SBIRT:
A Look at the Evidence
– and Gaps to Address
Richard L. Brown, MD, MPH
Director of WIPHL
Professor of Family Medicine & Community Health
School of Medicine and Public Health
University of Wisconsin
CEO and Chief Medical Officer, Wellsys LLC
wellsys.biz
Richard L. Brown, MD, MPH - “Rich”
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
Wisconsin Initiative to
Promote Healthy Lifestyles
Wisconsin Department
of Health Services
Three federally funded projects:
• $14M since 2006
• Helped 44 clinics deliver BSI
• Screened >100,000 patients
• Delivered >25,000 interventions
Results:
Patient satisfaction: 4.3 to 4.9 of 5 points
20%
15%
55%
Binge
drinking
Marijuana
use
Depression
symptoms
Best outcomes: Bachelor’s-level HEs
Savings per Medicaid pt screened: $546/2 yrs
Brown, American Journal of Managed Care, 2014; Paltzer, unpublished
3
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
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
6
Drinking and Drug Use Continuum
Absti-
nence
High
Problem
Low
risk
Not
risk
dependent
use
use
use
No addiction
Dep
Addicted
Abstinent x 1 mo
Loss of control
Cravings
Preoccupation
Addicted
Abstinent x 2 yr
7
Need for SBIRT - US Adults
(Use in Past Month)
Binge alcohol use
25%
Illicit drug use
About 1 in 3 adults
would benefit from
alcohol or drug services
9%
Marijuana use
Other illicit drug use
7%
3%
SAMHSA, National Survey on Drug Use and Health, 2012-2013
8
Prevalence of Alcohol/Drug Disorders
– US Adults –
Alcohol
Drugs
7.1%
2.6%
Abuse or Dependence
SAMHSA, National Survey on Drug Use and Health, 2012-2013
9
Receipt of Alcohol/Drug Treatment
– US Adults –
Alcohol
Drugs
Untreated:
95%
Untreated:
89%
Treated:
5%
Treated:
11%
SAMHSA, National Survey on Drug Use and Health, 2012-2013
10
Economic Impacts - $412 Billion
$161B
Alcohol
Drugs
Healthcare
$34B
$25B
$11B
$61B
$120B
Productivity
Other
Societal
11
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation
12
SBIRT Overview
Screen
Brief Assessment
Abstinence
or low risk
High risk or mild to
moderate disorder
Dependence or
severe disorder
(Brief Treatment)
Brief Intervention
Referral to Treatment
Follow-up and Support
13
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
14
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
15
Alcohol Screening - CAGE
Cut down
Annoyed
Guilt
Eye-opener
- Misses risky
-
drinking
Other screens
are briefer
and more
accurate
16
Alcohol Screening - AUDIT-C
0
1
2
3
4
1 How often do you
have a drink
containing alcohol?
2 How many drinks
containing alcohol do
you have on a typical
day when you are
drinking?
Never
Monthly
or less
2 - 4 times
a month
2 - 3 times
a week
1 or 2
3 or 4
5 or 6
7 to 9
4 or more
times a
week
10 or more
3 How often do you
have more than
X drinks on one
occasion?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Positive screen: ≥4 points for men, ≥3 points for women
17
Alcohol Screening -
Single Alcohol Screening Question
How many times in
the past year have
you had more than
4 drinks in an
occasion?
How many times in
the past year have
you had more than
3 drinks in an
occasion?
__ 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
18
Drug Screening -
Single Alcohol Screening Question
How many times in the past year have you used
an illegal drug or used a prescription medication
for non-medical reasons?
__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times
Modified from: Smith, Archives of Internal Medicine, 2010
19
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
20
AUDIT - Questions 1 to 3
0
1
2
3
4
1 How often do you
have a drink
containing alcohol?
2 How many drinks
containing alcohol do
you have on a typical
day when you are
drinking?
Never
Monthly
or less
2 - 4 times
a month
2 - 3 times
a week
1 or 2
3 or 4
5 or 6
7 to 9
4 or more
times a
week
10 or more
3 How often do you
have more than
X* drinks on one
occasion?
Never
Less than
monthly
Monthly
Weekly
* For X, substitute 3 for women, 4 for men
Daily or
almost daily
21
AUDIT - Questions 4 to 8
0
Never
1
Less than
monthly
2
Monthly
3
Weekly
4
Daily or
almost daily
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?
22
AUDIT - Questions 9 to 10
0
No
2
Yes, but not in
the last year
4
Yes, during
the last year
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?
