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The Trauma Surgery Perspective. Alcohol Screening and Intervention:. Larry Gentilello, MD Professor of Surgery, Management, Policy, and Community Health University of Texas Dallas, Texas. Alcohol-Related Mortality. 40,933. Injuries. (CDC - MMWR, 2004).

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Alcohol screening and intervention l.jpg

The Trauma Surgery Perspective

Alcohol Screening and Intervention:

Larry Gentilello, MD

Professor of Surgery,

Management, Policy, and Community Health

University of Texas

Dallas, Texas


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Alcohol-Related Mortality

40,933

Injuries

(CDC - MMWR, 2004)


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Years of Potential Life Lost - YPLL’s

Alcohol - Related Diseases

2,279,322

Chronic

Disease

Injuries

(CDC - MMWR, 2004)


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Alcohol and Trauma

(Gentilello, Am J Surg 1988)


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Positive Alcohol Screens


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(Gentilello, Am J Surgery, 1988)


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Standard Practice

instrument

“not familiar with”

  • 87% reported no prior training in substance abuse

  • 18% routinely screen BAC

  • < 15% use questionnaires

  • intervention or referral is rare

(Danielson, Gentilello, et al, Archives of Surgery, 1999)


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Trauma Recidivism

  • 5 year follow-up of 246 patients

    • 40% readmission rate

    • 20% mortality rate

    • 77% of deaths due to continuing substance abuse

(Sims, et al, J Trauma)


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Severity of Alcohol Problems

Dependent drinking/Alcoholism

Harmful drinking/Abuse

severity

Risky/Hazardous drinking

Safe drinking

abstinent


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Brief Intervention Outcomes

1,735 patients

percent days abstinent

drinks per drinking day


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(Miller WR, 1995)


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Cost-Effectiveness

effectiveness

cost


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(Miller WR, 1995)


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Drinking Pyramid

Goals

Types of Drinkers

Prevalence in US

.

Referral to treatment

~ 5 %

Alcohol Dependent

Brief Intervention

Risky or Harmful

~ 25%

Low Risk or

Abstinent

No intervention

~ 70%


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Do you think this patient will change his drinking or reduce his risk as a result of this conversation?


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MOTIVATIONAL INTERVIEWING

  • No confrontation, labeling, stereotyping

  • Ask open-ended questions

  • Reflective listening to encourage talk about drinking

  • Offer information in a non-personal manner.

  • Make connection between drinking and ED visit

  • “What do you like about drinking?”

  • “What do you like less about drinking?”


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Hypothesis

Alcohol interventions as a routine component

of trauma care will reduce subsequent

alcohol intake, and decrease the

rate of trauma recidivism


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Alcohol Interventions in a Trauma Center

  • Study design

    • 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


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Follow-up

  • Objective

    • Harborview ED records for one year after discharge

    • statewide database of all trauma admissions

    • police department records

    • Department of Licensing records (motor vehicle)

  • Self-report

    • 6 and 12 month patient interviews

    • corroboration interviews with family members


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Patient Enrollment

eligible trauma patients

3,358

screened

2,524

screened negativescreened positive

1,371 (54%) 1,153 (46%)

randomized

762 (66%)

controlintervention

396 366


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Baseline Characteristics


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Trauma Recidivism - HMC

injury

recurrence

days follow-up


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Trauma Recidivism - Statewide

injury

recurrence

days follow-up


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Changes in Alcohol Intake

(p = 0.01)

6 month follow-up

12 month follow-up


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Changes in Alcohol Use at One Year


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Other Outcomes

.83

.84

.77

.56

.50

0.00

0.50

1.00

1.50

2.00

less frequentmore frequent


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Trauma Center Requirements

  • Physical therapy

  • Occupational therapy

  • Vocational therapy

  • Speech therapy

  • Spinal chord therapy

  • Nutritional therapy

  • Play therapy

  • Alcohol therapy?


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Trauma Center Designation

Chapter 18- Prevention

The trauma center must have a mechanism to identify patients who are problem drinkers.

