sbirt: a look at the evidence – and gaps to address - a look at the evidence _ dr. richard...a...

A Look at the Evidence – and Gaps to Address

Richard L. Brown, MD, MPH Director of WIPHL

Professor of Family Medicine & Community HealthSchool of Medicine and Public Health

University of WisconsinCEO and Chief Medical Officer, Wellsys LLC

SBIRT:

wellsys.biz

R i c h a r d L . B r o w n , M D , M P H - “ R i c h ”

22 years of practice as a family doctor Tenured Professor at UW since 1990 NIH-funded researcher Past President, AMERSA AMERSA McGovern Awardee Director, Project MAINSTREAM Director, Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL)

2

3

Three federally funded projects: • $14M since 2006 • Helped 44 clinics deliver BSI • Screened >100,000 patients • Delivered >25,000 interventions

Wisconsin Departmentof Health Services

Results: Patient satisfaction: 4.3 to 4.9 of 5 points

Bingedrinking

20%

Marijuanause

15%

Depressionsymptoms

55%

Wisconsin Initiative toPromote Healthy Lifestyles

Brown, American Journal of Managed Care, 2014; Paltzer, unpublished

Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs

Conflict of Interest Disclosure

Owner and CEO of Wellsys, LLC (wellsys.biz)

Provides training, consultation and software to help healthcare settings and workplaces deliver SBIRT and similar services for other behavioral risks and disorders

This presentation will be evidence-based

4

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

Intervention

Referral to treatment

Brief treatment

Implementation & spread

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

6

Intervention


Brief treatment


7

No addiction Addicted Abstinent x 1 mo

Addicted Abstinent x 2 yr

Loss of control Cravings

Preoccupation

Drinking and Drug Use Continuum

Not dependent DepAbsti-nence Dep

Low riskuse

High riskuse

Problemuse

8

Need for SBIRT - US Adults

(Use in Past Month)

Binge alcohol use

25%Illicit drug use

9%Marijuana use

7%Other illicit drug use

3%SAMHSA, National Survey on Drug Use and Health, 2012-2013

About 1 in 3 adults would benefit from

alcohol or drug services

Prevalence of Alcohol/Drug Disorders

– US Adults –

9

Alcohol Drugs

7.1% 2.6%

Abuse or Dependence

SAMHSA, National Survey on Drug Use and Health, 2012-2013

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Alcohol

Untreated: 95%

Treated: 5%

Untreated: 89%

Treated: 11%

Receipt of Alcohol/Drug Treatment

– US Adults –

Drugs

SAMHSA, National Survey on Drug Use and Health, 2012-2013

Economic Impacts - $412 Billion

11

$11B

$120B$61B

$34B

$161B

$25BAlcohol

Drugs

Healthcare

Productivity

Other Societal

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

12

Intervention


Brief treatment

Implementation

13

SBIRT OverviewScreen

Brief Assessment

Abstinence or low risk

High risk or mild to moderate disorder

Dependence orsevere disorder

Brief Intervention Referral to Treatment

Follow-up and Support

(Brief Treatment)

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

14

Intervention


Brief treatment


15

Screening

Indicates who MIGHT be at risk or have a disorder

Enhances efficiency of SBIRT by quickly identifying those needing no additional services

Ideally minimizes false negatives, allowing more false positives

16

Alcohol Screening - CAGE

Cut downAnnoyedGuiltEye-opener

- Misses riskydrinking

- Other screensare brieferand moreaccurate

17

Alcohol Screening - AUDIT-C0 1 2 3 4

1 How often do you have a drink containing alcohol?

Never Monthlyor less

2 - 4 timesa month

2 - 3 times a week

4 or more times a week

2 How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3 How often do you have more thanX drinks on one occasion?

Never Less than monthly

Monthly Weekly Daily or almost daily

Posit ive screen: ≥4 points for men, ≥3 points for women

How many times in the past year have you had more than 4 drinks in an occasion?

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__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times

Modified from:http://pubs.niaaa.nih.gov/publications/practitioner/PocketGuide/Pocket.pdf

Alcohol Screening -Single Alcohol Screening Question

How many times in the past year have you had more than 3 drinks in an occasion?

How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?

