivery; care outcomes; chronic alcohol ingestion; chronic liver disease; comorbidity; coronavirus disease; disorder prevention; drinking; effective intervention; efficacy evaluation; ethnic minority; experience; follow-up; health care availability; health care delivery; health care service; health disparity; health disparity populations; high risk; improved; infection risk; innovation; liver function; liver transplantation; medical specialties; mortality; motivational enhancement therapy; novel; pandemic disease; pandemic impact; pandemic response; patient population; post-pandemic; prevent; prospective; public health priorities; racial minority; reduced alcohol use; response; safety net; satisfaction; screening; screening services; socioeconomic disadvantage; telehealthcare; treatment as usual

PROJECT SUMMARY The COVID-19 pandemic has had a significant adverse impact on vulnerable populations with serious comorbid medical conditions. Individuals with advanced chronic liver disease (CLD) are among those most strongly affected by disruptions in care and are also highly susceptible to poor outcomes associated with SARS-CoV-2 infection. It is critical to understand how to effectively manage these patients during the course of the pandemic. The rising prevalence of cirrhosis, an end-stage of CLD, is a significant contributor to morbidity and mortality in the United States and alcohol use is a major risk factor. Thus, effective intervention for alcohol cessation is a high-priority need. In addition, high quality advanced CLD with adherence to known quality indicators is associated with positive patient outcomes, critical to enhanced survival, and quality of life. Vulnerable populations including veterans and those receiving care in safety net systems are at significant risk for liver and COVID-19 related health disparities. They also have known barriers to healthcare access and are at high risk for disengagement from care. The COVID-19 pandemic has significantly disrupted the traditional health care delivery models, but the impact on outcomes of vulnerable patients with advanced CLD is currently unknown. Moreover, the widespread use of telemedicine as a mitigation strategy within these health systems due to COVID-19 has provided an unprecedented opportunity for evaluation and innovation of care delivery models. Better understanding of patients' experience with telemedicine and impact on their outcomes is urgently needed to establish processes and polices that ensure equity in access, sustainability, and high-quality care delivery. To address these critical issues, we propose to evaluate the care of patients with advanced CLD during the pandemic within hepatology practices in two generalizable health systems serving vulnerable populations, a public safety net system and Veterans Affairs healthcare systems. Furthermore, we will examine the efficacy of a stepped care intervention (i.e., motivational interviewing and addiction physician management) via telemedicine to treat alcohol use as an adjunct to usual hepatology care. We will also examine COVID-19 outcomes. We propose the following aims: 1) Evaluate the impact of the COVID-19 pandemic on clinical outcomes of vulnerable patients with advanced CLD receiving care in hepatology practices, in a natural experiment; 2) Evaluate patient-reported experiences with use of telemedicine in response to the pandemic to deliver hepatology specialty care in those with advanced CLD; and 3) Conduct a randomized controlled trial evaluating the efficacy and feasibility of a stepped alcohol treatment using telemedicine on unhealthy alcohol use in patients with alcohol-related CLD receiving care in hepatology practices, compared with usual care. We hypothesize that we will observe an increase in adverse patient outcomes in the post-pandemic period, that the patient experience and satisfaction with telemedicine as a mitigation strategy to reduce COVID-19 risk will improve, and that patients receiving stepped care will be more likely to reduce or abstain from alcohol use. 1

项目摘要 COVID-19大流行对严重合并的脆弱人群产生了重大不利影响 医疗状况。患有晚期慢性肝病（CLD）的人是最强烈的人之一 受护理中断影响，也很容易受到与SARS-COV-2相关的不良结果的影响 感染。了解如何在大流行过程中有效管理这些患者至关重要。 CLD的终阶段的肝硬化患病率上升，是引起发病率和死亡率的重要原因 美国和饮酒是主要的危险因素。因此，有效的饮酒干预是 高优先级的需求。此外，遵守已知质量指标的高质量高级CLD是 与积极的患者结局相关，对增强生存和生活质量至关重要。脆弱的人群 包括退伍军人和在安全网系统中接受护理的人对肝脏和Covid-19处有很大的风险 相关的健康差异。他们还知道医疗保健障碍的障碍，并且有高风险 脱离护理。 COVID-19大流行极大地破坏了传统的医疗保健 交付模型，但是目前尚不清楚对弱势群体患者的结果的影响。 此外，由于这些卫生系统中，远程医疗的广泛使用作为缓解策略 Covid-19为评估和创新护理模型提供了前所未有的机会。 迫切需要更好地了解患者对远程医疗的经验和对其结果的影响 建立确保访问，可持续性和高质量护理交付的股权的流程和政策。 为了解决这些关键问题，我们建议评估高级CLD患者的护理 在两个可为脆弱人群服务的可推广卫生系统中，肝病学实践中的大流行 公共安全网系统和退伍军人事务医疗系统。此外，我们将研究 通过 远程医疗将酒精使用视为通常的肝病护理的辅助手段。我们还将检查Covid-19 结果。我们提出以下目的：1）评估COVID-19的影响对临床的影响 自然而然地接受肝病学治疗的高级CLD接受护理的脆弱患者的结果 实验; 2）评估使用远程医疗的患者报告的经验，以应对大流行 在患有高级CLD的人中提供肝病专业护理； 3）进行随机对照试验 评估使用远程医疗在不健康酒精中使用梯级酒精治疗的疗效和可行性 与通常的护理相比，与酒精相关的CLD接受护理的患者使用。我们 假设我们将观察到大流行时期不良患者预后的增加， 患者经验和对远程医疗作为减轻Covid-19风险的缓解策略的满意度将会 改善，接受阶梯护理的患者更有可能减少或戒酒。 1