Can a radical transformation of preventive care reduce mortality by 20% in low SES populations? Preparatory work focusing on AUD/heavy alcohol use, HIV risk, and cardiovascular risk

PROJECT SUMMARY
Among SES- and race/ethnicity-related health disparities in the U.S., 11 preventable conditions cause >50% of
mortality. Our preliminary modeling work suggests that only 9 prevention goals could attain 40% mortality
reduction from these 11 conditions, a 20% mortality reduction overall, because of interdependencies and
common pathways. For example, alcohol use disorder and/or heavy drinking (AUD/HD) impacts liver failure,
but also sexual risk-taking and medication nonadherence. But achieving mortality reduction would require a
radical transformation of preventive care, such as proposed here: personalization, navigation, and
compensation. Personalization means maximizing individual-level benefit by modulating intervention
characteristics in 3 three domains: (1) intensity of screening; (2) frequency of screening; and (3) intensity or
duration of response, based on individual harm/benefit profile and preferences. Navigation means reducing
barriers posed by fragmentation of health and social systems. Compensation means offsetting dependent care,
time costs, and travel costs relating to care based on cost-attribution methods used in cost-effectiveness
analysis. For this proposal, disparity-impacted means any SES, race/ethnicity, and sex strata among 35-64-
year-olds with substantially raised mortality (=1% per year). This R34 (n=150) is preparatory for a post-R34-
Goal of an n=15,000 5-year RCT which would have adequate power to test the hypothesis of 20% mortality
reduction. While the R34’s scope includes all 9 health goals, it focuses especially on AUD/HD, HIV risk and
cardiovascular (CV) risk. The overall objective of this administrative supplement is to preserve the parent
proposal’s intention to complement self-report measures used in screening and identification of AUD/HD with
quantitative data. Specifically, we seek to include biomarker testing for alcohol consumption,
Phosphatidylethanol (PEth) and Ethyl Glucuronide (EtG), at baseline and final (12 month) study time points.
Inclusion of these biomarkers is invaluable, it not only provides a more comprehensive and objective
assessment of alcohol consumption, reducing the potential for underreporting or inaccuracies, but also more
accurately identifies high-risk individuals who may be susceptible to alcohol-related health complications. Their
inclusion contributes significantly to our study's overarching goal of tailoring interventions to address the
unique health needs of each participant, ultimately leading to a more effective, cost-effective, and targeted
approach to reducing mortality in this population.

Grant Number: 3R34AA030484-03S1
NIH Institute/Center: NIH
Principal Investigator: Ronald Braithwaite