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__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times

Modified from: Smith, Archives of Internal Medicine, 2010

Drug Screening -Single Alcohol Screening Question

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

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Intervention


Brief treatment


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0 1 2 3 41 How often do you

have a drink containing alcohol?

Never Monthlyor less

2 - 4 timesa month

2 - 3 times a week

4 or more times a week

2 How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3 How often do you have more thanX* drinks on one occasion?

Never Less than monthly

Monthly Weekly Daily or almost daily

AUDIT - Questions 1 to 3

* For X, substitute 3 for women, 4 for men

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4 How often during the last year have you found that you were not able to stop drinking once you had started?

5 How often during the last year have you failed to do what was normally expected of you because of drinking?

6 How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?

7 How often during the last year have you had a feeling of guilt or remorse after drinking?

8 How often during the last year have you been unable to remember what happened the night before because of your drinking?

0 1 2 3 4Never Less than

monthlyMonthly Weekly Daily or

almost daily


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9 Have you or someone else been injured because of your drinking?

10 Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

0 2 4No Yes, but not in

the last yearYes, during the last year


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AUDIT - Scoring

PointsInterpretationMen up to

age 64Women and older men

0 to 7 0 to 6 Low risk - reassure

8 to 15 7 to 15 Medium risk - intervene

16 to 19 Medium high risk – intervene & follow

20 to 40 High risk – refer for assessment

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DAST - Questions 1 to 5

In the past 12 months … PointsYes No

1 Have you used drugs other than those required for medical reasons? 1 0

2 Do you abuse (use) more than one drug at a time? 1 0

3 Are you always able to stop using drugs when you want to? 0 1

4 Have you had “blackouts” or “flashbacks” as a result of drug use? 1 0

5 Do you ever feel bad or guilty about your drug use? 1 0

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DAST - Questions 6 to 10

In the past 12 months … PointsYes No

6 Has your spouse or parents ever complained about your involvement with drugs? 1 0

7 Have you neglected your family because of your use of drugs? 1 0

8 Have you engaged in illegal activities in order to obtain drugs (other than possession)? 1 0

9 Have you experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 1 0

10 Have you had medical problems as a result of your drug use (eg, memory loss, hepatitis, convulsions, bleeding, etc …)? 1 0

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DAST - Scoring

Score Extent of Problems Related to Drug Use

Recommended Clinical Service

0 None Reinforcement1 Low Brief Intervention (BI)2 Low BI

3 to 5 Moderate BI and Follow-up6 to 8 Substantial Referral for Assessment

9 to 10 Severe Referral for assessment

AUDIT & DAST - Advantages & Disadvantages

Advantages- AUDIT is well validated in many countries - AUDIT is translated into many languages - AUDIT and DAST scores guide subsequent service delivery

Disadvantages- DAST is not well validated in primary care/general populations - Some DAST items are poorly worded - Scores mask important differences in symptom patterns - Feedback on scores is meager

28

Alternative Brief Assessment

Alcohol, Substance and Smoking Involvement

Screening Test (ASSIST)

Quantity-Frequency questions on alcohol

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NIDA-ASSIST

For tobacco, alcohol and 10 categories of drugs: Lifetime use Use in past 3 months Strong desire or urge Health, social, legal or financial problems Failed to do what was normally expected Friend or relative expressed concern Loss of control

Final question on injection use30

NIDA-ASSIST

For each category: low, moderate and high risk Focus on tobacco might increase acceptance Same questions for tobacco, alcohol and drugs Complicated skip patterns - best delivered by computer

Does not distinguish dependence well

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Alternative Brief Assessment

Quantity-Frequency questions

Short Index of Problems (SIP) or

Short Index of Problems-Alcohol & Drugs (SIP-AD)

Severity of Dependence Scale (SDS)

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Quantity-Frequency Questions

Alcohol:- Days per week in the last month (X)- Standard drinks on an average drinking day (Y)- Maximum standard drinks - past 3 months (Z)

- (X) x (Y) = average standard drinks per week High risk: >14 for men, >7 for women

- (Z) = maximum consumed in a day High risk: > 4 for men, >3 for women

Drugs:- Days per week in the last month for each substance

SIP-AD (Short Index of Problems - Alc/Drugs)

Over the last 12 months …

1. have you been unhappy because of your drinking or drug use?

2. lost weight or not eaten properly because of your drinking or drug use?

