A Look at the Evidence – and Gaps to Address Richard L. Brown, MD, MPH Director of WIPHL Professor of Family Medicine & Community Health School of Medicine and Public Health University of Wisconsin CEO and Chief Medical Officer, Wellsys LLC SBIRT: wellsys.biz
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A Look at the Evidence – and Gaps to Address
Richard L. Brown, MD, MPH Director of WIPHL
Professor of Family Medicine & Community HealthSchool of Medicine and Public Health
University of WisconsinCEO and Chief Medical Officer, Wellsys LLC
SBIRT:
wellsys.biz
R i c h a r d L . B r o w n , M D , M P H - “ R i c h ”
22 years of practice as a family doctor Tenured Professor at UW since 1990 NIH-funded researcher Past President, AMERSA AMERSA McGovern Awardee Director, Project MAINSTREAM Director, Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL)
Results: Patient satisfaction: 4.3 to 4.9 of 5 points
Bingedrinking
20%
Marijuanause
15%
Depressionsymptoms
55%
Wisconsin Initiative toPromote Healthy Lifestyles
Brown, American Journal of Managed Care, 2014; Paltzer, unpublished
Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs
Conflict of Interest Disclosure
Owner and CEO of Wellsys, LLC (wellsys.biz)
Provides training, consultation and software to help healthcare settings and workplaces deliver SBIRT and similar services for other behavioral risks and disorders
This presentation will be evidence-based
4
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
Intervention
Referral to treatment
Brief treatment
Implementation & spread
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
6
Intervention
Referral to treatment
Brief treatment
Implementation & spread
7
No addiction Addicted Abstinent x 1 mo
Addicted Abstinent x 2 yr
Loss of control Cravings
Preoccupation
Drinking and Drug Use Continuum
Not dependent DepAbsti-nence Dep
Low riskuse
High riskuse
Problemuse
8
Need for SBIRT - US Adults
(Use in Past Month)
Binge alcohol use
25%Illicit drug use
9%Marijuana use
7%Other illicit drug use
3%SAMHSA, National Survey on Drug Use and Health, 2012-2013
About 1 in 3 adults would benefit from
alcohol or drug services
Prevalence of Alcohol/Drug Disorders
– US Adults –
9
Alcohol Drugs
7.1% 2.6%
Abuse or Dependence
SAMHSA, National Survey on Drug Use and Health, 2012-2013
10
Alcohol
Untreated: 95%
Treated: 5%
Untreated: 89%
Treated: 11%
Receipt of Alcohol/Drug Treatment
– US Adults –
Drugs
SAMHSA, National Survey on Drug Use and Health, 2012-2013
Economic Impacts - $412 Billion
11
$11B
$120B$61B
$34B
$161B
$25BAlcohol
Drugs
Healthcare
Productivity
Other Societal
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
12
Intervention
Referral to treatment
Brief treatment
Implementation
13
SBIRT OverviewScreen
Brief Assessment
Abstinence or low risk
High risk or mild to moderate disorder
Dependence orsevere disorder
Brief Intervention Referral to Treatment
Follow-up and Support
(Brief Treatment)
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
14
Intervention
Referral to treatment
Brief treatment
Implementation & spread
15
Screening
Indicates who MIGHT be at risk or have a disorder
Enhances efficiency of SBIRT by quickly identifying those needing no additional services
Ideally minimizes false negatives, allowing more false positives
16
Alcohol Screening - CAGE
Cut downAnnoyedGuiltEye-opener
- Misses riskydrinking
- Other screensare brieferand moreaccurate
17
Alcohol Screening - AUDIT-C0 1 2 3 4
1 How often do you have a drink containing alcohol?
Never Monthlyor less
2 - 4 timesa month
2 - 3 times a week
4 or more times a week
2 How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3 How often do you have more thanX drinks on one occasion?
Never Less than monthly
Monthly Weekly Daily or almost daily
Posit ive screen: ≥4 points for men, ≥3 points for women
How many times in the past year have you had more than 4 drinks in an occasion?
18
__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times
How many times in the past year have you had more than 3 drinks in an occasion?
How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?
