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: 10249625
• 负责人: Mandana Khalili
• 金额: $ 70.87万
• 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/10249625
• 关键词: 2019-nCoV; Address; Adherence; Affect; Alcohol consumption; Alcoholic Liver Diseases; Alcohols; Ascites; Biological Models; COVID-19; COVID-19 pandemic; 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; Dissemination and Implementation; Encephalopathies; Ensure; Esophageal Varix; Evaluation; Fibrosis; Gastrointestinal Hemorrhage; Goals; Health; Health system; Healthcare Systems; Hepatology; High Prevalence; Individual; Intervention; Laboratories; Life Experience; 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; Prevalence; Prevention; Preventive measure; Primary Health 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; Social isolation; Substance Use Disorder; Surveys; System; Telemedicine; Testing; Time; United States; United States Department of Veterans Affairs; Veterans; 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 population; experience; follow-up; health care availability; 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; patient population; prevent; prospective; public health priorities; racial and ethnic; reduced alcohol use; response; safety net; satisfaction; screening; screening services; socioeconomic disadvantage; telehealth; 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

项目概要 COVID-19 大流行对患有严重合并症的弱势群体产生了重大不利影响 医疗条件。患有晚期慢性肝病 (CLD) 的个体是最强烈的人群之一 受到护理中断的影响，并且也极易受到与 SARS-CoV-2 相关的不良结果的影响 感染。了解如何在大流行期间有效管理这些患者至关重要。 肝硬化（慢性肺病的终末期）患病率不断上升，是导致慢性肺病发病率和死亡率的重要因素。 在美国，饮酒是一个主要危险因素。因此，有效的戒酒干预措施是 高优先级需求。此外，遵守已知质量指标的高质量先进 CLD 是 与积极的患者结果相关，对于提高生存率和生活质量至关重要。弱势群体 包括退伍军人和在安全网系统中接受护理的人员都面临着肝脏和 COVID-19 的重大风险 相关的健康差异。他们在获得医疗保健方面也存在已知的障碍，并且面临着很高的风险 脱离护理。 COVID-19 大流行严重扰乱了传统的医疗保健 交付模式，但对患有晚期 CLD 的弱势患者的结果的影响目前尚不清楚。 此外，由于以下原因，在这些卫生系统内广泛使用远程医疗作为缓解策略： COVID-19 为评估和创新护理服务模式提供了前所未有的机会。 迫切需要更好地了解患者的远程医疗体验及其对其结果的影响 建立确保公平获取、可持续性和高质量护理服务的流程和政策。 为了解决这些关键问题，我们建议评估晚期 CLD 患者在治疗期间的护理情况。 在为弱势群体提供服务的两个普遍卫生系统的肝病学实践中发生了大流行， 公共安全网系统和退伍军人事务部医疗保健系统。此外，我们将检验以下方法的功效： 阶梯式护理干预（即动机性访谈和成瘾医生管理） 远程医疗治疗饮酒，作为常规肝病护理的辅助手段。我们还将检查 COVID-19 结果。我们提出以下目标： 1) 评估 COVID-19 大流行对临床的影响 患有晚期慢性肺病的弱势患者在肝病实践中接受护理的结果，以自然的方式 实验; 2) 评估患者报告的使用远程医疗应对大流行的经验，以 为患有晚期慢性肺病的患者提供肝病专业护理； 3) 进行随机对照试验 评估使用远程医疗对不健康酒精进行阶梯式酒精治疗的有效性和可行性 与常规护理相比，在肝病实践中接受护理的酒精相关慢性肺病患者中的使用情况。我们 假设我们将观察到大流行后时期患者不良结果的增加， 作为降低 COVID-19 风险的缓解策略的远程医疗的患者体验和满意度将 改善，接受分级护理的患者更有可能减少或戒酒。 1