3. failed to do what is expected because of your drinking or drug use?

Never(0)

Once or afew times

(1)

Once ortwice a week

(2)

Daily oralmost daily

(3)


4. has your personality changed for the worse when drinking or using drugs?

5. have you taken foolish risks when drinking or using drugs?

6. you said harsh or cruel things to someone when drinking or using drugs?


Never(0)

Once or afew times

(1)

Once ortwice a week

(2)


(3)


7. have you done impulsive things you regretted when drinking or using drugs?

8. have you had money problems because of drinking or drug use?

9. has your physical appearance been harmed because of drinking or drug use?


Never(0)

Once or afew times

(1)

Once ortwice a week

(2)


(3)


10. has your family been hurt by your drinking or drug use?

11. has a friendship or close relationship been damaged by your drinking or drug use?

12. have you lost interest in activities or hobbies because of your drinking or drug use?


Never(0)

Once or afew times

(1)

Once ortwice a week

(2)


(3)


13. has your drinking or drug use gotten in the way of your personal growth?

14. has your drinking or drug use damaged your social life, popularity or reputation?

15. have you spent too much money or lost money because of your drinking or drug use?


Never(0)

Once or afew times

(1)

Once ortwice a week

(2)


(3)

SDS - Severity of Dependence Scale

Never or almost never

(0)

Some-times

(1)

Once ortwice a week

(2)

Always oralmost always

(3)

1. do you think your use of ___ was out of control? 2. has the prospect of missing a drink/fix/dose made

you anxious or worried? 3. have you worried about your drinking/use of ___? 4. have you wished you could stop drinking/using ___?


SDS - Severity of Dependence Scale

5. How difficult do you find it to stop or go without ____?

Notdifficult

(0)

Quitedifficult

(1)

Verydifficult

(2)

Impossible

(3)

Adults: Total score of 3 or more = likely dependent Teens: Total score of 4 or more = likely dependent

Brief Alcohol and Drug Assessment

Questionnaire Assesses for Category, if positiveQ/F High risk use At least

high risk use

SIP-AD Negative consequences

At leastproblem use

SDS Dependence Likely dependence

Gap in Screening/Assessment Studies

Typical StudyClinical

environmentResearch

environmentRecruit subjects ✓

Administer instrument to be tested ✓

Apply “gold standard” diagnostic process ✓

Research Question When responses to the instrument are not shared with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?

Gap in Screening/Assessment Studies

Typical Studies Needed StudiesClinical

environmentResearch

environmentClinical

environmentResearch

environmentRecruit subjects ✓ ✓

Administer instrumentto be tested ✓ ✓

Apply “gold standard” diagnostic process ✓ ✓

Research Question When responses to the instrument are not shared with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?

When responses to the instrument are sharedwith clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?

Two-Item Conjoint Screen (TICS)

1. In the last twelve months, have you ever drunk alcohol or used drugs more than you meant to? __ Yes __ No

2. In the last twelve months, have you felt you wanted or needed to cut down on your drinking or drug use? __ Yes __ No

Single AlcoholScreening Question

Single DrugScreening Question

Two-ItemConjoint Screen+ +

WIPHL: Adding the TICS to the screen for risky/problem drinkers - Increases identification of drug users from 80% to 90%, as

compared to the ASSIST - Reduces false negatives by half

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WIPHL’s Experience

Among patients who saw WIPHL health educators and participated in confidential 6-month follow-up phone calls - Higher reports of lifetime substance use when information was not shared with clinicians

Adding the TICS to the screen for risky/problem drinkers- Increased identification of drug users from 80% to 90%, as compared to the ASSIST- Reduced false negatives by half

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

46

Intervention


Brief treatment


Alcohol Interventions - Effectiveness

Dozens of studies and several meta-analyses: 10% to 30% declines in binge drinking Declines last up to 4 years with 1 to 3 booster sessions Reductions in

- Injuries - Vehicular crashes - Hospitalizations and ED visits - Deaths - Arrests

$3 to $4 reductions in healthcare costs per $1 spent National Commission on Prevention Priorities:

4th most effective and cost-effective preventive service

Drug Interventions - Effectiveness

Zgierska A, Amaza IP, Brown RL, Mundt M, Fleming MF. Unhealthy drug use: How to screen, when to intervene. Journal of Family Practice 2014; 63:524-540.

