Alcohol SBIRT Implementation in Primary Care in an Integrated Health Care System

Background: Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) in adult primary care (PC) is cost-effective, but research on implementation is lacking. The ADVISe study examines whether non-physician (versus physician) delivery of SBIRT in PC clinics increases implementation. Methods: This is a clustered, randomized controlled trial of 54 adult PC clinics in Kaiser Permanente Northern California. We compared a control condition versus training, technical support and performance feedback for physician (PCP) versus non-physician (NPP) delivery. The study included qualitative interviews with providers and patients and a pre-training survey of MD clinic leaders. Results: Patient conditions likely to trigger screening included depression (80%), drug use (75%), anxiety (64%), GI (60%), and sleep (58%) disorders. Yet, only 42%, 40%, 31% and 24% would be triggered to screen in patients with pain, hypertension, diabetes, and injuries, respectively. On average, interventions were longer in duration in the NPP arm. NPP model barriers included patient resistance, exam room availability, and time constraints. Barriers salient for physician delivery included a region-wide PC access initiative and new competing priorities due to health care reform. Inclusion of the screener in the EMR and monthly feedback were facilitators. Patients generally reported feeling that providers were empathic and viewed the intervention as helpful. Conclusions: PC leaders still view preventive screening for unhealthy drinking as a lower priority than other preventive services, and seldom recognize the importance of screening in several conditions affected by alcohol. Some systematic barriers may be particularly difficult to address, but EMR tools are important facilitators.