The trauma center must have a mechanism to provide an intervention for patients identified as problem drinkers.


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Financial Costs in Colorado

Failure to do SBIRT in ER’s cost CO businesses and residents $39 million each year in health care expenses

Estimated Annual Savings from Treating CO Emergency Patients for Alcohol Problems

*Goplerud E. et al. http://www.ensuringsolutions.org.


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2008 CPTCommon Procedure Terminology

  • New codes published Nov 2 in 2008 CPT Manual

    • 99408

      • Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

    • 99409   

      • greater than 30 minutes

  • Separate or added service

  • Majority of major commercial health plans

  • agree to pay in 2008


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New CMS Codes for SBI

  • New codes Medicaid codes

    • H0049 Screening

    • H0050 Brief Intervention

  • New Medicare codes

    • G0396 SBI > 15 minutes

    • G0397 SBI > 30 minutes


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Reimbursement for SBI


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Medicaid Code Adoption

UPPL Status as of 2000

WASHINGTON

WASHINGTON

NORTH

NORTH

MINNESOTA

MINNESOTA

MAIN

MAIN

MONTA

MONTA

N

NA

DAK

DAK

OTA

OT

E

E

A

A

V

V

OREGON

OREGON

T

T

N

N

WISCONSIN

WISCONSIN

MASS

MASS

H

H

SOUTH

SOUTH

IDAHO

IDAHO

DAK

DAK

OT

OTA

NEW

NEW

MICHIGAN

MICHIGAN

WYOMING

WYOMING

RI

RI

YO

YORK

RK

CONN

CONN

IOWA

IOWA

PE

PE

N

N

NE

NE

NEBR

NEBRA

A

SK

SKA

JERSE

JERSE

N

N

W

W

NEVADA

NEVA

D

OHIO

OHIO

A

Y

Y

DELAWA

DELAWA

R

R

A

INDIAN

INDIAN

ILLINOIS

ILLINOIS

E

E

UT

UT

AH

A

A

A

COLORADO

COLORADO

MARY

MARY

L

L

A

A

N

N

W

W

D

D

V

V

KANS

KANS

A

AS

VIRGINIA

VIRGINIA

MISSOURI

MISSOURI

S

KEN

KEN

T

T

U

U

CK

CK

CALIFOR

CALIFORNIA

NIA

NORTH

NORT

H

Y

Y

CAROLI

CAROLI

N

N

TENNESS

TENNESS

E

E

A

A

ARIZO

ARIZO

N

NA

ARK

ARK

A

A

NS

NS

A

A

E

E

OK

OK

L

L

AHO

A

MA

SOU

SOU

T

T

A

S

S

CAROLI

CAROLI

N

N

H

H

NEW MEXICO

NEW MEXICO

A

A

MISS

MISS

GEORGIA

GEORGIA

AL

AL

A

A

BA

BA

M

M

A

A

TEX

TEX

AS

A

S

FLORIDA

FLORIDA

LOUISIANA

LOUISIANA

ALA

ALA

SK

SK

A

A

HAWAII

HAWAII

States that have adopted H codes

States considering adoption of H codes


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Joint Commission Undertakes Development of Standards for SBI

To further advance the expansion of the continuum of healthcare to include SBI, the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) has decided to undertake the development of standards for screening and brief intervention for alcohol and other drugs. The Joint Commission standards are generally developed with input from healthcare professionals, providers, measurement experts, consumers, government agencies and employers. As such, because of your expertise on SBI, you are being asked to collaborate with the Joint Commission in the development of standards and quality improvement for SBI.


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Summary

  • SBIRT prevents repeated injuries

  • SBIRT saves money

  • Trauma centers are the first to require SBIRT

  • Billing codes are available

  • Making it routine hospital care is next


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Message to Trauma Patients

Make not thyself helpless drinking in

the beer shop, falling down.

Thy limbs will be broken, and no one

Will give thee a hand to help thee up

Egyptian Papyrus, 1500 BC


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