19
__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times
Modified from: Smith, Archives of Internal Medicine, 2010
Drug Screening -Single Alcohol Screening Question
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
20
Intervention
Referral to treatment
Brief treatment
Implementation & spread
21
0 1 2 3 41 How often do you
have a drink containing alcohol?
Never Monthlyor less
2 - 4 timesa month
2 - 3 times a week
4 or more times a week
2 How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3 How often do you have more thanX* drinks on one occasion?
Never Less than monthly
Monthly Weekly Daily or almost daily
AUDIT - Questions 1 to 3
* For X, substitute 3 for women, 4 for men
22
4 How often during the last year have you found that you were not able to stop drinking once you had started?
5 How often during the last year have you failed to do what was normally expected of you because of drinking?
6 How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?
7 How often during the last year have you had a feeling of guilt or remorse after drinking?
8 How often during the last year have you been unable to remember what happened the night before because of your drinking?
0 1 2 3 4Never Less than
monthlyMonthly Weekly Daily or
almost daily
AUDIT - Questions 4 to 8
23
9 Have you or someone else been injured because of your drinking?
10 Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
0 2 4No Yes, but not in
the last yearYes, during the last year
AUDIT - Questions 9 to 10
24
AUDIT - Scoring
PointsInterpretationMen up to
age 64Women and older men
0 to 7 0 to 6 Low risk - reassure
8 to 15 7 to 15 Medium risk - intervene
16 to 19 Medium high risk – intervene & follow
20 to 40 High risk – refer for assessment
25
DAST - Questions 1 to 5
In the past 12 months … PointsYes No
1 Have you used drugs other than those required for medical reasons? 1 0
2 Do you abuse (use) more than one drug at a time? 1 0
3 Are you always able to stop using drugs when you want to? 0 1
4 Have you had “blackouts” or “flashbacks” as a result of drug use? 1 0
5 Do you ever feel bad or guilty about your drug use? 1 0
26
DAST - Questions 6 to 10
In the past 12 months … PointsYes No
6 Has your spouse or parents ever complained about your involvement with drugs? 1 0
7 Have you neglected your family because of your use of drugs? 1 0
8 Have you engaged in illegal activities in order to obtain drugs (other than possession)? 1 0
9 Have you experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 1 0
10 Have you had medical problems as a result of your drug use (eg, memory loss, hepatitis, convulsions, bleeding, etc …)? 1 0
27
DAST - Scoring
Score Extent of Problems Related to Drug Use
Recommended Clinical Service
0 None Reinforcement1 Low Brief Intervention (BI)2 Low BI
3 to 5 Moderate BI and Follow-up6 to 8 Substantial Referral for Assessment
9 to 10 Severe Referral for assessment
AUDIT & DAST - Advantages & Disadvantages
Advantages- AUDIT is well validated in many countries - AUDIT is translated into many languages - AUDIT and DAST scores guide subsequent service delivery
Disadvantages- DAST is not well validated in primary care/general populations - Some DAST items are poorly worded - Scores mask important differences in symptom patterns - Feedback on scores is meager
28
Alternative Brief Assessment
Alcohol, Substance and Smoking Involvement
Screening Test (ASSIST)
Quantity-Frequency questions on alcohol
29
NIDA-ASSIST
For tobacco, alcohol and 10 categories of drugs: Lifetime use Use in past 3 months Strong desire or urge Health, social, legal or financial problems Failed to do what was normally expected Friend or relative expressed concern Loss of control
Final question on injection use30
NIDA-ASSIST
For each category: low, moderate and high risk Focus on tobacco might increase acceptance Same questions for tobacco, alcohol and drugs Complicated skip patterns - best delivered by computer
Does not distinguish dependence well
31
Alternative Brief Assessment
Quantity-Frequency questions
Short Index of Problems (SIP) or
Short Index of Problems-Alcohol & Drugs (SIP-AD)
Severity of Dependence Scale (SDS)
32
Quantity-Frequency Questions
Alcohol:- Days per week in the last month (X)- Standard drinks on an average drinking day (Y)- Maximum standard drinks - past 3 months (Z)
- (X) x (Y) = average standard drinks per week High risk: >14 for men, >7 for women
- (Z) = maximum consumed in a day High risk: > 4 for men, >3 for women
Drugs:- Days per week in the last month for each substance
SIP-AD (Short Index of Problems - Alc/Drugs)
Over the last 12 months …
1. have you been unhappy because of your drinking or drug use?
