Implementation of Alcohol Screening and Brief Intervention in a Health System: Sustainability, Fidelity and Patient Outcomes

摘要 危险饮酒是一个重大的公共卫生问题，影响着大约20%的美国成年人 初级保健患者，造成约65,000人死亡，给美国卫生系统造成超过250美元的成本 每年10亿美元。临床试验已经证明酒精筛查和治疗的疗效和成本效益 短暂干预(ASBI)，包括在这里研究的卫生系统，它现在是一种得到广泛认可的 对危险用途进行识别和早期干预的方法。然而，相对较少的研究已经 考察了实际的ASBI实施及其长期可持续性，以及它们与患者的关系 结果、利用率和成本。这项研究将利用正在进行的卫生系统范围ASBI倡议 在一个大型、不同种类的医疗保健提供系统中，Kaiser Permanente North California在2013年 将ASBI纳入其成人初级保健工作流程，平均进行145,000次筛查和 每月为成人初级保健患者提供9,500次简短干预(BIS)。使用理论驱动的概念 框架，这项创新的研究将严格审查促进或阻碍成功的房地产市场的因素 世界ASBI的实施和长期可持续性。在PRISM的指导下(实用、稳健 实施和可持续发展模型)框架，这项混合方法研究将使用电子健康 记录2014年1月1日至2021年12月31日的(EHR)数据，以及初级保健提供者调查、患者电话 访谈和定性关键线人访谈，以审查ASBI的实施情况(2014年1月1日- 2015年12月31日)、短期可持续性(2016年1月1日至2018年12月31日)和长期可持续性(2019年1月1日- 2021年12月31日)结果(筛查和BI率)；患者结果(酗酒天数和典型饮酒 数量和频率、保健服务利用率和成本)；以及国际清算银行的保真度和质量。我们将使用 PRISM领域，以加强我们对ASBI实施和长期可持续性的了解。第一, 我们将使用间接标准化(观察与预期比率)方法来对ASBI进行基准测试 实施，短期和长期的8年可持续绩效，并检查相关因素。 第二，我们将进行多层次的模型分析，以确定是否以及如何实施ASBI和 可持续性与患者的饮酒结果以及卫生服务的使用和费用有关。最后，我们会 通过询问患者和PCP的接收和交付经验来衡量BI的保真度和质量 BIS，并检查它们与患者预后的关系。结果将提供具体、务实的指导 关于促进ASBI成功实施和可利用的长期可持续性的因素 广泛地通过这个和其他卫生系统来改善我们识别和治疗各种不健康疾病的方式 酒精使用，以及我们如何实施、维持和研究对它的基于人群的反应。

ABSTRACT Hazardous drinking is a significant public health problem, affecting approximately 20% of U.S. adult primary care patients, contributing to about 65,000 deaths and costing the US health system more than $250 billion annually. Clinical trials have documented the efficacy and cost-effectiveness of Alcohol Screening and Brief Intervention (ASBI), including in the health system studied here, and it is now a widely-endorsed approach to identification and early intervention for hazardous use. However, relatively few studies have examined real-world ASBI implementation and, its long-term sustainability, and their relationship to patient outcomes, utilization and cost. This study will take advantage of an ongoing health system-wide ASBI initiative in a large, heterogeneous health care delivery system, Kaiser Permanente Northern California, which in 2013 incorporated ASBI into its adult primary care workflow and conducts an average of 145,000 screenings and 9,500 brief intervention (BIs) monthly for adult primary care patients. Using a theory-driven conceptual framework, this innovative study will rigorously examine the factors which facilitate or impede successful real- world ASBI implementation and long-term sustainability. Guided by the PRISM (Practical, Robust Implementation and Sustainability Model) framework, this mixed-methods study will use electronic health record (EHR) data from 1/1/2014 to 12/31/2021, along with primary care provider surveys, patient telephone interviews, and qualitative key informant interviews to examine ASBI implementation (1/1/2014 – 12/31/2015), short-term sustainability (1/1/2016-12/31/2018) and long-term sustainability (1/1/2019 – 12/31/2021) outcomes (screening and BI rates); patient outcomes (heavy drinking days and typical drinking quantity and frequency, health services utilization and costs); and the fidelity and quality of BIs. We will use the PRISM domains to enhance our understanding of ASBI implementation and long-term sustainability. First, we will employ indirect standardization (observed-to-expected ratios) methodology to benchmark ASBI implementation, short- and long-term sustainability performance over 8 years and examine associating factors. Second, we will conduct multi-level models analyses to determine whether and how ASBI implementation and sustainability are related to patient drinking outcomes and use of health services and costs. Finally, we will measure BI fidelity and quality by asking patients and PCPs about their experiences receiving and delivering BIs, and examine how they are related to patient outcomes. Results will provide concrete, pragmatic guidance on factors which facilitate successful ASBI implementation and long-term sustainability that can be used widely by this and other health systems to improve how we identify and treat the full spectrum of unhealthy alcohol use, and how we implement, sustain and study population-based responses to it.