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Improving Brief Intervention Reducing Alcohol Related Morbidity and Mortality in Primary Care J. Paul Seale, M.D. Principal Investigator Department of Family Medicine Mercer University School of Medicine Funded by Grant R25 AA014915-01A1 National Institute for Alcohol Abuse & Alcoholism

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improving brief intervention reducing alcohol related morbidity and mortality in primary care
Improving Brief InterventionReducing Alcohol Related Morbidity and Mortality in Primary Care

J. Paul Seale, M.D.Principal InvestigatorDepartment of Family MedicineMercer University School of Medicine

Funded by Grant R25 AA014915-01A1

National Institute for Alcohol Abuse & Alcoholism

National Institutes of Health

co principal investigator
Georgia

Harold DuCloux MD

William McAfee PhD

Randy Robinson MD

Harry Strothers MD

Texas

Carlos Dumas MD

Lisa Davis MD

Rebecca Gladu MD

Robert McClellan MD

Co-Principal investigator

Mary M. Velasquez, PhD, Co-PI

Site Coordinators

module 1 objectives
Module 1 Objectives
  • Describe the importance of alcohol misuse as a health issue
  • Examine the evidence base for alcohol screening and brief intervention (SBI)
  • Outline the rationale for implementing SBI in primary health care
  • Provide an overview of the steps in “Improving Brief Intervention” Project
what is sbi
What is SBI?
  • Screening - identifying patients who are at risk because of their pattern of alcohol consumption
  • Intervention – Assisting patients in achieving abstinence or reducing their drinking to low risk levels
slide5

Relationship between alcohol problems and alcohol use

Problems

Alcohol Use

Severe

Heavy

Moderate

Moderate

Few

Light

None

None

slide6

Who needs attention?

14 million people

5%

Alcohol dependent

slide7

Who needs attention?

47 million people

17%

At Risk drinking

slide8

NIAAA (2005) definition of At risk drinking

  • Men ≤65
    • More than 4 standard drinks in a day &/or
    • More than 14 standard drinks in a week
  • Men>65 and All Women
    • More than 3 standard drinks in a day &/or
    • More than 7 standard drinks in a week

A standard drink is 14 grams of pure alcohol

why is management of alcohol misuse important to family physicians
Why is management of alcohol misuseimportant to Family Physicians?
  • Prevalence
  • Morbidity and Mortality
  • Cost
  • Potential for effective intervention
alcohol misuse is commonly encountered by family physicians
Alcohol Misuse is commonly encountered by Family Physicians
  • 7-20% of primary care patients exhibit patterns of alcohol misuse
  • 30-40% of patients in ERs
  • 50% of trauma patients

Fiellin, et al, 2000; D’Onofrio et al, 1998

prevalence of alcohol misuse in primary care
Prevalence of Alcohol Misuse in Primary Care

Possibly

dependent

5%

Alcohol

Misuse

At Risk

drinkers

17%

Low risk

Drinkers

38%

Abstainers

40%

Manwell, Fleming, Johnson, Barry, 1998

why important morbidity mortality
Why important: Morbidity & Mortality
  • Alcohol is the third leading cause of preventable death in the US (CDC), (76,000 deaths, or 5% of all deaths in 2001)
  • Alcohol is the third leading preventable cause of healthy years lost to death & disability in developed nations (WHO).
slide14

5%

Alcohol Dependent Patients

Significant morbidity, mortality, and economic cost

47 million people

Alcohol dependent

slide15

At risk Drinkers:Why do they need attention?

At risk for short and long term health problems

May put others at risk

47 million people

17%

At Risk drinking

major causes of alcohol related morbidity mortality
Chronic liver disease & cirrhosis

8 specific cancers

Heart disease

Pancreatitis

Stroke

Depression

Injuries

Homicide, suicide

Family Violence

Major Causes of Alcohol-related Morbidity & Mortality

MMWR Weekly Sept 24, 2004/ 53(7); 866-870

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm

Naimi, 2002

morbidity mortality due to chronic alcohol misuse
Morbidity & Mortality due to chronic alcohol misuse
  • 46% of total deaths
  • 35% of years of life lost
  • Leading cause of liver disease
morbidity mortality due to acute alcohol misuse
Morbidity & Mortality due to acute alcohol misuse
  • 54% of total deaths
  • 65% of years of life lost
  • Leading cause of MVAs in US
why important morbidity
Why important: Morbidity
  • Alcohol interacts with many medications
  • Exacerbates numerous chronic medical conditions (HTN, DM, PUD, etc.)
economic cost 185 billion annually
Economic cost: $185 billion annually

