Alcohol Screening and Intervention

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Alcohol Screening and Intervention
The Trauma Surgery Perspective

• Larry Gentilello, MD
• Professor of Surgery,
• Management, Policy, and Community Health
• University of Texas
• Dallas, Texas

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Alcohol-Related Mortality
40,933
Injuries
(CDC - MMWR, 2004)
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Years of Potential Life Lost - YPLLs
Alcohol - Related Diseases
2,279,322
Chronic Disease
Injuries
(CDC - MMWR, 2004)
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Alcohol and Trauma
(Gentilello, Am J Surg 1988)
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Positive Alcohol Screens
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(Gentilello, Am J Surgery, 1988)
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Standard Practice
instrument
not familiar with

• 87 reported no prior training in substance abuse
• 18 routinely screen BAC
• lt 15 use questionnaires
• intervention or referral is rare

(Danielson, Gentilello, et al, Archives of
Surgery, 1999)
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Trauma Recidivism

• 5 year follow-up of 246 patients
• 40 readmission rate
• 20 mortality rate
• 77 of deaths due to continuing substance abuse

(Sims, et al, J Trauma)
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Severity of Alcohol Problems
Dependent drinking/Alcoholism
Harmful drinking/Abuse
severity
Risky/Hazardous drinking
Safe drinking
abstinent
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Brief Intervention Outcomes
1,735 patients
percent days abstinent
drinks per drinking day
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(Miller WR, 1995)
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Cost-Effectiveness
effectiveness
cost
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(Miller WR, 1995)
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Drinking Pyramid






Types of Drinkers
Prevalence in US
Goals





.





Referral to treatment

5



Alcohol Dependent











Brief Intervention
Risky or Harmful
25












Low Risk or Abstinent


No intervention
70












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Do you think this patient will change his
drinking or reduce his risk as a result of this
conversation?
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MOTIVATIONAL INTERVIEWING

• No confrontation, labeling, stereotyping
• Ask open-ended questions
• Reflective listening to encourage talk about
  drinking
• Offer information in a non-personal manner.
• Make connection between drinking and ED visit
• What do you like about drinking?
• What do you like less about drinking?

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Hypothesis
Alcohol interventions as a routine component of
trauma care will reduce subsequent alcohol
intake, and decrease the rate of trauma
recidivism
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Alcohol Interventions in a Trauma Center

• Study design
• Harborview Medical Center, Seattle
• October 1994 to November 1997
• NIH sponsored RCT
• patients screened with BAC and questionnaire
• consent for follow-up only
• randomized
• 15 - 30 minute intervention plus follow-up letter
• standard trauma care

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Follow-up

• Objective
• Harborview ED records for one year after
  discharge
• statewide database of all trauma admissions
• police department records
• Department of Licensing records (motor vehicle)
• Self-report
• 6 and 12 month patient interviews
• corroboration interviews with family members

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Patient Enrollment
eligible trauma patients 3,358 screened 2,524 scr
eened negative screened positive
1,371 (54)
1,153 (46)
randomized
762 (66)
control intervention
396 366

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Baseline Characteristics
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Trauma Recidivism - HMC
injury recurrence
days follow-up
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Trauma Recidivism - Statewide
injury recurrence
days follow-up
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Changes in Alcohol Intake
(p 0.01)
6 month follow-up
12 month follow-up
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Changes in Alcohol Use at One Year
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Other Outcomes
.83
.84
.77
.56
.50
1.00
1.50
2.00
0.50
0.00
less frequent more frequent
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Trauma Center Requirements

• Physical therapy
• Occupational therapy
• Vocational therapy
• Speech therapy
• Spinal chord therapy
• Nutritional therapy
• Play therapy
• Alcohol therapy?