2. lost weight or not eaten properly because of your drinking or drug use?
3. failed to do what is expected because of your drinking or drug use?
Never(0)
Once or afew times
(1)
Once ortwice a week
(2)
Daily oralmost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
4. has your personality changed for the worse when drinking or using drugs?
5. have you taken foolish risks when drinking or using drugs?
6. you said harsh or cruel things to someone when drinking or using drugs?
Over the last 12 months …
Never(0)
Once or afew times
(1)
Once ortwice a week
(2)
Daily oralmost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
7. have you done impulsive things you regretted when drinking or using drugs?
8. have you had money problems because of drinking or drug use?
9. has your physical appearance been harmed because of drinking or drug use?
Over the last 12 months …
Never(0)
Once or afew times
(1)
Once ortwice a week
(2)
Daily oralmost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
10. has your family been hurt by your drinking or drug use?
11. has a friendship or close relationship been damaged by your drinking or drug use?
12. have you lost interest in activities or hobbies because of your drinking or drug use?
Over the last 12 months …
Never(0)
Once or afew times
(1)
Once ortwice a week
(2)
Daily oralmost daily
(3)
SIP-AD (Short Index of Problems - Alc/Drugs)
13. has your drinking or drug use gotten in the way of your personal growth?
14. has your drinking or drug use damaged your social life, popularity or reputation?
15. have you spent too much money or lost money because of your drinking or drug use?
Over the last 12 months …
Never(0)
Once or afew times
(1)
Once ortwice a week
(2)
Daily oralmost daily
(3)
SDS - Severity of Dependence Scale
Never or almost never
(0)
Some-times
(1)
Once ortwice a week
(2)
Always oralmost always
(3)
1. do you think your use of ___ was out of control? 2. has the prospect of missing a drink/fix/dose made
you anxious or worried? 3. have you worried about your drinking/use of ___? 4. have you wished you could stop drinking/using ___?
Over the last 12 months …
SDS - Severity of Dependence Scale
5. How difficult do you find it to stop or go without ____?
Notdifficult
(0)
Quitedifficult
(1)
Verydifficult
(2)
Impossible
(3)
Adults: Total score of 3 or more = likely dependent Teens: Total score of 4 or more = likely dependent
Brief Alcohol and Drug Assessment
Questionnaire Assesses for Category, if positiveQ/F High risk use At least
high risk use
SIP-AD Negative consequences
At leastproblem use
SDS Dependence Likely dependence
Gap in Screening/Assessment Studies
Typical StudyClinical
environmentResearch
environmentRecruit subjects ✓
Administer instrument to be tested ✓
Apply “gold standard” diagnostic process ✓
Research Question When responses to the instrument are not shared with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?
Gap in Screening/Assessment Studies
Typical Studies Needed StudiesClinical
environmentResearch
environmentClinical
environmentResearch
environmentRecruit subjects ✓ ✓
Administer instrumentto be tested ✓ ✓
Apply “gold standard” diagnostic process ✓ ✓
Research Question When responses to the instrument are not shared with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?
When responses to the instrument are sharedwith clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?
Two-Item Conjoint Screen (TICS)
1. In the last twelve months, have you ever drunk alcohol or used drugs more than you meant to? __ Yes __ No
2. In the last twelve months, have you felt you wanted or needed to cut down on your drinking or drug use? __ Yes __ No
Single AlcoholScreening Question
Single DrugScreening Question
Two-ItemConjoint Screen+ +
WIPHL: Adding the TICS to the screen for risky/problem drinkers - Increases identification of drug users from 80% to 90%, as
compared to the ASSIST - Reduces false negatives by half
45
WIPHL’s Experience
Among patients who saw WIPHL health educators and participated in confidential 6-month follow-up phone calls - Higher reports of lifetime substance use when information was not shared with clinicians
Adding the TICS to the screen for risky/problem drinkers- Increased identification of drug users from 80% to 90%, as compared to the ASSIST- Reduced false negatives by half
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
46
Intervention
Referral to treatment
Brief treatment
Implementation & spread
Alcohol Interventions - Effectiveness
Dozens of studies and several meta-analyses: 10% to 30% declines in binge drinking Declines last up to 4 years with 1 to 3 booster sessions Reductions in
- Injuries - Vehicular crashes - Hospitalizations and ED visits - Deaths - Arrests
$3 to $4 reductions in healthcare costs per $1 spent National Commission on Prevention Priorities:
4th most effective and cost-effective preventive service
Drug Interventions - Effectiveness
Zgierska A, Amaza IP, Brown RL, Mundt M, Fleming MF. Unhealthy drug use: How to screen, when to intervene. Journal of Family Practice 2014; 63:524-540.
