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

描述(申请人提供)：这项卫生服务实施研究是一项分组随机试验，响应NIAAA的PA-07-066“酒精使用障碍：治疗、服务研究和康复(R01)”。这是一个难得和及时的机会来研究筛查短暂干预和转诊治疗(SBIRT)的实施情况，因为最近在美国最大的私人医疗计划之一--北加州凯撒永久医疗计划中，NIAAA推荐的酒精筛查问题被纳入电子医疗记录。筛查和短暂干预解决过度饮酒问题是有效的，已得到NIAAA、SAMSHA和美国预防服务工作组的认可。它已在国家实践指南(包括NIAAA的临床医生指南)中得到推荐，但尚未在一般卫生保健环境中广泛实施。研究大型非学术健康计划的实施情况可以为未来SBIRT在美国医疗保健系统中的实施提供参考。在美国只进行了几项严格的实施研究，这些研究仅限于退伍军人管理局，或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成三组--一种控制条件，以及NIAAA初级保健环境中SBIRT临床医生指南的两种替代交付方式。在初级保健医生或“初级保健医生”部门，初级保健医生将接受NIAAA临床医生指南中概述的SBIRT方案的培训，并根据需要进行简短的干预和转介。在非医生提供者或“NPP”部门，医务助理将接受使用NIAAA筛查器的培训，并将结果输入电子医疗记录，而NPP(例如，行为医学专家、临床护士和健康教育人员)将进行简短的干预和转介。基于NIAAA指南的SBIRT内容在NPP和PCP分支中是相同的；我们比较了按提供商类型进行的交付以及与控制条件的比较，在控制条件下，提供商和员工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、短暂干预、后续筛查和短暂干预的比率，转诊至化学依赖治疗的比率，以及酒精使用障碍的服药率。我们还检查了每个ARM的实施和干预成本，并将确定预测每个研究ARM实施SBIRT的组织、临床医生和患者因素。作为次要目标，我们还包括通过研究ARM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生专业人员方面具有创新性，并将酒精筛查转移到医疗助理的“生命体征”筛查角色，这可能会促进更系统的酒精筛查。 公共卫生相关性：过量饮酒是导致疾病和伤害的主要因素。在初级保健中进行筛查和短暂干预以解决过度饮酒问题是美国预防服务工作组建议的一种有效的预防性健康做法，但很少有医生进行筛查。这项研究旨在了解如何通过初级保健机构增加筛查和短暂干预的使用，以便美国初级保健患者可以从这一预防实践中受益。

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.