Alcohol SBIRT Implementation in an HMO: Non-Physician Providers vs. Physicians

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DESCRIPTION (provided by applicant): This health services implementation study is a clustered, randomized trial and responds to NIAAA's PA-07-066 "Alcohol Use Disorders: Treatment, Services Research, and Recovery (R01)". This is a rare and timely opportunity to study implementation of Screening Brief Intervention and Referral to Treatment (SBIRT), following the recent inclusion of the NIAAA-recommended alcohol screening questions in the Electronic Medical Record at one of the largest private health plans in the US, Kaiser Permanente Northern California. Screening and brief intervention to address excessive drinking is efficacious, has been endorsed by NIAAA, SAMSHA, and the US Preventive Services Task Force. It has been recommended in national practice guidelines (including NIAAA's Clinician's Guide), but has not been widely implemented in general health care settings. Studying implementation in a large, non-academic health plan can inform future implementation of SBIRT in the U.S. health care system. Only a few rigorous implementation studies have been conducted in the U.S. and these have been limited to the Veterans Administration, or examined approaches other than those currently recommended such as the NIAAA Clinician's Guide. We propose to randomize primary care clinics to three arms-a control condition and two alternative modes of delivery of the NIAAA Clinician's Guide to SBIRT in primary care settings. In the Primary Care Physician or "PCP" arm, PCPs will be trained on SBIRT protocols outlined in the NIAAA Clinicians' Guide and conduct brief intervention and referrals as needed. In the Non- Physician Provider or "NPP" arm, Medical Assistants will be trained to use the NIAAA screener and enter the results in the Electronic Medical Record, and NPPs (e.g., Behavioral Medicine Specialists, Clinical Nurses and Health Educators) will conduct brief intervention and referral. The SBIRT content, based on the NIAAA Guide, is the same in the NPP and PCP arms; we compare delivery by the type of provider and versus the control condition, in which providers and staff will not receive any training on SBIRT protocols. We examine implementation outcomes: rates of screening, brief intervention, follow-up screening and brief intervention, referral to Chemical Dependency treatment, and alcohol use disorders medication rates. We also examine implementation and intervention costs for each arm and will identify the organizational, clinician, and patient factors that predict SBIRT Implementation for each study arm. We also include, as secondary aims, an effectiveness study examining patient outcomes by study arm, and an examination of the implementation process and feasibility. The research is innovative in its use of the electronic medical record and non-physician professionals, and in moving alcohol screening into the Medical Assistant's "vital signs" screening role, which may promote more systematic alcohol screening. PUBLIC HEALTH RELEVANCE: Excessive alcohol use is a major contributor to disease and injury. Screening and brief intervention to address excessive drinking in primary care is an effective preventive health practice that is recommended by the U.S. Preventive Services Task Force, but few physicians conduct screening. This study aims to learn how to increase use of screening and brief intervention by primary care settings, so that U.S. primary care patients may benefit from this preventive practice.