Review of prior studies: Randomized controlled trials General healthcare settings Population-wide screening
5 studies
Drug Interventions
Bernstein et al- Screened 23,699 adults in urgent care, women's health and homeless clinics with the DAST- Randomized 1,175 patients to single BI session vs. brochure - Conducted follow-up at 6 months
49Bernstein et al, Drug & Alcohol Dependence, 2005
P r o p o r t i o n A b s t i n e n tp-value
Brochure Brief Intervention
Cocaine 17% 22% 0.045
Heroin 31% 40% 0.050
Drug Interventions
Zahradnik et al- Screened 6,000 internal medicine, surgical or GYN inpatients - Randomized 126 patients with prescription drug misuse or dependence to a 2-session intervention vs. a brochure
50Zahradnik et al, Addiction, 2009; Otto et al, Drug & Alcohol Dependence, 2009
Proportion with ≥25% ReductionBrochure Brief Intervention p-value
3 months 30% 52% 0.01712 months 49% 50% 0.833
Drug Interventions
Humeniuk et al- Screened primary care patients in Australia, Brazil, India & USA - Randomized 731 marijuana, cocaine, amphetamine and opioid users at moderate risk, according to the ASSIST, to brief intervention vs. usual care
51Humeniuk et al, Addiction, 2012
0%
10%
20%
30%
Australia Brazil India USA
20%10%9%
2%11%
24%25%17% Brief Intervention
Usual care
Decline in ASSIST Scores - 3 Months
Drug Interventions
Saitz et al- Screened 1,504 primary care patients at an inner city hospital - Randomized 528 patients to control, brief intervention (10 to 15 minutes) and modified motivational intervention (30 to 45 minutes)
52
048
1216
Control BI MMI
14.114.213.8 13.815.114.3
Baseline6 months
Days of Use of Primary Drug in Past 30 Days
Saitz et al, JAMA, 2014
Drug Interventions
Roy-Byrne et al - Screened 10,337 patients at 7 Washington State safety-net clinics- Randomized 868 patients to • Face-to-face BI + phone F/U • Usual care + brochure
53Roy-Byrne et al, JAMA, 2014
Another negative study …
54
Kaner et al
55
29 primary care practices in England - urban, suburban, rural - socioeconomically diverse communities - affluent to impoverished - culturally diverse patients
Eligible patients - New or seeking help for mental health, GI, hypertension or minor injury - Positive alcohol screen - Ages 18+ - Live within 20 miles of practice - Not seeking help for drinking
“Alcohol screening and intervention did not decrease the percentage of patients drinking to excess”
59
“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA
Why might the Kaner study be negative?
60
2. “Only 57% of patients in the brief lifestyle counselling group actually received the intervention, which could have reduced its potential impact.”
3. “It is possible that the lack of intervention differences may have been due to unsuccessful implementation of the brief intervention protocols by the primary care clinicians.”- Training: epidemiology, standard drinks, demonstrations of screening and intervention, role plays, assurance of competence via skills checklist - Fidelity: “The issue of intervention fidelity will be explored in an in-depth qualitative (interview based) process study with clinicians from this trial, which occurred after patient follow-up was completed.”
1. “Recruiting individuals into the study might reduce their drinking.”