Mokdad et al, 2000; Harwood, 2000

increasing patient recognition of alcohol as a health issue
Increasing patient recognition of alcohol as a health issue
  • Expectation that health care providers will give sound advice about alcohol
    • Potential benefits for cardiovascular conditions
    • Potential breast cancer risk among women
what is the evidence base for sbi
What is the Evidence Base for SBI?
  • Does SBI really change patients’ drinking behavior?
brief intervention works
Brief Intervention Works!

SBI meta-analyses & reviews:

  • More than 34 randomized controlled trials
  • Focused primarily on at risk and problem drinkers
  • Result in 10-30% reduction in alcohol consumption at 12 months

Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

net percentage reduction in mean drinks per week uspstf review
Net percentage reduction in mean drinks per week (USPSTF review)
  • 9 high quality studies reviewed
    • 3 single intervention studies resulted in reductions in weekly alcohol consumption ranging from 6-19%
    • 6 multi-contact intervention studies resulted in reductions in weekly alcohol consumption ranging from 7-34%

Whitlock et al, 2004

us preventive services task force sbi recommended for all pc patients
US Preventive Services Task Force: SBI recommended for all PC patients
  • Class B recommendation (flu shots, cholesterol screening, SBI)
  • “…good evidence that screening in PC can accurately identify patients whose levels of alcohol consumption…place them at risk for increased morbidity and mortality”
  • “…good evidence that brief behavioral counseling interventions…produce small to moderate reductions in alcohol consumption”

USPSTF, 2004

slide28

Nursing Involvement Significantly Increases Clinician Intervention Rates

  • 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 alcohol assessment results by the nurse

Seale et al, 2005; Seale et al, 2006

what does this mean for your patients
What does this mean for your patients?

Calculate based on the numbers of adult patients you see per week…

For example, if

  • You see on average 40 patients per week
  • 4-8 of these patients are at risk (10-20%)
  • With brief intervention, 1-3 patients weekly are likely to lower their risk
slide30

Other Benefits of SBI

1. Fewer hospitalizations & ER visits

2. Cost savings

Total benefit: $1170 / patient

Screening & intervention cost: $177 / patient

Benefit: cost ratio: 6.6/1

Fleming, et al, 2002

sbi is underutilized in primary care
SBI is underutilized in Primary Care
  • Less than half of self-reported problem drinkers are asked by their PC physicians about their alcohol consumption or advised to quit drinking or cut back.
  • Most PC physicians prefer not to counsel nondependent problem drinkers themselves.

D’Amico et al, 2005; Spandorfer et al, 1999

baseline screening intervention data from your individual residency program 2006
Baseline Screening & Intervention Data from Your Individual Residency Program, 2006
  • N= patients

__% of patients reported at risk drinking

__% of patients screened for tobacco use by their physicians

__% of patients screened for alcohol use by their physicians

__% reported ever having received intervention for their alcohol use by their physician

__% reported receiving an alcohol intervention on the day interviewed

sbi can be effectively implemented in primary care
SBI can be effectively implemented in Primary Care
  • Effective models exist for implementing screening and brief intervention in residency training.
  • Trained clinicians typically intervene with more than 70% of patients.

Seale et al, 2005; Adams et al, 1998

key to implementation systems approach targeting both the clinicians office system
Key to implementation: Systems approach targeting both the clinicians & office system
  • Train clinicians & clinic staff in SBI
  • Create office system that will support SBI
    • Screening & prompting system
    • Assessment instruments
    • Intervention materials
    • Reminder system for re-assessment & reinforcement
4 basic components of this project s sbi system
4 Basic Components of this project’s SBI system
  • Prescreening of all patients using single question screen
  • Screeningof all prescreen-positive patients using the Alcohol Use Disorders Identification Test (AUDIT)
  • Brochure-based Clinician Interventions for all screen-positive patients
  • Follow-up (re-assessment & reinforcement) at future visits
summary of module 1
Summary of Module 1
  • Alcohol misuse is a major cause of morbidity & mortality in the US
  • SBI is effective in decreasing at risk drinking & its related consequences
  • Clinician training & systems intervention are effective in implementing primary care SBI protocols
  • Training Modules 2-4 will equip this clinic to effectively perform SBI—stay tuned!
module 2

