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

描述（由申请人提供）：本卫生服务实施研究是一项群集随机试验，并响应NIAAA的PA-07-066“酒精使用障碍：治疗、服务研究和恢复（R 01）"。这是一个难得的和及时的机会来研究实施筛查简短干预和转诊治疗（SBIRT），在最近包括NIAAA推荐的酒精筛查问题在电子病历在美国最大的私人健康计划之一，凯撒永久北方加州。筛查和简短的干预，以解决过量饮酒是有效的，已通过NIAAA，SAMSHA，和美国预防服务工作组。它已在国家实践指南（包括NIAAA的临床医生指南）中推荐，但尚未在一般医疗保健环境中广泛实施。研究在一个大型的，非学术的健康计划的实施可以告知未来的SBIRT在美国的实施。在美国，只有少数严格的实施研究已经进行，这些研究仅限于退伍军人管理局，或研究目前推荐的方法以外的方法，如NIAAA临床医生指南。我们建议将初级保健诊所随机分为三组，一组是对照组，另一组是在初级保健环境中提供NIAAA临床医生指南SBIRT的两种替代模式。在初级保健医生或“PCP”组中，PCP将接受NIAAA临床医生指南中概述的SBIRT方案培训，并根据需要进行简短的干预和转诊。在非医生提供者或“NPP”组中，医疗助理将接受培训，以使用NIAAA筛选器并将结果输入电子病历和NPP（例如，行为医学专家、临床护士和健康教育者）将进行简短的干预和转介。基于NIAAA指南的SBIRT内容在NPP和PCP组中是相同的;我们比较了提供者类型和对照条件的交付情况，其中提供者和工作人员将不会接受任何关于SBIRT协议的培训。我们检查实施结果：筛查率，简短干预，后续筛查和简短干预，转介到化学依赖治疗，酒精使用障碍药物治疗率。我们还检查了实施和干预成本为每个手臂，并将确定组织，临床医生和患者的因素，预测SBIRT实施为每个研究arm. We还包括，作为次要目标，有效性研究，检查患者的结果研究手臂，并检查实施过程和可行性。该研究在使用电子病历和非医生专业人员方面具有创新性，并将酒精筛查纳入医疗助理的“生命体征”筛查角色，这可能会促进更系统的酒精筛查。

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.