23
AUDIT - Scoring
Points
Interpretation
Men up to
age 64
Women 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
24
DAST - Questions 1 to 5
In the past 12 months …
Points
Yes 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
25
DAST - Questions 6 to 10
In the past 12 months …
6
Has your spouse or parents ever complained about your involvement
with drugs?
7 Have you neglected your family because of your use of drugs?
Points
Yes No
1
0
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
26
DAST - Scoring
Score
Extent of Problems
Related to Drug Use
Recommended Clinical
Service
0
None
Reinforcement
1
Low
Brief Intervention (BI)
2
Low
BI
3 to 5
Moderate
6 to 8
Substantial
Referral for Assessment
9 to 10
Severe
Referral for assessment
BI and Follow-up
27
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
29
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 use
30
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
31
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)
32
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 a
few times
(1)
Once or
twice a week
(2)
Daily or
almost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
Over the last 12 months …
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 a
few times
(1)
Once or
twice a week
(2)
Daily or
almost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
Over the last 12 months …
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 a
few times
(1)
Once or
twice a week
(2)
Daily or
almost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
Over the last 12 months …
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 a
few times
(1)
Once or
twice a week
(2)
Daily or
almost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
Over the last 12 months …
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 a
few times
(1)
Once or
twice a week
(2)
Daily or
almost daily
(3)
SDS - Severity of Dependence Scale
Over the last 12 months …
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 ___?
Never or
almost never
(0)
Some-
times
(1)
Once or
Always or
twice a week
almost always
(2)
(3)
SDS - Severity of Dependence Scale
5. How difficult do you find it to stop or go
without ____?
Not
difficult
(0)
Quite
difficult
(1)
Very
difficult
(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 positive
Q/F
High risk use
At least
high risk use
SIP-AD
Negative
consequences
At least
problem use
SDS
Dependence
Likely dependence
Gap in Screening/Assessment Studies
Typical Study
Clinical
environment
Recruit subjects
Research
environment
✓
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
Clinical
environment
Recruit subjects
Research
environment
✓
Clinical
environment
Research
environment
✓
Administer instrument
to be tested
✓
Apply “gold standard”
diagnostic process
✓
Research Question
Needed Studies
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 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?
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 Alcohol
Single Drug
+
+
Screening Question
Screening Question
Two-Item
Conjoint 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
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
45
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
46
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
- Hospitalizations and ED visits
- Arrests
- Vehicular crashes
- Deaths
$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
Proportion Abstinent
p-value
Brochure
Brief Intervention
Cocaine
17%
22%
0.045
Heroin
31%
40%
0.050
Bernstein et al, Drug & Alcohol Dependence, 2005
49
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
Proportion with ≥25% Reduction
Brochure
Brief Intervention
p-value
3 months
30%
52%
0.017
12 months
49%
50%
0.833
Zahradnik et al, Addiction, 2009;
Otto et al, Drug & Alcohol Dependence, 2009
50
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
Decline in ASSIST Scores - 3 Months
30%
20%
10%
25%
24%
20%
17%
9%
10%
11%
Brief Intervention
Usual care
2%
0%
Australia
Humeniuk et al, Addiction, 2012
Brazil
India
USA
51
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)
Days of Use of Primary Drug in Past 30 Days
16
12
8
4
0
14.3
13.8
14.2
13.8
14.1
Baseline
6 months
Control
Saitz et al, JAMA, 2014
15.1
BI
MMI
52
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
Roy-Byrne et al, JAMA, 2014
53
Another negative study …
54
Kaner et al
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
55
Kaner et al
Cluster RCT with randomization by clinic
Intervention Components
Group
1
Group
2
Group
3
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
✓
56
Kaner et al
Presenting patients:
3,562
Eligible for screen:
2,991 (84%)
Hazardous or harmful drinkers:
900 (30%)
Consented to participate:
754 (84%)
Brochure only
+ Brief advice
+ Brief counseling
251
251
254
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%)
Randomization
Received brochure
57
Proportion With AUDIT < 8
Baseline
6 months
12 months
Odds
Ratio
95%
C. I.
p-
value
Brochure
+ Advice
+ Counseling
0%
10%
20%
30%
0.85
0.52 - 1.39
0.51
0.91
0.53 - 1.56
0.73
0.78
0.48 - 1.25
0.30
0.99
0.60 - 1.60
0.96
40%
58
The Fallout …
“Alcohol screening and intervention did not decrease
the percentage of patients drinking to excess”
“SBIRT is dead in the water.”
Mark Willenbring, MD
Addiction Psychiatrist, Allina Health
Former Director, Division of Treatment
and Recovery Research, NIAAA
59
Why might the Kaner study be negative?