61
Not a study of effectiveness of alcohol screening and intervention
A study of effectiveness of training primary care physicians and nurses to deliver alcohol screening and intervention, where patients with risky or problem drinking are invited back for one intervention session
Kaner et al: The Bottom Line
62
Characteristics of Subjects in Recent Drug Intervention TrialsSaitz
- Age: 41 ± 12 years (mean ± standard deviation) - Never married: 62% - Medicaid or Medicare: 81% - Mood disorder: 46% - Self-help group participation in past 3 months: 18% - Residential addiction treatment in past 3 months: 8%
Roy-Byrne - Age: 48 ± 11 years (mean ± standard deviation) - 19% married - 9% employed, 64% disabled - 56% have diagnosed mental illness - 30% homeless for ≥1 night during the past 90 days - 30% DAST score of ≥7
Brief drug interventions appear ineffective for urban populations with high rates of- poverty - social instability - disability - mental health disorders - drug dependence
They may be effective for other general healthcare populations.
63
WIPHL’s Experience
15% decline in marijuana use among 100+ patients- Pre-intervention - health educator interview in clinical settings - Post-intervention - researcher interview not shared with clinicians, in which patients reported higher lifetime substance use
Binge Drinking and Drug Use areMajor Problems for Employers
64
US Binge Drinkers - 2010
Employed
75%
SAMHSA, National Survey on Drug Use and Health, 2010
US Adult Drug Users - 2010
EmployedFull Time
48%
EmployedPart Time
18%
Out of Labor Force21%
Unemployed 13%
Employed
66%
Alcohol Screening and Intervention:Cost SavingsFleming et al, 2000 (Project TrEAT): $523 reduction in healthcare costs over the next year for $205 spent per primary care patient receiving an intervention
Estee et al, 2010 (WASBIRT): $4,392 net reduction in healthcare costs over the next year per disabled Medicaid patient receiving SBIRT in Washington State EDs
Paltzer et al, 2015 (WIPHL): $546 net reduction in healthcare costs over the next 2 years per Medicaid patient screened in Wisconsin primary care settings
Rankings of USPSTF Preventive Services
66Search: National Commission on Prevention Priorities
Which services would best … prevent disease, injury and death reduce healthcare costs?
Meta-analysis of 13 studies on receipt of alcohol services after intervention:- RCTs in medical settings- Non-treatment seeking patients with unhealthy drinking - Linkage to alcohol services- English language
9 studies in US, others in Australia, France, Germany, Poland
Results: No effectiveness for … - All patients - High-severity patients
69Glass, Addiction, 2015
70
WIPHL’s Experience
Of about 1,500 substance-dependent patients identified in general healthcare settings by screening and the ASSIST
completed an assessment or initial treatment session at a treatment program, despite availability of funding for patients who couldn’t afford treatment
o n l y 1 0 %
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
71
Intervention
Referral to treatment
Brief treatment
Implementation & spread
Brief Treatment
A few to several sessions intended to motivate, implement and sustain change Blurs with brief intervention plus follow-up For patients with moderate disorder For patients severe disorder who cannot or will not obtain treatment Ideally delivered in general healthcare settings
73
“Less than a third of all people with alcohol problems receive treatment of any kind, and less than 10 percent are prescribed medications.”
75
SBIRT OverviewScreen
Brief Assessment
Abstinence or low risk
High risk or mild to moderate disorder
Dependence orsevere disorder
Brief Intervention Referral to Treatment
Follow-up and Support
(Brief Treatment)
SBIRT - Adjusting the Model
Screen
Brief Assessment
Abstinence or low risk
High risk or mild to moderate disorder
Dependence orsevere disorder
Brief Intervention Referral to Treatment
Follow-up and Support
On-site medication-assisted therapy
Outline
The problem
SBIRT - an overview
Screening
Brief assessment
77
Intervention
Referral to treatment
Brief treatment
Implementation & spread
Few Americans Receive Evidence-Based SBIRT
CDC:1 in 6 Americans talked about their drinking with their healthcare
providers in 2011
National Survey on Drug Use and Health: 72% of Americans underwent alcohol screening in 2013 Most with risky/problem drinking got no intervention
78http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html Glass et al, Unpublished, 2015
79
Prevalence – US Adults
The Problem:>40% of Deaths and Most Chronic Disease
CDC, Behav iora l R isk Factor Surve i l lance System, 2013; SAMHSA, Nat iona l Survey on Drug Use and Hea l th , 2013
Results: Patient satisfaction: 4.3 to 4.9 of 5 points
Bingedrinking
20%
Marijuanause
15%
Depressionsymptoms
55%
Wisconsin Initiative toPromote Healthy Lifestyles
Brown, American Journal of Managed Care, 2014; Paltzer, unpublished
Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs
Spreading SBIRT: What Hasn’t Worked
Facilitators and Barriers to Spread
87
Possible Facilitators BarriersMedicare and the ACA → ↑reimbursement
- Reimbursement for services by paraprofessionals is patchy. - Reimbursement is inadequate incentive.
