Presentation Transcript

1. National SBIRT ATTC Advisory Committee Baltimore, MD March 13,, 2013 Eric Goplerud, Ph.D. Senior Vice President Director, Substance Abuse, Mental Health and Criminal Justice Studies goplerud-eric@norc.org 301-634-9525 Screening and Brief Intervention (SBI) – The next frontier for integrating behavioral medicine into medicine, behavioral health into health
2. Who we are: NORC at the University of Chicago NORC is an independent research organization that collects, analyzes, and disseminates objective information to decision makers and the public on key social, economic, and behavioral issues facing the nation and international community. Hospital SBIRT – the next frontier for the opportunistic detection and management of prescription medication misuse
3. Who I am Eric Goplerud, Ph.D. SVP, Director Substance Abuse, Mental Health, Criminal Justice Co-chair, Joint Commission’s Expert Panel, Substance Abuse and Tobacco screening & treatment performance metrics Facilitator of the BIG (Brief Intervention Group) Initiative with EAPs, and the BIG Hospital SBIRT Initiative Led team that secured AMA and CMS approval of new substance abuse screening and brief intervention billing codes Chair, Substance Use Treatment Evidence-Based Practices, National Quality Forum. Former senior policy director, SAMHSA Goplerud-eric@norc.org 301-634-9525
4. Converting evidence based practices into routine care Original research 18% variable Negative results Dickerson, 1987 Submission 46% 0.5 year Kumar, 1992 17 years to apply 14% of research knowledge to patient care! Koren, 1989 Acceptance Negative results 0.6 year Kumar, 1992 Publication 17:14 Expert opinion 35% 0.3 year Poyer, 1982 Balas, 1995 Lack of numbers Bibliographic databases 50% 6. 0 - 13.0 years Antman, 1992 Poynard, 1985 Reviews, guidelines, textbook Inconsistent indexing 9.3 years Patient Care Balas Yearbook Medical Informatics 2000gtre4, courtesy M Overhage
5. "Every single change must be critically important to the CEO or it shouldn't be undertaken” “The changes will not work unless it improves bottom line" "If we try to take all our ideas from inside the field, we just get variants of the same thing. If we want ideas that shake the foundation of our organization, we have to go outside.“ David Gustafson, NIATx What’s needed to accelerate change? An industrial engineering perspective.
6. Science Financing, Reimbursement, Purchaser Expectations Practical demonstrations of effectiveness Performance metrics Education and training systems System change processes Levers for system change
7. 361 controlled studies evaluated at least one treatment for AUD compared it with an alternative condition used a procedure designed to create equivalent groups before treatment reported at least 1 outcome measure of drinking or alcohol-related consequences The Science: Mesa Grande In alcohol treatment research, is the Dodo Bird’s verdict in Alice in Wonderland, true? “everybody has won, so all shall have prizes”. Miller, WR Addiction 2002 97(3)
8. Mesa Grande – the Big Table What we need to do more: SBI, MI, Medications (naltrexone acamprosate), CBT, Social Skills Training
9. Screening, Brief Interventions for Alcohol:Saves Healthcare Costs
10. Finance, Reimbursement and Purchaser Expectations New Procedure Codes - Billing 2007 CMS Medicaid SBI Procedure Codes 2008 AMA CPT SBI Procedure Codes 2008 CMS Medicare SBI Procedure Codes 2012 CMS Medicare SBI Prevention Procedure Codes Levers for system change
11. Ambulatory, ED & Hospital SBIRT Reimbursement Supports
12. Practical Demonstrations of Effectiveness In Settings where Unhealthy or Dependent Use is common
