Tuesday, February 5, 2013

Why SBIRT Is Dead in the Water

In the latest issue of Health Affairs, Grace Lin et al. describe an effort to introduce decision-making aids to facilitate shared decision-making regarding back pain and colo-rectal cancer screening. Essentially, nothing changed, in spite of making the aids easily accessible, conducting training sessions, and so on. What's important is the authors' conclusion that "The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy."

Their experience mirrors my own in trying for over 20 years to get substance use addressed in primary care. Most recently, I have two separate but relate experiences here in Minnesota where I essentially ran up against a brick wall. Why? First, primary care doctors are besieged by quality improvement initiatives aimed at reducing variability of practice and improving outcomes for depression, diabetes, heart failure, back pain, asthma, hypertension and many others. These are typically mandated from the top of health care organizations (remember that most primary care physicians are now employees of a large health care organization (HCO.) By attempting to implement not only SBIRT but treatment of alcohol dependence in primary care (I call it Screening, Evaluation and Treatment, or SET, but another term could be SBIRT+) by asking physicians to voluntarily take it on was a non-starter. Typical comments were "It's a good idea but we can't take on anything more right now," or "We're having enough trouble trying to get this clinic's operations running smoothly, and until we do, it wouldn't work." 


A second factor is one of priorities. I have argued for years that universal SBIRT is not cost-effective, but should be more targeted. Related to this is a crucial question: since visit length is not going to increase, what do you want the doctor to stop doing so they can do these new things, like shared decision-making and SBIRT+?  In other words, in a typical visit, the patient has certain expectations about why they are there and what they want, and most patients have multiple chronic diseases like obesity, arthritis, hypertension and diabetes. Oh, and of course they smoke. So, do you want the doctor to not address the patient's presenting complaint (e.g., arthritis pain, insomnia), or not address their hypertensive control so they have the time to spend on shared decision-making for back pain, or to conduct SBIRT+? How do you think patients would feel about this? This applies especially to SBIRT, because it is attempting to identify a problem they patient is unaware of and not concerned about. "Doctor, I came here because my right knee is all swollen and painful, and you want to take 2 out of the 8 minutes you spend with me asking me about drinking!?"

So have come to a similar conclusion: until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT or SET are DOA. My most recent attempt has been to start with something that has the attention of every primary care doctor: pain management. I'm providing training to all the primary care doctors in Allina Health in management of chronic pain, and the response so far has been overwhelmingly positive. I'm hoping that by getting to know so many primary care physicians in this HCO, they will be more receptive to introducing SET. However, it has also become clear that the only way this will occur is if the top leadership of the organization decides that SET is important enough to get it into the queue of quality improvement projects, and thus mandate its implementation. 

Primary care, even with the medical home, is not going to be all things to all people, and choices are going to have to be made about what is important enough to include and what might ideally be included but which doesn't make the cut because it is not cost-effective or clinically significant enough.

Besides, if we were serious about addressing the heavy disease burden associated with heavy drinking, we would triple the taxes on alcoholic beverages. That would have a greater public health impact than implementing SBIRT in every primary care practice in the country. 

MW

Here's the abstract:


An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles

  1. Dominick L. Frosch7,*
+Author Affiliations
  1. 1Grace A. Lin is an assistant professor in the Division of General Internal Medicine and at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.
  2. 2Meghan Halley is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute, in California.
  3. 3Katharine A.S. Rendle is a research associate in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  4. 4Caroline Tietbohl is a research assistant in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  5. 5Suepattra G. May is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  6. 6Laurel Trujillo is medical director of quality at the Palo Alto Foundation Medical Group and chair of the Quality Improvement Steering Committee, both at the Palo Alto Medical Foundation, in Los Altos, California.
  7. 7Dominick L. Frosch (dominick.frosch@moore.org) is an associate adjunct professor in the Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles.
  1. *Corresponding author

Abstract

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010–12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

2 comments:

  1. I think that this also reflects gross mismanagement of physicians at all levels. Any physician employed by a health care organization is subjected to any number of initiatives by their non-physician managers. At times the frequency is such that it literally seems like whatever bright idea one of these administrators wakes up with in the morning needs to be implemented by physicians, sometimes at considerable personal cost. Many of these protocols have a questionable scientific basis. In other cases, the data analysis is questionable.

    What better way to protest this Dilbert based system than to refuse to do it?

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  2. At Boston Medical Center Emergency Department we have had 20 years experience with targeted screening, brief intervention and referral to treatment conducted by designated staff known as health promotion advocates (behavioral health integrated in medical practice). The physician and nurses often detect unhealthy alcohol and drug use and refer to the health promotion advocates. Providers need to know about patient alcohol and drug use to avoid prescribing certain drugs that can have adverse interactions with prescribed medications. The above take-home lessons from decision aids can be applied to SBIRT--there is a need for "cultural changes in health care practice and policy and ongoing incentives for use, physician training, and a team-based practice model in which all care team members (MD,RN,SW,Designated staff) bear formal responsibility for the use" of some aspects of screening, brief intervention and referral to treatment when appropriate.

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