Module 2

The procedures of

Screening and Brief Intervention

objectives for module 2
Objectives for Module 2
  • Describe the four procedures of SBI
  • Practice using and scoring the Healthy Habits Prescreen and the Healthy Lifestyles Screen (AUDIT)
  • Review the steps of the intervention for at risk drinkers
  • Practice conducting an intervention for an at risk drinker (clinicians) or asking a patient to complete the 7-day diary (nursing staff)
4 basic components of this project s sbi system39
4 Basic Components of this project’s SBI system
  • Prescreening (single question screen)
  • Screening(Alcohol Use Disorders Identification Test or AUDIT)
  • Clinician Interventions for all screen-positive patients
  • Follow-up assessment/reinforcement at future visits
slide40

STEP 1: Prescreen is routine part of the vital signsPerformed by nursing staffTool: single alcohol screening question (NIAAA)

single question
Single Question:
  • “How many times in the past year have you had X or more drinks in a day?”
      • X = 5 for men age 65 and under
      • X = 4 for men over 65 and all women
  • Positive screen = one or more times in the past year
3 step process when prescreen is positive
3 Step Process when prescreen is positive
  • Give patient the Healthy Lifestyles Screen (AUDIT), folded in half
  • Ask pt to complete it and give to their clinician
  • Place colored dot on problem list or on patient summary sheet (for clinics with paper charts)
slide45

Expected results of prescreen

85%

negative

Prescreen

Screen (15%)

instrument healthy lifestyles screen audit
Instrument: Healthy Lifestyles Screen (AUDIT)
  • Adapted from World Health Organization
  • Validated in numerous studies worldwide
  • Fits American guidelines for at risk drinking
  • Content
    • 3 Quantity & frequency questions
    • 3 questions probing signs of dependency
    • 4 questions about alcohol-related problems
screening procedures
SCREENING PROCEDURES
  • Patient completes form in exam room
  • Patient gives form to clinician
  • Clinician notes items circled
  • Clinician calculates the score
  • Clinician obtains & documents alcohol & drug history
audit screen scoring
Audit Screen - Scoring
  • Note numbers in top shaded row
  • Enter checked number for each question
  • Enter total score of 10 questions
  • Ask the 3 questions under Provider Use Only (frequency, quantity, drugs)
slide51
View Video One of Nursing staffGivingVital Signs Healthy Habits Prescreen & Healthy Lifestyles Screen (AUDIT)
slide52

Clinicians: Practice scoring Healthy Lifestyles Screen (AUDIT)Nursing staff: Practice giving Vital Signs Healthy Habits Prescreen

step 3 intervention
STEP 3:INTERVENTION
  • Clinician identifies level of intervention based on Healthy Lifestyles Screen (AUDIT) score
  • Clinician conducts the intervention using the blue or red brochure as a guide
stratified intervention protocols
Stratified intervention protocols
  • Blue Brochure (AUDIT score 1-15)
    • At risk drinkers
    • Limited consequences or no consequences from drinking
    • Advice to cut back or quit
  • Red Brochure (AUDIT score 16 or more)
    • Major consequences, possibly dependent on alcohol
    • Focus on abstinence & referral
what brochure is used for these scores
What brochure is used for these scores?
  • Total score 15
  • Total score 22
  • Total score 3
step 4 follow up
Step 4: FOLLOW-UP