13. Alcohol Disease Management Utilization and Costs to a Health Insurance Plan Rehabilitation facilities days decreased 67% BH inpatient days decreased 68% Medical inpatient days decreased 4% ER visits decreased 24% Partial Hospital and IOP visits decreased 69% Psychiatrist visits increased 44% Therapist visits increased 35% AUDIT score decrease 80% Net total medical cost savings (ROI 2:1) 34% Trauma SBI: Standard Practice “not familiar with” 87% reported no prior training in substance abuse 18% routinely screen BAC < 15% use questionnaires intervention or referral is rare 14 (N = 358, 12 month continuous enrollment prior and post enrollment)
14. Trauma Center RCT: Harborview Medical Center, Seattle October 1994 to November 1997 NIH sponsored RCT patients screened with BAC and questionnaire consent for follow-up only randomized 15 - 30 minute intervention plus follow-up letter standard trauma care Gentillelo et al, 2002
15. Trauma Recidivism - Statewide injury recurrence days follow-up
16. Changes in Alcohol Intake (p = 0.01) 6 month follow-up 12 month follow-up
17. Other Outcomes .83 .84 .77 .56 .50 0.00 0.50 1.00 1.50 2.00 less frequent more frequent
18. Net cost savings -- $89/patient screened, or $330/patient offered a brief intervention Savings of $3.81/$1 spent Potential savings if universal trauma center SBI -- $1.82 billion annually (2000 $)
19. SBI in Hospital Emergency Departments Systematic review of ED SBI 12 RCTs with pre- and post-BI results 11 or 12 observed significant effects on alcohol intake, risky drinking practices, alcohol related negative consequences, injury frequency Nilsen et al, J Sub Ab Treat. 2008
20. Hospitals: SBI for heavy alcohol users admitted to general hospital wards Cochrane Collaboration review (McQueen et al, 2011) 14 RCTs, adults and adolescents Outcomes favor BI over non-treatment controls Significant reduction in 6 month alcohol consumption (69 grams/week) Significant 9 month alcohol consumption (183 grams/week) Not maintained at 1 year Self Report at 1 year favor BI Significantly fewer deaths at 6 months and 1 year
21. Consequences that matter to hospitalsUnstable discharges, rehospitalization risk
22. From perspective of primary care patients with substance use disorders: Most patients (53.7%) say their primary care physician did nothing about their addiction. Less than a third of primary care physicians (32.1%) carefully screen for substance abuse. Nearly 75% of patients say their primary care physician was not involved in their decision to seek treatment. 29.5% of patients said their physicians knew about their addiction and prescribed psychoactive drugs such as sedatives or valium, which could cause additional problems.
23. Adoption slow, but once started practices sustain Limited bandwidth – only so many innovations at a time (about 1) Time considerations Backing up – patient flow Time to manage resistant versus receptive patients Systematic or targeted – eligibility criteria? Lack of treatment referral options Little consensus on favorable outcome Not what the patient came in for Anecdotal Observations from SBIRT programs working with Primary Care
24. Evidence of effectiveness in ambulatory care http://bigsbirteducation.webs.com/apps/videos/
25. Rankings of 25 Preventive ServicesRecommended by the USPSTF Effectiveness& ROI scoring: 1 = lowest; 5 = highest Estimated net savings of $254 per person offered screening Medical care costs only, cost effectiveness ratio of $1,755 per QALY saved Maciosek, Am J Prev Med 2006; Solberg, Am J Prev Med 2008;http://www.prevent.org/content/view/43/71
