alcohol screening and intervention:
DESCRIPTION
The Trauma Surgery Perspective. Alcohol Screening and Intervention:. Larry Gentilello, MD Professor of Surgery, Management, Policy, and Community Health University of Texas Dallas, Texas. Alcohol-Related Mortality. 40,933. Injuries. (CDC - MMWR, 2004). - PowerPoint PPT PresentationTRANSCRIPT
Alcohol Screening and Intervention:
Larry Gentilello, MD
Professor of Surgery,
Management, Policy, and Community Health
University of Texas
Dallas, Texas
The Trauma Surgery Perspective
Alcohol-Related Mortality
34,833
0
10,000
20,000
30,000
40,000
50,000
All Chronic Diseases
(CDC - MMWR, 2004)
40,933
Injuries
Years of Potential Life Lost - YPLL’s
788,005
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
Alcohol - Related Diseases
(CDC - MMWR, 2004)
2,279,322
ChronicDisease
Injuries
Alcohol and Trauma
70%85%
27%
44% 49% 54% 65%
0%
25%
50%
75%
100%
Fall MCA MVA Ped GSW DomViol
Stabs
(Gentilello, Am J Surg 1988)
Positive Alcohol Screens
0%
10%
20%
30%
40%
50%
Ambulatory Medical
Inpatient Medical
Emergency Dept
Outpatient MentalHealthInpatient Psychiatry
Trauma Center
(Gentilello, Am J Surgery, 1988)
Standard Practice
BAC 13%
CAGE 70%
MAST 81%
AUDIT 89%
instrument “not familiar with”• 87% reported no prior training in substance abuse
• 18% routinely screen BAC
• < 15% use questionnaires
• intervention or referral is rare
(Danielson, Gentilello, et al, Archives of Surgery, 1999)
Trauma Recidivism
• 5 year follow-up of 246 patients
– 40% readmission rate
– 20% mortality rate
– 77% of deaths due to continuing substance abuse
(Sims, et al, J Trauma)
Severity of Alcohol Problems
Harmful drinking/Abuse
Risky/Hazardous drinking
Safe drinking
abstinent
Dependent drinking/Alcoholism
severity
Brief Intervention Outcomes
0
20
40
60
80
100
baseline 3 6 9 12
CBT MET 12-Step
0
3
6
9
12
15
baseline 3 6 9 12
CBT MET 12-Step
percent days abstinent drinks per drinking day
1,735 patients
(Miller WR, 1995)
Cost-Effectiveness
0%
100%
0 $ $$ $$$ $$$$
effectiveness
cost
(Miller WR, 1995)
Types of Drinkers
Alcohol Dependent
~ 5 %
~ 25%
~ 70%
Risky or Harmful
Prevalence in US
.
No intervention
Goals
Low Risk orAbstinent
Brief Intervention
Drinking Pyramid
Referral to treatment
Do you think this patient will change
his drinking or reduce his risk as a
result of this conversation?
MOTIVATIONAL INTERVIEWING
• No confrontation, labeling, stereotyping
• Ask open-ended questions
• Reflective listening to encourage talk about
drinking
• Offer information in a non-personal manner.
• Make connection between drinking and ED visit
• “What do you like about drinking?”
• “What do you like less about drinking?”
Hypothesis
Alcohol interventions as a routine component
of trauma care will reduce subsequent
alcohol intake, and decrease the
rate of trauma recidivism
Alcohol Interventions in a Trauma Center
• Study design– Harborview Medical Center, Seattle
– October 1994 to November 1997
– NIH sponsored RCT
– patients screened with BAC and questionnaire
– consent for follow-up only
– randomized
• 15 - 30 minute intervention plus follow-up letter
• standard trauma care
Follow-up
• Objective– Harborview ED records for one year after discharge
– statewide database of all trauma admissions
– police department records
– Department of Licensing records (motor vehicle)
• Self-report– 6 and 12 month patient interviews
– corroboration interviews with family members
Patient Enrollment
eligible trauma patients3,358
screened2,524
screened negative screened positive 1,371 (54%) 1,153 (46%)
randomized 762 (66%)
control intervention
396 366
Baseline Characteristics
intervention control
Age (years) 35.4 36.8
male 82 82
married 15% 14%
high school or less 53% 51%
employed 52% 48%
drug use 47% 53%
BAC (mean) 153 mg% 151 mg%
sMAST score >8 20% 15%
Trauma Recidivism - HMC
0.00
0.05
0.10
0 90 180 270 360
intervention control
days follow-up
injuryrecurrence
Trauma Recidivism - Statewide
0
0.025
0.05
0 250 500 750 1000
intervention control
injuryrecurrence
days follow-up
Changes in Alcohol Intake
0
-21.6
02.3
-17.9
-14.1
-25
-15
-5
5
15
25intervention control
6 month follow-up 12 month follow-up
(p = 0.01)
Changes in Alcohol Use at One Year
Intervention Control p
sMAST 3-8 - 22 + 2 0.01
Single/div/wid - 22 - 3 0.01
Married - 25 - 21 0.81
Unemployed - 26 - 1 0.03
Employed - 18 - 13 0.51
Prior ETOH Rx - 32 - 12.5 0.15
No Prior ETOH Rx - 16 + 16 < 0.01
Other Outcomes
any traffic violation
moving violation
DUI violation
any arrest
alcohol related arrest
.83
.84
.77
.56
.50
1.00 1.50 2.000.500.00
less frequent more frequent
Trauma Center Requirements
• Physical therapy
• Occupational therapy
• Vocational therapy
• Speech therapy
• Spinal chord therapy
• Nutritional therapy
• Play therapy
• Alcohol therapy?