Review of prior studies: Randomized controlled trials General healthcare settings Population-wide screening

5 studies

Drug Interventions

Bernstein et al- Screened 23,699 adults in urgent care, women's health and homeless clinics with the DAST- Randomized 1,175 patients to single BI session vs. brochure - Conducted follow-up at 6 months

49Bernstein et al, Drug & Alcohol Dependence, 2005

P r o p o r t i o n A b s t i n e n tp-value

Brochure Brief Intervention

Cocaine 17% 22% 0.045

Heroin 31% 40% 0.050

Drug Interventions

Zahradnik et al- Screened 6,000 internal medicine, surgical or GYN inpatients - Randomized 126 patients with prescription drug misuse or dependence to a 2-session intervention vs. a brochure

50Zahradnik et al, Addiction, 2009; Otto et al, Drug & Alcohol Dependence, 2009

Proportion with ≥25% ReductionBrochure Brief Intervention p-value

3 months 30% 52% 0.01712 months 49% 50% 0.833

Drug Interventions

Humeniuk et al- Screened primary care patients in Australia, Brazil, India & USA - Randomized 731 marijuana, cocaine, amphetamine and opioid users at moderate risk, according to the ASSIST, to brief intervention vs. usual care

51Humeniuk et al, Addiction, 2012

0%

10%

20%

30%

Australia Brazil India USA

20%10%9%

2%11%

24%25%17% Brief Intervention

Usual care

Decline in ASSIST Scores - 3 Months

Drug Interventions

Saitz et al- Screened 1,504 primary care patients at an inner city hospital - Randomized 528 patients to control, brief intervention (10 to 15 minutes) and modified motivational intervention (30 to 45 minutes)

52

048

1216

Control BI MMI

14.114.213.8 13.815.114.3

Baseline6 months

Days of Use of Primary Drug in Past 30 Days

Saitz et al, JAMA, 2014

Drug Interventions

Roy-Byrne et al - Screened 10,337 patients at 7 Washington State safety-net clinics- Randomized 868 patients to • Face-to-face BI + phone F/U • Usual care + brochure

53Roy-Byrne et al, JAMA, 2014

Another negative study …

54

Kaner et al

55

29 primary care practices in England - urban, suburban, rural - socioeconomically diverse communities - affluent to impoverished - culturally diverse patients

Eligible patients - New or seeking help for mental health, GI, hypertension or minor injury - Positive alcohol screen - Ages 18+ - Live within 20 miles of practice - Not seeking help for drinking

56

Cluster RCT with randomization by clinic

Intervention Components Group1

Group2

Group3

16-page educational brochure ✓ ✓ ✓5 minutes of brief advice ✓ ✓

Appointment for 20-minute modified MI session ✓

Interventionists: Physicians and nurses (95%) Primary outcome: Proportion with AUDIT scores < 8 Analysis: Intention-to-treat

Kaner et al

57

Presenting patients: 3,562Eligible for screen: 2,991 (84%)Hazardous or harmful drinkers: 900 (30%)Consented to participate: 754 (84%)

Brochure only + Brief advice + Brief counselingRandomization 251 251 254Received brochure 251 (100%) 251 (100%) 254 (100%)Received brief advice – 250 (99%) 250 (99%)Received brief counseling – – 143 (57%)6-month follow-up 212 (85%) 215 (86%) 205 (81%)12-month follow-up 197 (79%) 209 (83%) 211 (83%)

Kaner et al

Proportion With AUDIT < 8

58

Brochure

+ Advice

+ Counseling

0% 10% 20% 30% 40%

Baseline 6 months 12 monthsOddsRatio

95% C. I.

p-value

0.85 0.52 - 1.39 0.510.91 0.53 - 1.56 0.73

0.78 0.48 - 1.25 0.300.99 0.60 - 1.60 0.96

The Fallout …

“Alcohol screening and intervention did not decrease the percentage of patients drinking to excess”

59

“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA

Why might the Kaner study be negative?

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2. “Only 57% of patients in the brief lifestyle counselling group actually received the intervention, which could have reduced its potential impact.”