1. “Recruiting individuals into the study might reduce their drinking.”
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.”
60
Kaner et al: The Bottom Line
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
61
Characteristics of Subjects in
Recent Drug Intervention Trials
Saitz
- 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.
62
WIPHL’s Experience
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
63
Binge Drinking and Drug Use are
Major Problems for Employers
US Binge Drinkers - 2010
US Adult Drug Users - 2010
Employed
Part Time
Employed
75%
18%
Employed
66%
48%
Employed
Full Time
Unemployed
13%
Out of
Labor Force
21%
SAMHSA, National Survey on Drug Use and Health, 2010
64
Alcohol Screening and Intervention:
Cost Savings
Fleming 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
Which services would best …
prevent disease, injury and death
reduce healthcare costs?
1
Aspirin prophylaxis
Alcohol screening & intervention
is ranked higher than:
Blood pressure screening
Cholesterol screening
Diabetes screening
2
Childhood immunizations
3
Tobacco screening & intervention
4
Alcohol screening & intervention
ROI within one year!
Search: National Commission on Prevention Priorities
Osteoporosis screening
Cancer screenings
Adult immunizations
66
How should interventions be delivered?
Inpatients
with Alcohol
Related
Trauma
Brief Advice
(4.7 ± 2.2 min)
Motivational
intervention
(22.5 ± 10.4 min)
6.0
5.5
Mean
Drinks 5.0
per
Drinking 4.5
Day
4.0
Base-
line
Field, Annals of Surgery, 2013
3 mo.
6 mo.
Motivational
intervention
(22.5 ± 10.4 min)
plus booster
(28.0 ± 10.4 min)
12 mo.
67
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
68
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
Glass, Addiction, 2015
69
WIPHL’s Experience
Of about 1,500 substance-dependent
patients identified in general healthcare
settings by screening and the ASSIST
only 10%
completed an assessment or initial
treatment session at a treatment program,
despite availability of funding for patients
who couldn’t afford treatment
70
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
71
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
“Less than a third of all
people with alcohol
problems receive treatment
of any kind, and less than
10 percent are prescribed
medications.”
73
SBIRT Overview
Screen
Brief Assessment
Abstinence
or low risk
High risk or mild to
moderate disorder
Dependence or
severe disorder
(Brief Treatment)
Brief Intervention
Referral to Treatment
Follow-up and Support
75
SBIRT - Adjusting the Model
Screen
Abstinence
or low risk
Brief Assessment
Dependence or
severe disorder
High risk or mild to
moderate disorder
On-site medication-
assisted therapy
Brief Intervention
Referral to
Treatment
Follow-up and Support
Outline
The problem
Intervention
SBIRT - an overview
Referral to treatment
Screening
Brief treatment
Brief assessment
Implementation & spread
77
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
http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html
Glass et al, Unpublished, 2015
78
The Problem:
>40% of Deaths and Most Chronic Disease
Prevalence – US Adults
Prevalence
100%
80%
60%
40%
20%
19%
29%
25%
9%
7%
Drug
use
Depression
0%
Smoking
Binge
drinking
CDC, Behavioral Risk Factor Surveillance System, 2013;
SAMHSA, National Survey on Drug Use and Health, 2013
Obesity
79
Costs of Behavioral Risks and Disorders
– United States –
Healthcare
Productivity
Justice, Social, Crashes
$300B
$250B
$200B
$156B
$34B
$150B
$100B
$50B
$73B
$61B
$503B
$166B
$25B
$11B
$5B
$52B
$26B
Alcohol
Drug Use
Depression
$120B
$133B
$0B
Smoking
$100B
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/
$147B
Obesity
$342B
$945B
Who SHOULD do SBIRT?
No direct comparison studies
Reviews:
• Healthcare providers may get
slightly better outcomes than paraprofessionals
• May be differences in case mix
81
T
O
O
M
T
N
I
O
P
Who SHOULD do SBIRT?
No direct comparison studies
Reviews:
• Healthcare providers may get
slightly better outcomes than paraprofessionals
• May be differences in case mix
82
Primary Care Providers Don’t Have Time
Extra Time Per Day Needed to
Address Positive Screens for
24 Patients at 5 Minutes Per Issue
Primary care providers ...
address 3 clinical issues in
Tobacco
6
Extra
Time
30
min.
Alcohol
6
30 min.
Drugs
2
10 min.
must delegate all prevention
Obesity
8
40 min.
services to serve expanding
Depression
2
10 min.