26. Employee Assistance Programs and Workplace Wellness
27. Impact of Workplace EAP SBI: Cuts risky use in 6 months post SBI Aetna, 2011
28. Post-SBI Productivity Gains = $1,420/month Aetna EAP, 2011. Work Limitations Questionnaire intake, 6 months post.
29. Accreditation and Performance Metrics American College of Surgeons-Committee on Trauma Level I and Level II Trauma Center accreditation includes SBI 203 Level I and 271 Level II Trauma Centers in US Hospitals Survey of current practice under editorial review (Zatzick)
30. Joint Commission Inpatient SBIRT Metrics Hospitalized patients are screened during the hospital stay using a validated screening questionnaire for unhealthy alcohol use Patients who screened positive for unhealthy alcohol use who received or refused a brief intervention Patients identified with SUD receive or refuse at discharge a prescription for FDA-approved medications for SUD, OR receive a referral for addictions treatment Discharged patients who received a SUD diagnosis are contacted within 30 days after hospital discharge
31. Joint Commission SBIRT Measures: Current Status, Expected CMS Endorsement Federal Register, 42 CFR Parts 412, 413, 424, et.al. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates, May 11, 2012:77(92) Part II. http://www.gpo.gov/fdsys/pkg/FR-2012-05-11/pdf/2012-9985.pdf Current Status Adopted by TJC 2011 as reportable measure sets for accreditation NQF review 2012, additional data submitted winter 2013 CMS Inpatient Prospective Payment System Rule (IPPS) “Once the e-specifications and the EHR-based collection mechanism are available for the smoking and alcohol cessations measures developed by TJC, we intend to propose two TJC smoking and alcohol cessation measure sets for inclusion in the Hospital IQR Program.” (p. 715)
32. Ambulatory & ED Alcohol SBI Metrics AMA Primary Care Performance Indicators: Screening & Brief Intervention in ambulatory care – tested, presented for NQF endorsement 2012, Meaningful Use 3 Veterans Health Administration (VA) Mandatory annual screening for alcohol use with AUDIT-C Indian Health Service Emergency Department: Alcohol SBI in IHS hospital EDs, tested
33. System Change Processes:The BIG (Brief Intervention Group) Initiative http://bigsbirteducation.webs.com/ A three-year campaign dedicated to mobilizing the entire EAP industry – businesses, clinicians, EAP companies and experts – to work together to make screening and brief counseling for hazardous alcohol use the routine practice for employers across North America. Involves more than 250 organizations Facilitated by Dr. Goplerud and Dr. McPherson By 2012, EAPs covering more than 75 million lives worldwide routinely screen for risky alcohol use
34. The “BIG” Solution: Routine SBI for risky alcohol use in every EAP Adapt medical procedure – screening and brief intervention (SBI) – to workplaces Create a learning collaborative to share challenges, successes, materials Train clinicians, increase capacity to effectively deliver SBI Change practice! http://bigsbirteducation.webs.com/
35. Collaboration of seven professional associations: Employee Assistance Professionals Association NAADAC - Association for Addiction Professionals Center for Clinical Social Work American Academy of Addiction Psychiatry American Society of Addiction Medicine Employee Assistance Society of North America NORC at the University of Chicago SBI Training Collaborating Partners
36. Advancing SBIRT in Hospitals: A learning collaborative of more than 250 hospitals, health profession organizations, researchers and hospital quality improvement professionals http://hospitalsbirt.webs.com http://www.hospitalsbirt.webs.com/
37. BIG Hospital Network BIG (Brief Intervention Group) Hospital Network Collaborative More than 200 hospitals participating TA & Training & Mutual Support Monthly calls 218-339-4600 426443# August 20, 2012 from 2pm - 3pm EST September 17, 2012 from 2pm - 3pm EST Eric Goplerud – 301-634-9525 goplerud-eric@norc.org http//hospitalsbirt.webs.com
38. Effective Brief Interventions Online Training to Help Primary Care and Behavioral Health Clinicians to Screen and Manage High Risk Substance Use
39. EBI Core Competencies
40. “Lisa” Responds to You
41. Developments: Looking into the near future Standardization of SBIRT Screening, prescreening measures Link with standard protocols for other routinely performed Training availability Remote – MedRespond and other web-based platforms Discipline specific – Nursing, Social Work, EAPs Competency standards Financial and clinical accountability ACO and PCMH Incentives through IPPS, bundled payment EHRs and HIEs Prescreening and management to avoid surgical complications Avoid drug-drug and alcohol-drug interactions
42. Developments Research Hospital SBIRT, Hospital SBIRT with community linkages Drug and prescription opioid SBIRT Nurse-led hospital SBRT Targeted, high risk, high cost inpatients with SUDs Community SA treatment infrastructure development Primary care Medical treatment Community BH and FQHCs
43. Has enough time passed for SBI? “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.” 1990 (22 years ago!) (IOM, Broadening the Base of Treatment for Alcohol Problems, 1990, p. 8)
44. Eric Goplerud Senior Vice President Substance Abuse, Mental Health and Criminal Justice Studies NORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 goplerud-eric@norc.org | office 301-634-9525 | mobile 301-852-8427