3. “It is possible that the lack of intervention differences may have been due to unsuccessful implementation of the brief intervention protocols by the primary care clinicians.”- Training: epidemiology, standard drinks, demonstrations of screening and intervention, role plays, assurance of competence via skills checklist - Fidelity: “The issue of intervention fidelity will be explored in an in-depth qualitative (interview based) process study with clinicians from this trial, which occurred after patient follow-up was completed.”

1. “Recruiting individuals into the study might reduce their drinking.”

61

Not a study of effectiveness of alcohol screening and intervention

A study of effectiveness of training primary care physicians and nurses to deliver alcohol screening and intervention, where patients with risky or problem drinking are invited back for one intervention session

Kaner et al: The Bottom Line

62

Characteristics of Subjects in Recent Drug Intervention TrialsSaitz

- Age: 41 ± 12 years (mean ± standard deviation) - Never married: 62% - Medicaid or Medicare: 81% - Mood disorder: 46% - Self-help group participation in past 3 months: 18% - Residential addiction treatment in past 3 months: 8%

Roy-Byrne - Age: 48 ± 11 years (mean ± standard deviation) - 19% married - 9% employed, 64% disabled - 56% have diagnosed mental illness - 30% homeless for ≥1 night during the past 90 days - 30% DAST score of ≥7

Brief drug interventions appear ineffective for urban populations with high rates of- poverty - social instability - disability - mental health disorders - drug dependence

They may be effective for other general healthcare populations.

63


15% decline in marijuana use among 100+ patients- Pre-intervention - health educator interview in clinical settings - Post-intervention - researcher interview not shared with clinicians, in which patients reported higher lifetime substance use

Binge Drinking and Drug Use areMajor Problems for Employers

64

US Binge Drinkers - 2010

Employed

75%

SAMHSA, National Survey on Drug Use and Health, 2010

US Adult Drug Users - 2010

EmployedFull Time

48%

EmployedPart Time

18%

Out of Labor Force21%

Unemployed 13%

Employed

66%

Alcohol Screening and Intervention:Cost SavingsFleming et al, 2000 (Project TrEAT): $523 reduction in healthcare costs over the next year for $205 spent per primary care patient receiving an intervention

Estee et al, 2010 (WASBIRT): $4,392 net reduction in healthcare costs over the next year per disabled Medicaid patient receiving SBIRT in Washington State EDs

Paltzer et al, 2015 (WIPHL): $546 net reduction in healthcare costs over the next 2 years per Medicaid patient screened in Wisconsin primary care settings

Rankings of USPSTF Preventive Services

66Search: National Commission on Prevention Priorities

Which services would best … prevent disease, injury and death reduce healthcare costs?

1 Aspirin prophylaxis

2 Childhood immunizations

3 Tobacco screening & intervention

4 Alcohol screening & intervention

Alcohol screening & interventionis ranked higher than:

Blood pressure screening Cholesterol screening Diabetes screening Osteoporosis screening Cancer screenings Adult immunizations

R O I w i t h i n o n e y e a r !

67

6.0

5.5

5.0

4.5

4.0

Mean Drinks

per Drinking

Day

Brief Advice(4.7 ± 2.2 min)

Motivationalintervention

(22.5 ± 10.4 min)

Motivationalintervention

(22.5 ± 10.4 min)plus booster

(28.0 ± 10.4 min)Base-

line3 mo. 6 mo. 12 mo.

Field, Annals of Surgery, 2013

How should interventions be delivered?

Inpatientswith Alcohol

RelatedTrauma

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

68

Intervention


Brief treatment


Referral to Treatment - Alcohol

Meta-analysis of 13 studies on receipt of alcohol services after intervention:- RCTs in medical settings- Non-treatment seeking patients with unhealthy drinking - Linkage to alcohol services- English language

9 studies in US, others in Australia, France, Germany, Poland

Settings: Hospitals, emergency departments, outpatient clinics

Results: No effectiveness for … - All patients - High-severity patients

69Glass, Addiction, 2015

70


Of about 1,500 substance-dependent patients identified in general healthcare settings by screening and the ASSIST

completed an assessment or initial treatment session at a treatment program, despite availability of funding for patients who couldn’t afford treatment

o n l y 1 0 %

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

71

Intervention


Brief treatment


Brief Treatment

A few to several sessions intended to motivate, implement and sustain change Blurs with brief intervention plus follow-up For patients with moderate disorder For patients severe disorder who cannot or will not obtain treatment Ideally delivered in general healthcare settings

73

“Less than a third of all people with alcohol problems receive treatment of any kind, and less than 10 percent are prescribed medications.”