Chapter 18- Prevention The trauma center must have a mechanism to identify patients who are problem drinkers. The trauma center must have a mechanism to provide an intervention for patients identified as problem drinkers.
Trauma Center Designation
Financial Costs in ColoradoFailure to do SBIRT in ER’s cost CO businesses and
residents $39 million each year in health care expenses
Estimated Annual Savings from Treating CO Emergency Patients for Alcohol Problems
*Goplerud E. et al. http://www.ensuringsolutions.org.
• New codes published Nov 2 in 2008 CPT Manual
– 99408
• Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
– 99409
• greater than 30 minutes
• Separate or added service
• Majority of major commercial health plans
agree to pay in 2008
2008 CPT
Common Procedure Terminology
New CMS Codes for SBI
• New codes Medicaid codes
– H0049 Screening
– H0050 Brief Intervention
• New Medicare codes
– G0396 SBI > 15 minutes
– G0397 SBI > 30 minutes
Reimbursement for SBI
Payer Code Description Fee Schedule
Commercial Insurance
CPT 99408Alcohol and/or drug use structured screening and
brief intervention services; 15-30 minutes$33.41
CPT 99409Alcohol and/or drug use structured screening and
brief intervention services; greater than 30 minutes$65.51
Medicare
G 0396Alcohol and/or drug use structured screening and
brief intervention services; 15-30 minutes$29.42
G 0397Alcohol and/or drug use structured screening and
brief intervention services; greater than 30 minutes$57.69
Medicaid
H 0049 Alcohol and/or drug screening $24
H 0050Alcohol and/or drug service, brief intervention, per
15 minutes$48.00
MONTANA
WYOMING IDAHO
WASHINGTON OREGON
NEVADA UTA
CALIFORNIA ARIZONA
NORTH DAKOTA SOUTH DAKOT NEBRASKA
COLORADO
NEW MEXICO
TEXAS
OKLAHOMA
KANSAS
ARKANSAS
LOUISIANA
MISSOURI
IOWA
MINNESOTA WISCONSIN
ILLINOIS INDIANA KENTUCKY
TENNESSEE
MISS ALABAMA
GEORGIA FLORIDA
SOUTH CAROLINA
NORTH CAROLINA
VIRGINIA WV
OHIO
MICHIGAN NEW YORK
PENN
MARYLAND DELAWARE
NEW JERSEY
CONN RI MASS
MAINE V
T NH
ALASKA
HAWAII
MONTANA
WYOMING IDAHO
WASHINGTON OREGON
NEVADA
UTAH
CALIFORNIA ARIZONA
NORTH DAKOTA SOUTH DAKOTA NEBRASKA
COLORADO
NEW MEXICO
TEXAS
OKLA
KANSAS
ARKANSAS
LOUISIANA
MISSOURI
IOWA
MINNESOTA WISCONSIN
ILLINOIS INDIANA KENTUCKY
TENNESSEE
MISS ALABAMA
GEORGIA FLORIDA
SOUTH CAROLINA
NORTH CAROLINA
VIRGINIA WV
OHIO
MICHIGAN NEW YORK
PENN
MARYLAND DELAWARE
NEW JERSEY
CONN RI MASS
MAINE V
T NH
ALASKA
HAWAII
UPPL Status as of 2000Medicaid Code Adoption
States that have adopted H codes
States considering adoption of H codes
Joint Commission Undertakes Development of Standards for SBI
To further advance the expansion of the continuum of healthcare to include SBI, the
Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)
has decided to undertake the development of standards for screening and brief
intervention for alcohol and other drugs. The Joint Commission standards are
generally developed with input from healthcare professionals, providers, measurement
experts, consumers, government agencies and employers. As such, because of your
expertise on SBI, you are being asked to collaborate with the Joint Commission in the
development of standards and quality improvement for SBI.
Summary
• SBIRT prevents repeated injuries
• SBIRT saves money
• Trauma centers are the first to require SBIRT
• Billing codes are available
• Making it routine hospital care is next
Message to Trauma Patients
Make not thyself helpless drinking in
the beer shop, falling down.
Thy limbs will be broken, and no one
Will give thee a hand to help thee up
Egyptian Papyrus, 1500 BC