Follow-Up Visit

use the Green brochure

  • Nursing staff member administers 7-day drinking diary
  • Clinician conducts green brochure intervention
documentation of diagnoses interventions
DOCUMENTATION OF DIAGNOSES & INTERVENTIONS
  • Problem: Clinicians frequently fail to document alcohol-related diagnoses and interventions
  • Results:
    • Failure to reinforce interventions at future visits
    • Other providers lack important clinical information when caring for these patients
documentation of diagnoses interventions58
DOCUMENTATION OF DIAGNOSES & INTERVENTIONS
  • Goal: Documentation system that
    • Reminds provider to follow up on alcohol consumption
    • Alerts other providers to at risk or problem drinking
    • Protects patients from stigma or discrimination
    • Respects current privacy legislation
documentation procedures nursing
DOCUMENTATION PROCEDURES (NURSING)
  • Nursing staff use coding dots for problem list or patient summary sheet
    • Note: Some practices may use an electronic flag system
documentation procedures clinicians
DOCUMENTATION PROCEDURES (CLINICIANS)
  • Fill out information in Healthy Lifestyles Screen (AUDIT) “Provider Use Only” area according to Zone and interventions accomplished
    • Use AUDIT check boxes to document interventions
    • Provider Signature
  • Document diagnosis & drinking goal in chart
    • Document diagnoses to the highest level of clinical certainty (alcohol use, at risk drinking, alcohol abuse, alcohol dependence)
diagnosis wording coding options clinicians
Diagnosis Wording & Coding Options (CLINICIANS)
  • Preferred: 2007 Medicare & Medicaid Billing Codes
    • H0049 Alcohol/Drug Screening
    • H0050 Alcohol/Drug Service 15 minutes
  • Other Options:
    • Alcohol use (no ICD code)
    • At risk drinking (no ICD code)
    • 305.0 Excessive drinking (episodic), alcohol abuse
    • 303.9 Alcohol dependence, alcoholism
    • V65.42 Counseling on substance use & abuse
    • V69.9 Lifestyle problem
    • V79.1 Special screening for mental disorders (alcoholism)

See DSM-IV diagnostic criteria on pages 2-16 and 2-17

billing options clinicians
BILLING OPTIONS (CLINICIANS)
  • Most interventions involve greater time spent or greater complexity
  • Document and Code for your work! (e.g. 99213, 214, 215)
  • Other option: use V codes from previous slide (reimbursement is lower)
options for protecting privacy confidentiality
OPTIONS FOR PROTECTING PRIVACY & CONFIDENTIALITY
  • Use more general terms describing behavior, not diagnoses
  • File AUDITs in chart areas separate from office notes
  • Place AUDITs in protected areas requiring special release of information
how to use the blue brochure guided discussion of five basic steps
How to Use the Blue Brochure:Guided discussion of five basic steps
  • Picture your drinking
  • Identify problems drinking can cause
  • Discover reasons to quit or cut down
  • Set a drinking limit
  • Offer congratulations
drinking zones using audit scores
DrinkingZonesUsing AUDIT Scores

Major Consequences/

Possibly Dependent

16+

15

At Risk Drinking

Low Risk Drinking

0

Zero

brochures
Brochures

Major Consequences/

Possibly Dependent

Red (Stop) –

6 steps

16+

15

At Risk Drinking

Blue –

5 steps

Low Risk Drinking

Zero

key elements of brief intervention
Key elements of brief intervention
  • Feedback
  • Advice
  • Goal-setting

Whitlock, 2004

US Preventive Services Task Force Guidelines, 2004

important qualitative elements of the alcohol interview
Important Qualitative Elements of the Alcohol Interview
  • Empathy
  • Expression of concern
  • Clear statement of medical need to change
  • Information about appropriate drinking levels
  • Encouragement
advise all patients not to drink
Advise all patients not to drink:
  • When driving or operating machinery
  • When pregnant or considering pregnancy
  • When contraindicated by a medical condition or medication
  • If a history of failed attempts to cut back
slide71

Follow-up procedures (Nursing staff)

  • Note colored dot or electronic flag on chart
  • May skip Vital Signs alcohol prescreen if positive in past 12 months
  • Give Green (Follow-Up) brochure
  • Ask patient to complete drinking diary
  • Ask patient to give brochure to clinician
slide72

View Video Three of Nursing staff Follow-Up Visit giving Green Brochurefor completing Drinking Diary

slide73

Module 2 Practice in Dyads

  • Nurses: Practice giving patient the green brochure and asking patient to complete drinking diary
  • Clinicians: Practice and develop skills in giving brief advice and interventions using Blue Brochure
module 3

