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Primary Care Residency Initiative

Primary Care Residency Initiative. Case example. Clark Smith’s semi-annual office visit. 68yo male, never married, retired accountant Known x 10years Hx HTN and mild DM2 since 1999, not obese Moved to Long Beach, WA 5 years ago

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Primary Care Residency Initiative

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  1. Primary Care Residency Initiative

  2. Case example Clark Smith’s semi-annual office visit • 68yo male, never married, retired accountant • Known x 10years • Hx HTN and mild DM2 since 1999, not obese • Moved to Long Beach, WA 5 years ago • Now presents twice annually for DM/HTN f/u, usually no medical complaints

  3. Case example Hi Clark. How’s the beach retirement going? What do you do with your time up there?

  4. Case example I usually hit golf balls on the beach in the morning and spend a couple hours playing pool at the bar before I go home for dinner.

  5. Case example That sounds great. Do you drink much when you’re playing pool at the bar?

  6. Case example I might have a few beers.

  7. Case example Interesting! In an average week, how many beers would you guess you might drink?

  8. Case example Hmmm . . . 1, 2, 3, 4 . . .

  9. Case example Oh, around 70.

  10. Wow. Clark doesn’t seem to think this is a big deal. Is it? And what can I do about it in our 15 minute diabetes f/u visit?

  11. Intro to SBIRT SBIRT:

  12. Intro to SBIRT • The SBIRT method Brief intervention Full screen Annual screen + + + Brief intervention + referral

  13. Intro to SBIRT Criteria for a good screening procedure

  14. Annual screen Alcohol misuse among PC patients Misuse 22% Low risk or abstention 78% National Institute on Alcohol Abuse and Alcoholism

  15. Intro to SBIRT Stratified prevalence of alcohol use among PC patients 5% Dependent 8% Harmful 9% Risky Low risk: 38% Abstain: 40% Manwell, Journal of Addictive Disease, 1998

  16. Intro to SBIRT Characteristics of the Risky zone • At-risk for future consequences • • Large body of evidence that shows drinking at this level will lead to health problems or make existing problems worse • Pts can fall into this category based on quantity alone • Any illicit drug use puts pt at risk for legal or employment problems IV III Risky II I

  17. Intro to SBIRT Characteristics of the Harmful zone • Repeated negative consequences: • • Distress or disability • • Failure to fulfill major role obligations at work, school, or home • • Physical hazards, legal problems • • Use continues despite persistent problems • Characteristics correlate with criteria for DSM-IV diagnosis of alcohol abuse IV Harmful III II I

  18. Intro to SBIRT Characteristics of the Dependent zone • Patient’s life orbits around use: • • Use leads to distress or disability • • Tolerance and withdrawal • • Use in larger amounts or longer period than intended • • Persistent desire to quit (or failed efforts) • • Great deal of time spent using or obtaining substance • • Characteristics resemble criteria for DSM-IV diagnosis for dependence Dependent IV III II I

  19. Impact of alcohol misuse • Alcohol misuse associated with: • Chronic liver disease & cirrhosis • Eight specific cancers • Heart disease • Pancreatitis • Stroke • Injuries • Pneumonia • Seizures • Gastritis/PUD • Alcoholic Cardiomyopathy • Interacting with many medications • Exacerbating numerous chronic medical conditions (HTN, DM, PUD, etc.) MMWR Weekly, 2004, Naimi, 2002

  20. Impact of alcohol misuse • Alcohol: Psychiatric co-morbidity Odds of co-occurrence of Current (12-month) NIAAA, 2004.

  21. Impact of alcohol misuse Alcohol impacts society • HOMELESSNESS • Vagrancy and the problems of Skid Row • IMPACT ON CHILDREN • School Failure • Neurotic and Behavioral Disorder • Delinquency • PUBLIC ORDER AND • AMENITIES • Public Drunkenness • Noise, Hooliganism • Public Disorder Alcohol misuse • MARITAL PROBLEMS • Physical Abuse • Sexual Abuse • Psychological Stress • Marital Breakdown • CRIME & PUBLIC SAFETY • Drunk Driving, • Assault and • Acquisitive Crime LIFESTYLE ISSUES Diet, Exercise, Smoking Center for Substance Abuse Treatment

  22. Impact of alcohol misuse The 10 Leading Risk Factors for Disease In Developed Countries Percent of disability-adjusted life years The World Health Report 2002

  23. Impact of alcohol misuse • Public spending on substance use NY TIMES May, 2009: • Government spending related to smoking and the abuse of alcohol and illegal drugs reached $468 billion in 2005, accounting for more than one-tenth of combined federal, state and local expenditures for all purposes. • Most abuse-related spending went toward direct health care costs or for law enforcement expenses, including incarceration. • Just over 2% of the total went to prevention, treatment and addiction research. “This is such a stunning misallocation of resources,” • Joseph A. Califano Jr., Chairman • National Center on Addiction and Substance Abuse.