75

SBIRT OverviewScreen

Brief Assessment






(Brief Treatment)

SBIRT - Adjusting the Model

Screen

Brief Assessment






On-site medication-assisted therapy

Outline

The problem

SBIRT - an overview

Screening

Brief assessment

77

Intervention


Brief treatment


Few Americans Receive Evidence-Based SBIRT

CDC:1 in 6 Americans talked about their drinking with their healthcare

providers in 2011

National Survey on Drug Use and Health: 72% of Americans underwent alcohol screening in 2013 Most with risky/problem drinking got no intervention

78http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html Glass et al, Unpublished, 2015

79

Prevalence – US Adults

The Problem:>40% of Deaths and Most Chronic Disease

CDC, Behav iora l R isk Factor Surve i l lance System, 2013; SAMHSA, Nat iona l Survey on Drug Use and Hea l th , 2013

Prev

alenc

e

0%

20%

40%

60%

80%

100%

29%

7%9%25%19%

Smoking Bingedrinking

Druguse

Depression Obesity

$0B$50B

$100B$150B$200B$250B$300B

Smoking Alcohol Drug Use Depression Obesity

$73B

$52B$120B

$166B

$156B

$147B

$26B$11B$25B

$133B

Healthcare Productivity Justice, Social, Crashes

http://www.cdc.gov/nchs/data/nhis/earlyrelease/200812_08.pdf; http://www.oas.samhsa.gov/NSDUH/2K6NSDUH/2K6results.cfm#Ch3; http://www.cdc.gov/NCCDPHP/publications/aag/osh.htm; www.ensuringsolutions.org; http://www.drugabuse.gov/NIDA_notes/NNVol13N4/Abusecosts.html; http://www.cdc.gov/Features/AlcoholConsumption/; http://archives.drugabuse.gov/about/welcome/aboutdrugabuse/magnitude/

$342B

$503B

$100B

$945B

$34B$61B

$5B

Costs of Behavioral Risks and Disorders

– United States –

Who SHOULD do SBIRT?

81

No direct comparison studies

Reviews:

• Healthcare providers may get slightly better outcomes than paraprofessionals

• May be differences in case mix

Who SHOULD do SBIRT?

82

No direct comparison studies

Reviews:

• Healthcare providers may get slightly better outcomes than paraprofessionals

• May be differences in case mix

MOOT

POINT

Primary Care Providers Don’t Have Time

address 3 clinical issues in a typical visit

must delegate all prevention services to serve expanding elderly and insured patients

Issues Extra TimeTobacco 6 30 min.

Alcohol 6 30 min.Drugs 2 10 min.Obesity 8 40 min.Depression 2 10 min.Total 24 120 min.

Extra Time Per Day Needed toAddress Positive Screens for

24 Patients at 5 Minutes Per Issue

Primary care providers ...

Altschuler, Annals of Family Medicine, 2012; Beasley, Annals of Family Medicine, 2004;Bodenheimer, Health Affairs, 2010

Workflow in Healthcare Settings

In clinics:

Medical assistant reviews screen

Health educatorsees patientat that visit

Patients complete screen while

waiting

In EDs & hospitals, health educators introduce themselves and deliver services

Three federally funded projects: • $14M since 2006 • Helped 44 clinics deliver BSI • Screened >100,000 patients • Delivered >25,000 interventions

Wisconsin Departmentof Health Services

Results: Patient satisfaction: 4.3 to 4.9 of 5 points

Bingedrinking

20%

Marijuanause

15%

Depressionsymptoms

55%

Wisconsin Initiative toPromote Healthy Lifestyles

Brown, American Journal of Managed Care, 2014; Paltzer, unpublished

Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs

Spreading SBIRT: What Hasn’t Worked

Facilitators and Barriers to Spread

87

Possible Facilitators BarriersMedicare and the ACA → ↑reimbursement

- Reimbursement for services by paraprofessionals is patchy. - Reimbursement is inadequate incentive.

Accountable care organizations (ACOs)

- Most are busy establishing infrastructure and addressing high-cost patients. - Fee-for-service reimbursement will continue to dominate for years.

