Mobile Health for Alcohol Use Disorders in Clinical Practice

This study evaluates the impact on risky drinking days and quality of life for patients with alcohol use disorder among patients who use a mobile health smart phone application. A third of the participants will receive access to the smart phone app without any monitoring; a third of the participants will receive access to the smart phone app monitored by and connected with a peer mentor; a third will receive access to the smart phone app monitored by and connected with a health coach who works within a healthcare system.

Patients in the trial will be given versions of an evidence-based mobile-health (mHealth) system (re-design based on A-CHESS) that is delivered using different implementation strategies according to study group. A-CHESS has more than 18 services designed to improve social relatedness, coping competence, and intrinsic motivation. The following describes key A-CHESS services that will be tested in the current study: Welcome message - patients write why they are choosing to reduce their drinking. Coping with Cravings - the system automatically notifies nearby pre-approved friends, family, and peers, who can respond to a request for support. The patient can also be linked to positive activities, such as suggested games to download and play and audio/video-based relaxation recordings. Monitoring functionality- self-assessment measures, record of A-CHESS use, and prediction of the patient's likelihood of having a heavy drinking episode in the next week. A-CHESS sends patients with worrisome responses suggestions of coping skills, online peer support, healthy events, etc. With patient permission, a prediction of high-risk can be shared with others in a position to provide support. Triage and feedback functionality is designed to derail a setback in goal attainment, giving the patient 'just in time,' tailored support by linking patients to relevant A-CHESS resources or individuals (depending on group assignment). The Specialist Report, harvests clinically relevant data from A-CHESS and presents it to a peer mentor (in the peer-supported group) or a health coach (in the clinically integrated group), at which point they may intervene with patients (e.g., through texting in A-CHESS). Facilitated discussion groups (in the clinically integrated group.) Discussions are monitored daily by an A-CHESS coach. Library - information about healthy lifestyle choices, calendar of healthy events in the area, etc. Drink tracker and report feature - patients to self-monitor their drinking and each week see a summary of how they did the past week. Profiles about why patients want to reduce their drinking. All patients enrolled in the study will participate in a 3-month intervention period followed by a 9-month follow-up period, for a total of 12 months. All patient will undergo a 72-hour run-in period. After 72 hours, patients who remain in the study will be randomized to one of the following groups and receive the appropriate access to features. One group will operate independently; one group will have help from a peer-mentor; one group will be connected to a healthcare system by a health coach.

The study will have rolling enrollment over two years. Patients will be enrolled and randomized to one of three interventions for 12 months.

Patients of this group will continue receiving regular care from their physician with no interference from the two experimental groups. Patient subjects will download the app on their Android or Apple smart phone that will direct them to external information hosted on the internet that may help reduce their drinking (e.g., NIAAA resources). For the first 12 weeks, once a week patients can set a weekly goal related to their alcohol use or other health related behaviors (e.g., "I will only drink on Friday this week."). At the end of the week subjects will be prompted to take a weekly survey, which will include questions such as a variation of the brief alcohol monitor (BAM) and timeline followback. Patients will then receive feedback on the amount of drinks they had compared to their goal. Then the patient will set a new goal for the following week. Patients will complete quarterly surveys on the A-CHESS app to assess study outcomes.

Patients will be asked to take the same surveys and have the access to the same information as the self-monitoring group. Patient subjects in this group will have access to discussion boards where they can talk to one another and have the ability to share and see stories of other patients. The only involvement of someone other than patients themselves in the peer-supported group will be by a sponsor (i.e., a dedicated user from the area with a sustained history of successful alcohol reduction). The sponsor will participate in discussion groups and encourage use of the system. Patient-reported feedback will be presented directly to the patient.

Patients in the clinically integrated group will receive the same intervention as the peer-supported group aside from three differences: 1) patients have the option to share selected elements of their app data with the University of Wisconsin (UW) Health health coach, 2) the health coach will replace the role of the sponsor in the peer-support group, and 3) patients will have the option to attend an initial 60- to 90-minute and two 30-minute follow-up consultations with the health coach in-person, via phone, or via video chat.

Patients have access to a smart phone app that provides information on tips on how to reduce drinking, a drink tracker, a journal, discussion boards, and private messaging with a research team member. Patients set weekly goals related to their drinking, reassess each week, and set a new goal for the upcoming week.

Patients have access to a smart phone app that provides information on tips on how to reduce drinking, a drink tracker, a journal, discussion boards, and private messaging with a counselor. Patients set weekly goals related to their drinking, reassess each week, and set a new goal for the upcoming week.

Patients have access to a smart phone app that provides information on tips on how to reduce drinking, a drink tracker, a journal, discussion boards, and private messaging with a health coach. Patients set weekly goals related to their drinking, reassess each week, and set a new goal for the upcoming week.

The number of days patients reported as risky drinking days. For women and men over 65 years old, risky drinking is defined as 3 or more drinks on any single day and 7 or more drinks per week. For men under 65 years old, it is defined as 4 or more drinks on any single day and 14 or more drinks per week.

