In 2010, with a grant from the National Institute on Alcohol Abuse and Alcoholism, the researchers of the Division of Research’s Drug and Alcohol Team — led by Behavioral Health & Aging Section Chief Connie Weisner, DrPH, MSW, and Principal Investigator Jennifer Mertens, PhD — began a study on the optimal model for implementing and sustaining a program of screening, brief intervention, and referral to treatment (SBIRT) for unhealthy drinkers.
A major challenge of the SBIRT study was to understand the barriers to implementation, which include lack of awareness as to what amount of alcohol consumption constitutes low-risk drinking, the perceived sensitive nature of the topic, and the many competing priorities physicians have in a primary care setting. Researchers randomized 54 clinics in 11 medical centers to three different approaches to learn not only which of the approaches is more likely to be implemented, but also which one is most sustainable.
According to the American Journal of Preventative Medicine, alcohol screening and brief intervention is ranked fourth of 25 preventive primary-care services — above screening for hypertension, diabetes, cholesterol, and depression — for improving health and lowering health care costs. Yet this screening for unhealthy drinkers has not been widely adopted by primary care practices in the United States, according to Division of Research scientists.
Addressing alcohol use in primary care has an impact on many key health problems as well as health care costs. For example:
- All unhealthy drinkers have a greater risk of highly prevalent conditions treated in primary care such as hypertension, injuries, gastrointestinal bleeding, sleep disorders, depression, and diabetes.
- For hypertension, clinical trials suggest that “regular drinking may antagonize efficacy of drug treatment and weight reduction, that alcohol restriction may lower blood pressure more than exercise, and that alcohol restriction may be more effective than salt restriction.”
- Alcohol is related to 20-30 percent of all emergency room visits and accounts for $26 billion in health care costs.
- Unhealthy drinking is associated with poorer medication adherence to statins, anti-hypertensives, diabetes medications, and antidepressants.
- For every $1 spent on screening and intervention, health care costs are reduced by $4.
- Some patient groups (i.e., older adults, women) are less likely to seek out specialty treatment or be identified with alcohol problems. These are the same groups who are likely to have strong relationships with their primary care physicians. Primary care is the ideal setting for screening and identifying these patients at risk.
An estimated 7 percent of patients in Kaiser Permanente primary care clinics are unhealthy drinkers. Ninety percent of these patients do not have alcohol dependence, and a brief intervention in primary care can reduce their alcohol consumption to a low-risk level. In addition, it helps the smaller group of patients (about 0.7%) who do have alcohol dependence to access specialty treatment, said the researchers.
A key finding from the Division of Research SBIRT study, for both implementation and sustainability of the workflow, is “keep it simple.” Medical assistants are automatically prompted by an electronic program to ask patients a few simple questions about alcohol consumption. When patients screen positive through answers that indicate they are above the low-risk limits, an alert lets the physician know that a conversation is needed. That conversation is a natural progression of noting the patient’s alcohol consumption level, explaining the effects it can have on their health, making them aware of low-risk levels, and asking them if they are willing to cut back.
When physicians find that patients with whom they’ve had a conversation have not been able to cut back over time, or they find other indications of dependence, their next step is to make a referral to Kaiser Permanente’s Chemical Dependency program.
At the study’s conclusion, findings were shared with Kaiser Permanente Northern California leaders and with departments across the region, and feedback was sought to design and implement future program changes to maximize efficiencies. In 2012, The Permanente Medical Group chiefs of medicine recommended that the SBIRT model be implemented in medicine departments throughout the region. The implementation phase began on June 20, 2013 with David Pating, MD, Chair, Chiefs of Addiction Medicine, as the clinical lead for the rollout. When the program is fully introduced, Kaiser Permanente Northern California will be the first private integrated health care system to implement a program of screening, brief intervention, and referral to treatment — incorporating alcohol as a vital sign in primary care — as routine and systematic.