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Trauma Center Designation
Chapter 18- Prevention The trauma center must
have a mechanism to identify patients who are
problem drinkers. The trauma center must
have a mechanism to provide an intervention for
patients identified as problem drinkers.
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Financial Costs in Colorado
Failure to do SBIRT in ERs cost CO businesses
and residents 39 million each year in health
care expenses
Estimated Annual Savings from Treating CO
Emergency Patients for Alcohol Problems
Goplerud E. et al. http//www.ensuringsolutions.o
rg.
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2008 CPTCommon Procedure Terminology

• New codes published Nov 2 in 2008 CPT Manual
• 99408
• Alcohol and/or substance use structured screening
  (eg, AUDIT, DAST), and brief intervention (SBI)
  services 15 to 30 minutes
• 99409   
• greater than 30 minutes
• Separate or added service
• Majority of major commercial health plans
• agree to pay in 2008

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New CMS Codes for SBI

• New codes Medicaid codes
• H0049 Screening
• H0050 Brief Intervention
• New Medicare codes
• G0396 SBI gt 15 minutes
• G0397 SBI gt 30 minutes

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Reimbursement for SBI
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Medicaid Code Adoption
UPPL Status as of 2000




WASHINGTON
WASHINGTON







NORTH

NORTH
MINNESOTA
MINNESOTA
MAIN
MAIN
MONTA
N
MONTA
NA



DAK
OT

DAK
OTA
E
E
A


A
V
V
OREGON

OREGON



T
T






N
N
WISCONSIN
WISCONSIN
MASS
MASS
H
H
SOUTH

SOUTH

IDAHO
IDAHO








DAK
OT
DAK
OTA
NEW
NEW


MICHIGAN
MICHIGAN
WYOMING
RI
WYOMING
RI
YO
RK
YORK


CONN
CONN
IOWA
IOWA




PE
N
NE
PE
N
NE






NEBR
A
SK
NEBRA
SKA
JERSE
JERSE

N
W
N
W
NEVA
D
NEVADA
OHIO
OHIO
A

Y

Y


A


DELAWA
R


DELAWA
R
INDIAN
INDIAN

ILLINOIS
ILLINOIS
E
E
UT
A
UT
AH


A
A
COLORADO
COLORADO


MARY
L
A
N
MARY
L
A
N


W
W



D
D
V
V
KANS
A
KANS
AS
VIRGINIA
VIRGINIA




MISSOURI
MISSOURI


S
KEN
T
U
CK
KEN
T
U
CK
CALIFORNIA
CALIFOR
NIA
NORTH
NORT
H
Y
Y


CAROLI
N
CAROLI
N


TENNESS
E
TENNESS
E

A

A


ARIZO
N

ARIZO
NA

ARK
A
NS
A
ARK
A
NS
A

E


E

OK
L
AHO
MA
OK
L
A
SOU
T
SOU
T
A
S

S

CAROLI
N
CAROLI
N

H

H
NEW MEXICO
NEW MEXICO


A
A
MISS
MISS
GEORGIA
GEORGIA


AL
A
BA
M
AL
A
BA
M
A
A






TEX
A
TEX
AS
S
FLORIDA
FLORIDA
LOUISIANA
LOUISIANA


ALA
SK
ALA
SK
A
A

HAWAII
HAWAII



States that have adopted H codes


States considering adoption of H codes




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Joint Commission Undertakes Development of
Standards for SBI To further advance the
expansion of the continuum of healthcare to
include SBI, the Joint Commission on
Accreditation of Healthcare Organizations (Joint
Commission) has decided to undertake the
development of standards for screening and brief
intervention for alcohol and other drugs. The
Joint Commission standards are generally
developed with input from healthcare
professionals, providers, measurement experts,
consumers, government agencies and employers. As
such, because of your expertise on SBI, you are
being asked to collaborate with the Joint
Commission in the development of standards and
quality improvement for SBI.
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Summary

• SBIRT prevents repeated injuries
• SBIRT saves money
• Trauma centers are the first to require SBIRT
• Billing codes are available
• Making it routine hospital care is next

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Message to Trauma Patients
Make not thyself helpless drinking in the beer
shop, falling down. Thy limbs will be broken, and
no one Will give thee a hand to help thee up
Egyptian Papyrus, 1500 BC
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