Candidate Performance Measures for Screening for, Assessing, and Treating Unhealthy Substance Use in Hospitals: Advocacy or Evidence-Based Practice?
Boston Medical Center, Boston University School of Medicine, and Boston University School of Public Health, Boston, Massachusetts 02118, USA. Annals of internal medicine
(Impact Factor: 17.81).
07/2010; 153(1):40-3. DOI: 10.1059/0003-4819-153-1-201007060-00008
The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care.
Available from: PubMed Central
- "http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/). An additional barrier is the lack of an unambiguous tool for monitoring the quality of SBIRT, which ideally should include assessment of core brief intervention components rather than non-specific provider or patient report of alcohol counseling [6,95]. Interestingly, implementation of a performance measure and electronic reminders were each associated with an increase in the receipt of brief intervention in outpatient VA settings , and this type of strategy has the potential to enhance SBIRT performance in the hospital . "
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ABSTRACT: There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.
Available from: Terry Horton
- "Randomized trials of BI for excessive alcohol use among primary care outpatients
 have shown significant reductions in self-reported drinking. Data from screening and BI (SBI) for primary care outpatients with unhealthy nondependent alcohol use
 led the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to include performance measures for its use in hospitals
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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.
Available from: Keri Lyn Rodriguez
- "The alcohol-related standards approved by the Joint Commission in July 2011 [18,19] generated considerable controversy during their pilot-testing and development, in part due to concerns about the lack of solid and consistent evidence for the efficacy of all three components of alcohol S, BI, and RT in hospitalized patients [35,36]. This evidence will be essential for healthcare provider and hospital administrator buy-in during implementation initiatives. "
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Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.
We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.
A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.
RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.
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