  24. Evidence behind SBIRT Evaluations of SBIRT Meta-analyses & reviews: • More than 34 randomized controlled trials • Focused primarily on at-risk and problem drinkers • Result: 10-30% reductionin alcohol consumption at 12 months Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

  25. Evidence behind SBIRT • Effectiveness of SBIRT example:

  26. Evidence behind SBIRT SBIRT effectiveness • Fewer hospitalizations & ER visits • Cost savings: Fleming, et al, 2002

  27. Evidence behind SBIRT • USPSTF on SBIRT • For both alcohol screening and brief intervention • Same level of recommendation as flu shots and cholesterol screening Class B rating USPSTF, 2004

  28. Evidence behind SBIRT “Suitable methods of identification and readily learned brief intervention techniques with good evidence of efficacy are now available. The committee recommends… broad deployment of identification and brief intervention.” Institute of Medicine, 1990 (20 years ago!) “Broadening the Base of Treatment for Alcohol Problems”

  29. Missed opportunities in primary care Missed opportunities • Most patients (68-98%) with alcohol abuse or dependence are not detected by physicians • Physicians are less likely to detect alcohol problems: • When screening tools are not used universally • In patients who they do not expect to have alcohol problems: whites, women, higher SES Buchsbaum et al., 1992; Yersin et al., 1995; Wilson et al., 2002.

  30. Hypothetical Patient – Physician survey Missed opportunities “A patient is a married, 38-year-old male/female with recurrent abdominal pains. He/she has intermittently elevated blood pressure, and gastritis visible on gastroscopy, as well as waking up frequently at night and irritability. He/she also reports normal libido, and no previous psychiatric history. Based on this information alone, what are the top five diagnoses that come to mind?” - Survey of a nationally representative sample of 648 primary care physicians CASA: Missed Opportunity, 2000

  31. Hypothetical patient: Top 5 physician diagnoses Missed opportunities CASA, 2000

  32. Missed opportunities Clinician barriers to discussing alcohol with patients CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000

  33. Overcoming barriers Survey on patient attitudes Miller, PM, et al. Alcohol & Alcoholism; 2006

  34. Notes from a phone call: “Called pt to let her know that BH can give her information to help with counseling resources. Pt reported that she was very impressed by the diagram her provider showed her about the safe amount to drink, and after she got home she decided she needed to wean herself off the beer slowly. She reported she was drinking a 12 pack a night, now is down to 5 beers a night and plans to keep decreasing the amount. She also reported she has gotten involved in a community action effort and is stoked about it.”

  35. Prevention and primary care Overcoming barriers “To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.” - Primary Care: Is There Enough Time for Prevention? American Journal of Public Health Yarnall KS, Pollak AI, et al.. 2003

  36. SBIRT and prevention Overcoming barriers SBIRT ranks in the top 5 highest-ranking preventive services, based on effectiveness and clinic burden. • Current levels of SBIRT delivery, meanwhile, are the lowest of comparably ranked services. Leif, et al. 2008

  37. Overcoming barriers Medical home: SBIRT • Vital Signs Study: • Clinicians were 12x more likely to intervene if nurses screened for at-risk drinking as part of vital signs. • Healthy Habits Study: • Clinicians were 3x more likely to intervene with at-risk drinkers if given assessment results by the nurse. Seale et al., Subst Abus., 2005; Seale, et al., Fam. Prac., 2005

  38. Overcoming barriers SBIRT is reimbursable

  39. Clark tells me his drinking 70 beers a week isn’t causing him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

  40. Annual screen • The SBIRT method Brief intervention Full screen Annual screen + + + Brief intervention + referral

  41. Annual screen Annual screen • Quick screen of all patients >18 years old: • Purpose: Identify pts who are likely misusing substances • One alcohol question Misuse • One drug question Healthy

  42. Annual screen: Alcohol Annual screen: Alcohol • Single item question recommended by the NIAAA • Sens: 82% Spec: 79% for risky alcohol use Smith, et al. 2009

  43. Annual screen: Alcohol Standard drinks National Institute on Alcohol Abuse and Alcoholism

  44. Annual screen: Alcohol Standard drinks, cont.

  45. Annual screen: Alcohol Clark’s annual alcohol screen: positive

  46. Annual screen: Drugs Annual screen: drugs • Sens: 93% Spec: 94% for self-reported current drug use. Smith, et al. 2010

  47. Is Clark currently hurting himself with this behavior? • Is he dependent on alcohol?

  48. Full screen • The SBIRT method Brief intervention Full screen Annual Screen + + + Brief intervention + referral

  49. Full screen Full screen The full screen stratifies patients into zones of misuse: Full screen for alcohol (AUDIT) Full screen for drugs (DAST) IV III II I • Zones act as a diagnostic aid and inform intervention

  50. Full screen: Alcohol Full screen: Alcohol • AUDIT(Alcohol Use Disorders Identification Test) • 10 questions - multiple choice • Addresses alcohol only • Created by WHO, accurate across many cultures/nations • Sens: 51% - 97% Spec: 78% - 96% Agency for Healthcare Research and Quality, 2004

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