Total
24
120 min.
elderly and insured patients
Issues
Altschuler, Annals of Family Medicine, 2012; Beasley, Annals of Family Medicine, 2004;
Bodenheimer, Health Affairs, 2010
a typical visit
Workflow in Healthcare Settings
In clinics:
Patients complete
screen while
waiting
Medical assistant
reviews screen
Health educator
sees patient
at that visit
In EDs & hospitals, health educators introduce themselves and deliver services
Wisconsin Initiative to
Promote Healthy Lifestyles
Wisconsin Department
of Health Services
Three federally funded projects:
• $14M since 2006
• Helped 44 clinics deliver BSI
• Screened >100,000 patients
• Delivered >25,000 interventions
Results:
Patient satisfaction: 4.3 to 4.9 of 5 points
20%
15%
55%
Binge
drinking
Marijuana
use
Depression
symptoms
Best outcomes: Bachelor’s-level HEs
Savings per Medicaid pt screened: $546/2 yrs
Brown, American Journal of Managed Care, 2014; Paltzer, unpublished
Spreading SBIRT: What Hasn’t Worked
Facilitators and Barriers to Spread
Possible Facilitators
Medicare and the ACA → ↑reimbursement
Accountable care
organizations (ACOs)
Patient-Centered Medical
Homes (PCMHs)
Joint Commission quality
metrics on SBIRT
Barriers
- Reimbursement for services by paraprofessionals is patchy.
- Reimbursement is inadequate incentive.
- Most are busy establishing infrastructure and addressing
high-cost patients.
- Fee-for-service reimbursement will continue to dominate for
years.
- PCMH recognition does not require delivery of SBIRT or medication-assisted therapy for alcohol or opioid
dependence.
- Use of these quality metrics is optional.
Healthcare organizations are
Improvements in
overwhelmed with current
behavioral healthcare must
mandates for change
compete with those mandates 87
The Quote Out of Context
“SBIRT is dead in the water.”
Mark Willenbring, MD
Addiction Psychiatrist, Allina Health
Former Director, Division of Treatment
and Recovery Research, NIAAA
88
The Full Quote
“SBIRT is dead in the water.”
Mark Willenbring, MD
Addiction Psychiatrist, Allina Health
Former 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 …”
Current quality metrics can be met
without evidence-based service delivery
}
Completion of screening or brief validated
3
assessment questionnaires
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
Measures
indicate
whether
services are
delivered,
not how well
90
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
A+
Brown & Smith, American Journal of Medical Quality, 2015
x
∆Bexpected
91
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
A+
x
∆Bexpected
Of patients who were eligible for screening, how many
completed screening?
Srecd = # of patients who received screening of those eligible
Selig = # of patients eligible for screening
Brown & Smith, American Journal of Medical Quality, 2015
92
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
A+
x
∆Bexpected
Of patients who were eligible for assessment because they
screened positive, how many completed assessment?
Arecd = # of patients who received assessment
S+ = # of patients with positive screens
Brown & Smith, American Journal of Medical Quality, 2015
93
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
A+
x
∆Bexpected
Of patients recognized with risky, problem or dependent
drinking, how many received the appropriate intervention
(including referral and pharmacotherapy for dependence)?
Irecd = # of patients who received an appropriate intervention (including referral and pharmacotherapy)
A+ = # of patients whose assessment was positive
Brown & Smith, American Journal of Medical Quality, 2015
94
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
A+
x
∆Bexpected
Of patients who received appropriate interventions,
how many manifested expected changes in drinking?
∆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
Brown & Smith, American Journal of Medical Quality, 2015
95
Population-Level Quality Measure for SBIRT
Q =
Screening
Assessment
Intervention
Behavioral outcomes
Srecd
Arecd
Irecd
∆Bactual
Selig
x
S+
x
x
A+
∆Bexpected
• 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
x
.75
x
Brown & Smith, American Journal of Medical Quality, 2015
.75
=
.32
96
Pay-for-Performance Program
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:
Performance
At end of year,
payer pays…
Net
Poor
Nothing
Loss of 2% of revenue
Fair
1% of revenue
Loss of 1% of revenue
Good
2% of revenue
Break even
Very good
3% of revenue
Gain of 1% of revenue
Excellent
4% of revenue
Gain of 2% revenue
Modeled after Medicare’s End Stage Renal Disease
Quality Incentive Program
}
4%
swing
in
margin
97
Summary
SBIRT 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.
SBIRT:
A Look at the Evidence
– and Gaps to Address
Richard L. Brown, MD, MPH
Director of WIPHL
Professor of Family Medicine & Community Health
School of Medicine and Public Health
University of Wisconsin
CEO and Chief Medical Officer, Wellsys LLC
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