Patient-Centered Medical Homes (PCMHs)

- PCMH recognition does not require delivery of SBIRT or medication-assisted therapy for alcohol or opioid dependence.

Joint Commission quality metrics on SBIRT

- Use of these quality metrics is optional.

Healthcare organizations are overwhelmed with current

mandates for changeImprovements in

behavioral healthcare mustcompete with those mandates

The Quote Out of Context

88

“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA

The Full Quote“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA

“Why SBIRT is Dead in the Water … Until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT [is] DOA …”

90

Current quality metrics can be metwithout evidence-based service delivery

Completion of screening or brief validated assessment questionnaires 3

Intervention delivery 3

Referral delivery 2

Pharmacotherapy recommendation 2

Follow-up contact 1

Treatment initiation and engagement 2

Drinking outcomes 0

TOTAL 11

Brown & Smith, American Journal of Medical Quality, 2015

}Measuresindicatewhetherservices aredelivered,not how well

91

Q = Srecd Selig

Arecd S+

x x∆Bactual

∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+

Population-Level Quality Measure for SBIRT


92

Q = Srecd

Selig Arecd

S+ x x

∆Bactual ∆Bexpected

x


Irecd A+

Srecd = # of patients who received screening of those eligible

Selig = # of patients eligible for screening

Of patients who were eligible for screening, how many completed screening?



93

Q = Srecd Selig

Arecd S+

x x∆Bactual

∆Bexpected x


Irecd A+

Arecd = # of patients who received assessment

S+ = # of patients with positive screens

Of patients who were eligible for assessment because they screened positive, how many completed assessment?



94

Q = Srecd Selig

Arecd S+

x x∆Bactual

∆Bexpected x


Irecd A+

Irecd = # of patients who received an appropriate intervention (including referral and pharmacotherapy)

Of patients recognized with risky, problem or dependent drinking, how many received the appropriate intervention (including referral and pharmacotherapy for dependence)?

A+ = # of patients whose assessment was positive



95

Q = Srecd Selig

Arecd S+

x x∆Bactual

∆Bexpected x


Irecd A+

∆Bactual = # of patients who manifested a certain level of behavior change – eg, 20% reduction in risky drinking days per month

∆Bexpected = # of patients expected to manifest that level of behavior change based on prior research

Of patients who received appropriate interventions,how many manifested expected changes in drinking?



96

Q = Srecd Selig

Arecd S+

x x∆Bactual

∆Bexpected x


Irecd A+

• 75% of eligible patients were screened • 75% of patients with + screens completed brief assessments • 75% of patients with + assessments received appropriate intervention • 75% of patients who received appropriate intervention reduced their

risky drinking as expected

Q = .75 x .75 = .32x .75 x .75



97

Payer withholds 2% of all revenue through each year True-up at end of year is based on quality metric performance on SBIRT and other behavioral services:

Pay-for-Performance Program

Modeled after Medicare’s End Stage Renal Disease Quality Incentive Program

Performance At end of year,payer pays… Net

Poor Nothing Loss of 2% of revenueFair 1% of revenue Loss of 1% of revenue

Good 2% of revenue Break evenVery good 3% of revenue Gain of 1% of revenueExcellent 4% of revenue Gain of 2% revenue

}4%swinginmargin

SummarySBIRT clearly works for unhealthy drinking. SBIRT substantially reduces healthcare costs for unhealthy drinkers. SBIRT does not work for complex, disadvantaged, urban drug users. SBIRT might work for other drug users. More research is coming soon. The SBIRT model should expand to include pharmacotherapy and behavioral treatment for dependent patients in general healthcare settings. Strategies to implement SBIRT must take into account other behavioral healthcare needs in primary care/general healthcare settings. Strategies to spread SBIRT and similar services for other behavioral risks and disorders must go beyond fee-for-service reimbursement.

A Look at the Evidence – and Gaps to AddressSBIRT:

wellsys.biz

Richard L. Brown, MD, MPH Director of WIPHL

Professor of Family Medicine & Community HealthSchool of Medicine and Public Health

University of WisconsinCEO and Chief Medical Officer, Wellsys LLC

sbirt: a look at the evidence – and gaps to address - a look at the evidence _ dr. richard...a...

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