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.
Here's the abstract: