Alcohol Screening and Brief Intervention in Primary Care Settings: Implementation Models and Predictors
Journal article by Thomas F. Babor, John Higgins-Biddle, Deborah Dauser, Pamela Higgins, Joseph A. Burleson; Journal of Studies on Alcohol, Vol. 66, 2005
Journal Article Excerpt
Alcohol Screening and Brief Intervention in Primary Care Settings: Implementation Models and Predictors *. by Thomas F. Babor , John Higgins-Biddle , Deborah Dauser , Pamela Higgins , Joseph A. Burleson AT-RISK DRINKING--consumption of beverage alcohol in amounts or ways that increase the probability of medical, behavioral and social problems--is prevalent among patients presenting to primary health care (Anderson et al., 1993; Cleary et al., 1988) and imposes a significant economic burden on the health care system and society (Harwood et al., 1998). Because most at-risk drinkers are not alcohol dependent, many could be helped to reduce their drinking to moderate levels by brief interventions in primary care (Caetano and Cunradi, 2002). Few primary care practices, however, have implemented programs to identify and intervene with patients who misuse alcohol (Beich et al., 2002; Fleming, 1997; National Center on Addiction and Substance Abuse at Columbia University [CASA], 2000; Reid et al., 1986; Rydon et al., 1992). Screening procedures have been developed to identify at-risk drinking (Saunders et al., 1993; Preventive Services Task Force, 1996) and research over the past two decades has shown that significant reductions in drinking and related risks can be achieved by brief interventions (Bein et al., 1993; Kahan et al., 1995; Moyer et al., 2002; Whitlock et al., 2004; Wilk et al., 1997). Little attention, however, has been paid to questions of how alcohol screening and brief intervention (SBI) can best be implemented in primary care practices.Most clinical trials of SBI have used physicians to deliver the interventions, with significant assistance from research staff. Two studies (Senft et al., 1997; WHO Brief Intervention Study Group, 1996), however, suggest that nonphysician staff can be equally effective. Beyond the question of who delivers the screening and intervention, only a few studies (Kaariainen et al., 2001; Welte et al., 1998) consider the organizational factors that help or hinder successful implementation and sustainability of the service.The present study evaluates the implementation of alcohol SBI under two different organizational models. One gave prime responsibility for SBI to medical providers and the other delegates responsibilities to mid-level professionals acting as the clinic's specialists to provide alcohol services. It was expected that the specialist model would result in greater implementation success because of its concentration of clearly delineated duties for a few staff members, compared with the time limitations and competing priorities of primary care practitioners. The study also provided an opportunity to investigate the role of different organizational and provider characteristics in the success or failure of SBI implementation.MethodSitesFive managed care organizations (MCOs) from the West, Southwest, Midwest and Northeast regions of the United States were recruited through a national solicitation for participation in the study. Four of the selected MCOs involved group models that provided services to either one health maintenance organization (HMO) exclusively or to an HMO and other patients on a paid basis; the fifth was a consortium of independent practice association health management organizations. The MCOs were expected to have at least three comparably sized family- or internal-medicine practices with at least 7,000 unduplicated patient visits per year, one MCO coordinator, clinic-based liaisons to help coordinate study activities and no current alcohol-screening programs. MCOs were reimbursed for most of the costs associated with the study.Within each of the five MCOs (herein referred to as MCOs 1 through 5), the three comparably sized clinics that agreed to participate were randomly assigned to one of three study conditions designed to evaluate a new SBI program called Cutting Back. In one condition (designated P for provider) all medical providers (physicians, physician assistants, nurse practitioners) delivered the brief intervention. In the other condition (designated S for specialist) selected mid-level professionals (nurses or health educators) performed that duty on behalf of all providers. The third clinic at each site was a control clinic studied solely for the purposes of a patient outcome evaluation, which is reported elsewhere (Babor, 2004). Because MCO 5 was only able to provide access to two clinics, its clinics were randomly assigned to the P and control conditions. To equalize the number of P and S clinics, MCO 3 provided an additional S clinic (3b) that was included in the analysis.Implementation processA comprehensive system was used to implement Cutting Back, consisting of decision-making, planning, training, operating and maintenance activities. Each MCO appointed an overall coordinator of operations and each clinic appointed a liaison. MCOs had flexibility in adapting the essential elements of the Cutting Back SBI procedures to their particular setting and ... |
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