Module 3

Establishing office systems

your implementation committee
Your Implementation Committee
  • Introduce Implementation Committee
  • Identify areas of responsibility
  • Suggest channels & procedures for feedback
your clinic team should inform participants how and where to find or access
Your clinic team should inform participants how and where to find or access:
  • Healthy Habits Prescreen sheets (VS)
  • Healthy Lifestyles Screens (AUDITs)
  • Colored dots (for paper charts)
  • Blue & Red brochures
  • Green brochures
  • Detox info sheets
  • Referral resource sheets
module 4

Module 4

Screening and Brief Intervention for Patients with Major Consequences

& Conducting Follow-up Visits

intervention tool red brochure
Intervention Tool: Red Brochure
  • Change of Emphasis—Red=STOP
  • Wording encourages abstinence, not just cutting back, especially in Step 4
slide79

Intervention Outline – Builds on Blue Brochure, adds two steps

  • Picture your drinking
  • Identify problems drinking can cause
  • Discover reasons to quit or cut down
  • Set a drinking limit
    • Questions to assess withdrawal potential
  • Get help
  • Offer congratulations
withdrawal assessment part of step 4
Withdrawal Assessment: Part of Step 4
  • Some people have the following after a day or two without drinking. Have you ever had these symptoms?
    • Sick or shaky
    • Tremors
    • Nausea
    • Heart racing
    • Seizures
    • Seen or heard things that were not there
withdrawal risk moves patient to zone 382
Zone II – Scoring 16+ and no W/D risk

Advice & Red Brochure

Offer menu of additional helps:

Medication

Self-Help Group

Specialist Referral

Follow-up

Zone III – Score 16+

with W/D risk

Advice and Red Brochure

Offer menu of additional helps

Medication

Self-Help Group

Specialist Referral

W/D arranged

W/D option list given

Follow-Up

Withdrawal Risk Moves Patient to Zone 3
two options for addressing potential withdrawal
Two options for Addressing Potential Withdrawal
  • Arrange withdrawal treatment immediately
    • Admission to hospital
    • Transfer to detox unit or treatment center
    • Outpatient detox where appropriate
  • Provide patient with list of resources
  • Be sure to document what you do on the AUDIT in Zone 3
step 5 is new get help
Step 5 is New: Get Help
  • Brochure offers menu of options
    • Medication: (naltrexone, acamprosate, or disulfiram)
    • Self-help group (Alcoholics Anonymous, etc.)
    • Alcohol Specialist Referral
get help procedures
Get Help: PROCEDURES
  • Ask whether patient is interested in any of these 3 options
  • Attempt to make contact with referral sources while patient is still in your office, if possible
  • Provide phone numbers, addresses, etc.
  • Record patient’s contact information where appropriate
slide86

View Video Four Clinician Intervention for Zones 2 & 3 Red Brochure Drinkers with Major Consequences/Possibly Dependent

module 4 practice session 1
Module 4—Practice Session 1
  • Practice and develop skills in giving brief advice and interventions using Red Brochure
step 4 follow up visit goals green brochure
STEP 4FOLLOW-UP VISIT: GOALS (Green Brochure)
  • Review previous agreement and progress
  • Offer relapse prevention hints
  • Review & renew contract
  • Consider referral/additional help if no progress
follow up procedures nursing personnel task
Follow-up procedures (Nursing Personnel Task)
  • Note the colored dot or electronic flag
  • Give Green (Follow-Up) brochure
  • Ask patient to complete drinking diary
  • Ask patient to give brochure to clinician
follow up procedures clinician
FOLLOW-UP PROCEDURES (Clinician)
  • Assess 7-day Drinking Diary
  • Review previous agreement & progress
  • Reinforce positive change
  • Identify drinking triggers
  • Review ways to cope with trigger situations
  • Keep moving forward: review & renew contract
  • Consider referral/additional help if no progress
tips to enhance intervention
Tips to enhance intervention
  • Use an empathic, non-confrontational style
  • Emphasize individual patient’s risk
  • Respect patient’s perspective
  • Avoid labeling (use terms “at risk”)
  • Encourage
    • “You can do it”
    • “Don’t give up”
dealing with time pressure
Dealing with Time Pressure
  • Key components: feedback, advice, and contracting
  • In 1 minute, most clinicians can do the following:
    • Tell patients they are at-risk because of their level of consumption
    • Give the blue brochure and point out healthier drinking limits
    • Ask patient to read the brochure and consider cutting back to the healthier limits
    • Offer to discuss this further at a future follow-up visit