Population-based Screening and Brief Intervention in Primary Care: Health and Drinking Outcomes, Cost and Utilization

摘要 高风险饮酒是一个严重的公共卫生问题，会导致严重的死亡率、发病率和医疗费用 每年。尽管这在初级保健患者中很常见-美国约20%的成年初级保健患者。 报告不健康的酒精使用--这很少在初级保健中得到解决。高风险使用在那些患有 慢性疾病，如高血压、糖尿病和抑郁症，并可影响疾病进展和 严重程度、自我管理和治疗结果。人们对短暂干预(BI)的有效性知之甚少 作为主流初级保健的一部分提供的饮酒和健康结果。这是以人口为基础的次要 分析研究检查了正在进行的全系统酒精筛查、短暂干预和转介的影响 大型医疗保健提供系统中的治疗(SBIRT)倡议，Kaiser Permanente North California，2013年 将SBIRT纳入其成人初级保健工作流程。使用2014年1月1日的电子健康记录(EHR)数据 2019年6月30日，约479,070名被确认为不健康饮酒者的成员，其中约191,628人将 有返回的初级保健访问，因此后续数据，我们将检查接受BI对饮酒的影响 危险饮酒筛查阳性者的结果、健康结果、费用和卫生服务利用 与那些没有收到BI的人相比，为了了解BI如何、为谁工作以及在什么情况下工作 危险的饮酒者。我们的研究解决了文献中的许多空白，包括对现实世界医疗保健的概括性 将筛查和BI作为常规医疗服务的一部分进行，并将数据作为护理的一部分进行收集的设置 临床医生的分娩过程，超出了以前的酒精筛查和简要随机对照试验研究的人群 干预。我们将包括所有被确认为危险饮酒者的成人初级保健患者，以及所有级别的饮酒 严重，其中许多人有慢性医疗和精神问题。我们的大样本的种族和种族多样性将 使我们能够检查不同年龄、性别和种族的商业智能有效性的差异，这将提供关键信息 解决在弱势人群中发现和及早干预酒精问题方面的差距。这个 EHR中的人口统计、临床共病和服务使用数据的可用性为我们提供了检查的机会 商业智能的动态及其对健康和服务的影响更全面。我们使用一种创新的模式来概念化 BIS与结果之间的关系，以及由此进行因果推断的新的统计方法 使用边际结构模型的观察性研究，以及使用逆概率加权解决选择偏差问题。 我们的研究假设是减少过度饮酒、改善健康状况和减少不必要的饮酒 如果得到证实，随着时间的推移，医疗成本和使用率可能会刺激酒精SBIRT在医疗系统和 它被接受为初级保健环境中的标准预防保健做法。这将对 我们如何治疗和研究不健康的酒精使用的全部光谱。

ABSTRACT Risky alcohol use is a serious public health problem contributing to significant mortality, morbidity and healthcare costs each year. Although it is common among primary care patients – around 20% of adult primary care patients in the U.S. report unhealthy alcohol use – it is rarely addressed in primary care. Risky use is even more prevalent among those with chronic medical conditions such as hypertension, diabetes, and depression, and can affect disease progression and severity, self-management and treatment outcomes. Little is known about the effectiveness of brief intervention (BI) on drinking and health outcomes when delivered as part of mainstream primary care. This population-based, secondary analysis study examines the impact of an ongoing system-wide alcohol screening, brief intervention and referral to treatment (SBIRT) initiative in a large health care delivery system, Kaiser Permanente Northern California, which in 2013 incorporated SBIRT into its adult primary care workflow. Using electronic health record (EHR) data from 1/1/2014 to 06/30/2019 for the approximately ~479,070 members identified as unhealthy drinkers, about 191,628 of whom will have had return primary care visits and thus follow-up data, we will examine the effects of receiving a BI on the drinking outcomes, health outcomes, and costs and health services utilization among those screening positive for risky drinking compared to those not receiving a BI, in order to understand how, for whom and under what circumstances BIs work for risky drinkers. Our study addresses many of the gaps in the literature, including generalizability to real-world healthcare settings where screening and BI occurs as part of routine healthcare delivery and data is collected as part of the care delivery process by clinicians, going beyond the populations studied in previous RCTs of alcohol screening and brief intervention. We will include all adult primary care patients identified as risky drinkers, with all levels of drinking severity, many of who have chronic medical and psychiatric problems. Our large sample’s ethnic and racial diversity will allow us to examine differences in BI effectiveness by age, gender, and ethnicity, which will provide critical information for addressing disparities in the detection and early intervention of alcohol problems in vulnerable populations. The availability of demographic, clinical comorbidity and services use data in the EHR provides us the opportunity to examine the dynamics of BI and its impact on health and services more holistically. We use an innovative model to conceptualize the relationships between BIs and outcomes, and novel statistical methods to make causal inference from this observational study using marginal structural models, and we address selection bias using inverse probability weighting. Our research hypotheses of reduced excessive alcohol use, improvement in health outcomes and decreases in unnecessary healthcare costs and utilization over time, if confirmed, could spur wider adoption of alcohol SBIRT in health systems and its acceptance as a standard preventive health practice in primary care settings. This would have a profound impact on how we treat and study the full spectrum of unhealthy alcohol use.