Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment Project
Research and Data Analysis Division, Washington State Department of Social and Health Services, Olympia, WA 98504-5204, USA. Medical care
(Impact Factor: 3.23).
11/2009; 48(1):18-24. DOI: 10.1097/MLR.0b013e3181bd498f
Substance abuse is a major determinant of morbidity, mortality, and health care resource consumption. We evaluated a screening, brief intervention, and referral to treatment (SBIRT) program, implemented in 9 hospital emergency departments (ED) in Washington State.
Working-age, disabled Medicaid patients who were screened and received a brief intervention (BI) from April 12, 2004 through September 30, 2006 were included in the study's intervention group (N = 1557). The comparison group (N = 1557), constructed using (one-to-one) propensity score matching, consisted of Medicaid patients who received care in one of the counties in which an intervention hospital ED was located but who did not receive a BI. We estimated difference-in-difference (DiD) regression models to assess the effects of the SBIRT program for different patient groups.
The SBIRT program was associated with an estimated reduction in Medicaid costs per member per month of $366 (P = 0.05) for all patients, including patients who received a referral for chemical dependency (CD) treatment. For patients who received a BI only and had no CD treatment in the year before or the year after the ED visit, the estimated reduction in Medicaid per member per month costs was $542 (P = 0.06). The SBIRT program was also associated with decreased inpatient utilization (P = 0.04).
SBIRT programs have potential to limit resource consumption among working-age, disabled Medicaid patients. The hospital ED seems especially well suited for SBIRT programs given the large number of injured patients treated in the ED and the fact that many conditions treated are related to substance abuse.
Available from: Edward Bernstein
- "This failure in sustainability of alcohol SBIRT has occurred despite data suggesting it results in net healthcare cost savings (Estee et al., 2010; Fleming et al., 2002; Gentilello et al., 2005; Zarkin et al., 2003). For example, one study has shown that for every dollar invested in SBIRT, $4.30 in medical costs were saved (Fleming et al., 2002). "
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ABSTRACT: Screening, brief intervention, and referral to treatment (SBIRT) is effective for reducing risky alcohol use across a variety of medical settings. However, most programs have been unsustainable because of cost and time demands. Telehealth may alleviate on-site clinician burden. This exploratory study examines the feasibility of a new Remote Brief Intervention and Referral to Treatment (R-BIRT) model.
Eligible emergency department (ED) patients were enrolled into one of five models. (1) Warm Handoff: clinician-facilitated phone call during ED visit. (2) Patient Direct: patient-initiated call during visit. (3) Electronic Referral: patient contacted by R-BIRT personnel post visit. (4) Patient Choice: choice of models 1-3. (5) Modified Patient Choice: choice of models 1-2, Electronic Referral offered if 1-2 were declined. Once connected, a health coach offered assessment, counseling, and referral to treatment. Follow up assessments were conducted at 1 and 3 months. Primary outcomes measured were acceptance, satisfaction, and completion rates.
Of 125 eligible patients, 50 were enrolled, for an acceptance rate of 40%. Feedback and satisfaction ratings were generally positive. Completion rates were 58% overall, with patients enrolled into a model wherein the consultation occurred during the ED visit, as opposed to after the visit, much more likely to complete a consultation, 90% vs. 10%, χ(2) (4, N=50)=34.8, p<0.001.
The R-BIRT offers a feasible alternative to in-person alcohol SBIRT and should be studied further. The public health impact of having accessible, sustainable, evidence-based SBIRT for substance use across a range of medical settings could be considerable.
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Available from: Sarah Peregrine Lord
- "It is intended to serve as a policy-relevant randomized controlled trial with broad external validity. It builds upon the significant knowledge base acquired in the study of brief interventions in medical settings for alcohol abuse including a well-documented intervention utilizing motivational interviewing (MI) [16-18] and a growing literature that focuses on public health outcomes of BI [19,20]. It is unusual in its focus on providing BIs to individuals with evidence of drug dependence and abuse in primary care. "
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A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.
The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.
This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.
Available from: Terry Horton
- "Patients in a large, federally funded SBIRT study conducted in six states reported decreases in illicit drug and heavy alcohol use subsequent to participation
. Studies of SBIRT in EDs have demonstrated decreased health-care costs and inpatient utilization
 and increased rates of admissions to SUD treatment
. Randomized trials of BI for excessive alcohol use among primary care outpatients
 have shown significant reductions in self-reported drinking. "
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ABSTRACT: Patients with untreated substance use disorders (SUDs) are at risk for frequent emergency department visits and repeated hospitalizations. Project Engage, a US pilot program at Wilmington Hospital in Delaware, was conducted to facilitate entry of these patients to SUD treatment after discharge. Patients identified as having hazardous or harmful alcohol consumption based on results of the Alcohol Use Disorders Identification Test-Primary Care (AUDIT-PC), administered to all patients at admission, received bedside assessment with motivational interviewing and facilitated referral to treatment by a patient engagement specialist (PES). This program evaluation provides descriptive information on self-reported rates of SUD treatment initiation of all patients and health-care utilization and costs for a subset of patients.
Program-level data on treatment entry after discharge were examined retrospectively. Insurance claims data for two small cohorts who entered treatment after discharge (2009, n = 18, and 2010, n = 25) were reviewed over a six-month period in 2009 (three months pre- and post-Project Engage), or over a 12-month period in 2010 (six months pre- and post-Project Engage). These data provided descriptive information on health-care utilization and costs. (Data on those who participated in Project Engage but did not enter treatment were unavailable).
Between September 1, 2008, and December 30, 2010, 415 patients participated in Project Engage, and 180 (43%) were admitted for SUD treatment. For a small cohort who participated between June 1, 2009, and November 30, 2009 (n = 18), insurance claims demonstrated a 33% ($35,938) decrease in inpatient medical admissions, a 38% ($4,248) decrease in emergency department visits, a 42% ($1,579) increase in behavioral health/substance abuse (BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA admissions, for an overall decrease of $37,760. For a small cohort who participated between June 1, 2010, and November 30, 2010 (n = 25), claims demonstrated a 58% ($68,422) decrease in inpatient medical admissions; a 13% ($3,308) decrease in emergency department visits; a 32% ($18,119) decrease in BH/SA inpatient admissions, and a 32% ($963) increase in outpatient BH/SA admissions, for an overall decrease of $88,886.
These findings demonstrate that a large percentage of patients entered SUD treatment after participating in Project Engage, a novel intervention with facilitated referral to treatment. Although the findings are limited by the retrospective nature of the data and the small sample sizes, they do suggest a potentially cost-effective addition to existing hospital services if replicated in prospective studies with larger samples and controls.
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