Patients in the clinically-integrated arm will have the option to share their data collected by A-CHESS with the health coach. Knowing how many patients are willing to share data about their drinking will allow researchers to make hypothesis about how effective A-CHESS can be in a healthcare setting.

Patients will be asked to indicate if they have used medical services in the past 6 months and list what services they used. Researchers will include this in the cost-effectiveness analysis.

The cost (in US dollars) of the intervention will be calculated to determine cost-effectiveness of the study.

Patients will take a revised Brief Alcohol Monitor survey that will ask about risk factors that will then be used to predict setbacks.

The number of days the health coach or other clinicians used the A-CHESS dashboard. This will help assess how useful the specialist report was to clinicians.

The AUDIT screening tool will be used to assess patient alcohol severity. For women, the scoring is as follows: 0-3 = low-risk; 4-12 = risky; 13-19 = harmful; 20+ = severe. For men, the scoring is as follows: 0-4 = low-risk; 5-14 = risky; 15-19 = harmful; 20+ = severe. The screening tool consists of 10 questions with 5 possible answers. Each answer has a score value ranging from 0-5.

The Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria of alcohol use disorder will be used to assess patient's alcohol use disorder severity. The severity of the AUD is defined as 1) mild: 2 to 3 symptoms; 2) moderate: 4 to 5 symptoms; 3) severe: 6+ symptoms.

The study will assess how connected patients feel with others. A-CHESS is based on relatedness. The more connected patients feel with others, the more less risky drinking days patients will have. Patients will be asked 5 questions on their relationships with others. Patients can respond on a 1-5 scale corresponding to "Never" to "Nearly Always", respectively. Higher relatedness scores typically correspond with less alcohol use.

The study will assess how patients perceive their ability to control and reduce their drinking. Patients typically drink less when they feel more confident about controlling their drinking. Patients will be asked 4 questions about their confidence to use alcohol responsibly in different situations. Patients can indicate their confidence on a 1-7 scale corresponding to "Not at all" to "Very true", respectively. Higher scores typically correspond to less alcohol use.

The study will asses how motivated patients are by their own goals. Patients typically drink less when they, themselves, want to reduce their alcohol. Patients will be asked 6 questions about why they will reduce their alcohol use and can indicate how much they identify with each statement on a 1-5 scale corresponding to "Not true" to "Very true", respectively. Higher scores typically correspond to less alcohol use.

The patient's ability to meet their weekly goal will be assessed. When patients are not on track to meet their weekly goal a setback alert will be triggered.

The variables that help predict a setback will be assessed and reported. Knowing the variables for setbacks will help researchers program A-CHESS to better predict when patients are likely to have a setback.

Clinicians and patients will be alerted when the system predicts that they may have a setback. This allows researchers to know how useful patients and health coaches found the alerts.

Score of overall quality of life as assessed by Patient Reported Outcomes Measurement Information System (PROMIS) Global-10

The Patient Reported Outcomes Measurement Information System Global-10 form will be used to assess quality of life. It consists of 10 questions that assess general domains of health and functioning including overall physical health, mental health, social health, pain, fatigue, and overall perceived quality of life. Each question will ask patients to indicate their health of each domain on a scale of 1-5, which corresponds to poor to excellent. 2 additional questions related to impact of COVID-19 on participant's physical and mental health will be asked. Higher scores correspond to better overall quality of life.

The number of pages viewed by patients and health coaches will be assessed know how useful patients found different content.

Patients will take a revised Brief Alcohol Monitor survey that will ask about protection factors that will then be used to predict setbacks.

Inclusion Criteria: are 21+ years old, interested in learning about ways to reduce drinking, willing to download and use A-CHESS, lives in within the geographical boundaries of the UW Health system be able to understand and sign an electronic consent form in English, own an Apple or android smart phone, meets the criteria for at risk drinking on the AUDIT screening, responds yes to at least one question on the Alcohol Use Disorder (AUD) Diagnostic and Statistical Manual-5 survey, and indicates in the past week they have had at least 7 drinks and 3 on a single day (women), or had at least 14 drinks and 4 on a single day (men). Exclusion Criteria: has a severe alcohol use disorder (yes to 6+ items on the Alcohol Use Disorder (AUD) Diagnostic and Statistical Manual-5) have a current psychotic disorder have an acute medical problem requiring immediate hospitalization have a known terminal illness

Individual participant data collected during the trial, after deidentification will be available to researchers for independent verification of study outcomes or to conduct subsequent clinical research, whose proposed use of the data has been approved by an independent review committee identified for this purpose.

Proposals should be directed to PI Andrew Quanbeck at arquanbe@wisc.edu. If approved after review by regulatory counsel, requestors will enter into a formal data sharing agreement. Data will be shared via encrypted single-user file transmission protocol.

Park LS, Chih MY, Stephenson C, Schumacher N, Brown R, Gustafson D, Barrett B, Quanbeck A. Testing an mHealth System for Individuals With Mild to Moderate Alcohol Use Disorders: Protocol for a Type 1 Hybrid Effectiveness-Implementation Trial. JMIR Res Protoc. 2022 Feb 18;11(2):e31109. doi: 10.2196/31109.