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，影响了大约20%的美国成年人。 初级保健患者，造成约65，000人死亡，使美国卫生系统花费超过250美元 每年十亿。临床试验已经证明了酒精筛查的有效性和成本效益， 短期干预（ASBI），包括在这里研究的卫生系统，它现在是一个广泛认可的 危险用途的识别和早期干预方法。然而，相对较少的研究 检查了现实世界的ASBI实施情况及其长期可持续性，以及它们与患者的关系 成果、利用率和成本。这项研究将利用正在进行的卫生系统范围的ASBI倡议 在一个大型的、异构的医疗保健提供系统中，凯撒医疗北方加州，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， 每月为成人初级保健患者提供9，500次简短干预（BI）。使用理论驱动的概念 框架，这项创新的研究将严格审查的因素，促进或阻碍成功的真实的- 世界ASBI实施和长期可持续性。以PRISM（实用、稳健）为指导 实施和可持续发展模式）框架，这项混合方法的研究将使用电子健康 从2014年1月1日到2021年12月31日的记录（EHR）数据，沿着初级保健提供者调查，患者电话 访谈，以及定性的关键线人访谈，以检查ASBI的实施情况（2014年1月1日- 12/31/2015），短期可持续性（1/1/2016-12/31/2018）和长期可持续性（1/1/2019 - 2021年12月31日）结局（筛选和BI率）;患者结局（重度饮酒日和典型饮酒 数量和频率、卫生服务利用率和成本）;以及BI的保真度和质量。我们将使用 PRISM领域，以提高我们对ASBI实施和长期可持续性的理解。第一、 我们将采用间接标准化方法（预测与预期比率）对ASBI进行基准测试 实施情况、8年内的短期和长期可持续性绩效，并审查相关因素。 其次，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， 可持续性与患者饮酒结果以及卫生服务的使用和成本有关。最后我们将 通过询问患者和PCP的接收和交付体验来衡量BI的保真度和质量 BI，并检查它们如何与患者结局相关。结果将提供具体、务实的指导 促进成功实施ASBI和可用于长期可持续性的因素 广泛地通过这个和其他卫生系统，以改善我们如何识别和治疗各种不健康的 酒精使用，以及我们如何实施，维持和研究基于人口的应对措施。

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.