Accountable care organizations (ACOs)
- Most are busy establishing infrastructure and addressing high-cost patients. - Fee-for-service reimbursement will continue to dominate for years.
Patient-Centered Medical Homes (PCMHs)
- PCMH recognition does not require delivery of SBIRT or medication-assisted therapy for alcohol or opioid dependence.
Joint Commission quality metrics on SBIRT
- Use of these quality metrics is optional.
Healthcare organizations are overwhelmed with current
mandates for changeImprovements in
behavioral healthcare mustcompete with those mandates
The Quote Out of Context
88
“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA
The Full Quote“SBIRT is dead in the water.”Mark Willenbring, MDAddiction Psychiatrist, Allina HealthFormer Director, Division of Treatment and Recovery Research, NIAAA
“Why SBIRT is Dead in the Water … Until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT [is] DOA …”
90
Current quality metrics can be metwithout evidence-based service delivery
Completion of screening or brief validated assessment questionnaires 3
Intervention delivery 3
Referral delivery 2
Pharmacotherapy recommendation 2
Follow-up contact 1
Treatment initiation and engagement 2
Drinking outcomes 0
TOTAL 11
Brown & Smith, American Journal of Medical Quality, 2015
}Measuresindicatewhetherservices aredelivered,not how well
Irecd = # of patients who received an appropriate intervention (including referral and pharmacotherapy)
Of patients recognized with risky, problem or dependent drinking, how many received the appropriate intervention (including referral and pharmacotherapy for dependence)?
A+ = # of patients whose assessment was positive
Population-Level Quality Measure for SBIRT
Brown & Smith, American Journal of Medical Quality, 2015
• 75% of eligible patients were screened • 75% of patients with + screens completed brief assessments • 75% of patients with + assessments received appropriate intervention • 75% of patients who received appropriate intervention reduced their
risky drinking as expected
Q = .75 x .75 = .32x .75 x .75
Population-Level Quality Measure for SBIRT
Brown & Smith, American Journal of Medical Quality, 2015
97
Payer withholds 2% of all revenue through each year True-up at end of year is based on quality metric performance on SBIRT and other behavioral services:
Pay-for-Performance Program
Modeled after Medicare’s End Stage Renal Disease Quality Incentive Program
Performance At end of year,payer pays… Net
Poor Nothing Loss of 2% of revenueFair 1% of revenue Loss of 1% of revenue
Good 2% of revenue Break evenVery good 3% of revenue Gain of 1% of revenueExcellent 4% of revenue Gain of 2% revenue
}4%swinginmargin
SummarySBIRT clearly works for unhealthy drinking. SBIRT substantially reduces healthcare costs for unhealthy drinkers. SBIRT does not work for complex, disadvantaged, urban drug users. SBIRT might work for other drug users. More research is coming soon. The SBIRT model should expand to include pharmacotherapy and behavioral treatment for dependent patients in general healthcare settings. Strategies to implement SBIRT must take into account other behavioral healthcare needs in primary care/general healthcare settings. Strategies to spread SBIRT and similar services for other behavioral risks and disorders must go beyond fee-for-service reimbursement.
A Look at the Evidence – and Gaps to AddressSBIRT:
wellsys.biz
Richard L. Brown, MD, MPH Director of WIPHL
Professor of Family Medicine & Community HealthSchool of Medicine and Public Health
University of WisconsinCEO and Chief Medical Officer, Wellsys LLC