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

描述（由申请人提供）：这项卫生服务实施研究是一项集群、随机试验，响应NIAAA的PA-07-066“酒精使用障碍：治疗、服务研究和康复（R01）”。这是一个罕见而及时的机会来研究筛查短暂干预和转诊治疗（SBIRT）的实施，最近在美国最大的私人健康计划之一，北加州凯撒医疗保险公司，niaaa推荐的酒精筛查问题被纳入电子病历。筛查和简短的干预是有效的，已经得到NIAAA， SAMSHA和美国预防服务工作组的认可。在国家实践指南（包括NIAAA的临床医生指南）中已推荐使用，但尚未在一般卫生保健机构中广泛实施。在一个大型的、非学术性的健康计划中研究实施情况，可以为未来在美国卫生保健系统中实施SBIRT提供信息。在美国，只有少数严格的实施研究进行过，这些研究仅限于退伍军人管理局，或者检查了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——一组为对照条件，另一组为NIAAA初级保健机构临床医生SBIRT指南的两种可选交付模式。在初级保健医生或“PCP”部门，PCP将接受NIAAA临床医生指南中概述的SBIRT协议的培训，并根据需要进行简短的干预和转诊。在非医师提供者（NPP）部门，医疗助理将接受培训，使用NIAAA筛选器并将结果输入电子病历，NPP（如行为医学专家、临床护士和健康教育工作者）将进行简短的干预和转诊。根据NIAAA指南，NPP和PCP武器的SBIRT含量是相同的；我们将按提供者类型的交付情况与控制条件进行比较，在控制条件下，提供者和工作人员将不接受任何关于SBIRT协议的培训。我们检查了实施结果：筛查率、短暂干预率、随访筛查和短暂干预率、转介到化学依赖治疗和酒精使用障碍药物治疗率。我们还检查了每个研究组的实施和干预成本，并将确定预测每个研究组实施SBIRT的组织、临床医生和患者因素。作为次要目的，我们还包括一项通过研究组检查患者结果的有效性研究，以及对实施过程和可行性的检查。这项研究在使用电子病历和非医师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化的酒精筛查。

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. 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.