Screening for Youth Alcohol and Drug Use: A Study of Primary Care Providers

Study Overview
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Brief Summary
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This study evaluates the implementation and effectiveness of two modalities of Screening, Brief Intervention and Referral to Treatment (SBIRT) to reduce adolescent alcohol and other drug (AOD) use in a large pediatrics clinic.

Detailed Description
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Health systems have not implemented Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents despite research demonstrating its effectiveness. Based on prior research that identified barriers to AOD screening for adolescents in pediatric Primary Care (PC) and a pilot study that found SBIRT was feasible, well-received and promoted referrals to and initiation of specialty treatment, the current research application proposes to randomize 45 Primary Care Physicians (PCPs) in the pediatrics clinic of a medical center within a large, managed care health system, Kaiser Permanente Northern California, to three arms - 1) Usual Care; 2) SBIRT delivered by PCPs; and 3) SBIRT delivered by Behavioral Medicine Specialists (BMS). The study objective is to compare the implementation, effectiveness and cost-effectiveness of SBIRT for adolescents in PC in the three study arms. Patients will complete evidence-based screening and AOD assessment measures which have been embedded in the health plan's electronic medical record (EMR). A mixed model will be used to compare implementation outcomes (rates of screening and identification, brief intervention, referral to Chemical Dependency treatment and treatment initiation), and effectiveness (patient outcomes of AOD use and abstinence) at 12 months. The model accounts for the intra-class correlations across patients within providers. Cost-effectiveness relative to implementation and patient outcomes will be examined. Barriers and facilitators of implementation, and feasibility via qualitative interviews with clinicians and administrators will be examined as well. The study is significant in that it examines issues that must be addressed to spur widespread adaptation of SBIRT. The proposed interventions are highly feasible in the current environment of health reform due to increased resources and training to Federally Qualified Health Centers and private health plans. It is innovative in using the EMR to change clinical practice and systematically integrate AOD in PC, and as a platform for collecting research data.

Official Title
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Screening for Youth Alcohol and Drug Use: A Study of Primary Care Providers

Conditions
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Substance Related Disorders

Intervention / Treatment
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* Behavioral: Primary Care Physician
* Behavioral: Behavioral Medicine Specialist


Participation Criteria
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Eligibility Criteria
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There are two study populations as described below thus the large age limit range. Inclusion Criteria: All adolescent primary care providers at the pediatric primary care clinic will be included. All adolescent patient electronic records, ages 12-18, at the pediatric primary care will be examined. Exclusion Criteria: Any adolescent primary care providers not practicing at the pediatric primary care clinic research site will be excluded. Adolescents electronic records who are not part of the research site pediatric clinic will be excluded.

Ages Eligible for Study
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Minimum Age: 12 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Screening
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Primary Care Physician<br>If the adolescent is identified at risk for substance use, the screening and brief intervention referral to treatment delivered is by the primary care physician | Behavioral: Primary Care Physician<br>* The screening, brief intervention and referral to treatment is delivered by the Primary Care Physician<br>|
| Experimental: Behavioral Medicine Specialist<br>If the adolescent is identified at risk for substance use, the screening and brief intervention referral to treatment delivered by the behavioral medicine specialist | Behavioral: Behavioral Medicine Specialist<br>* The screening, brief intervention and referral to treatment is delivered by the Behavioral Medicine Specialist.<br>|
| No Intervention: Usual Care<br>Care is administered as usual | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Screening rate | The proportion of patients who are screened with the Teen Well Check Questionnaire AOD use or Mood symptom questions, among all patients with Teen well-child visits. | Initial screening rate - at index well-visit | 
| Problem Identification rate | The proportion of patients screened who answer yes to AOD use or Mood symptoms in past 12 months and yes to at least one non-car CRAFFT question. (Being in a car with someone using AOD may not be related to child's problem, but to having a parent/other adult who has driven while drinking/using). | Initital problem identification rate - at index well-visit, following screening | 
| Assessment rate | Proportion of patients screening positive for alcohol or other drug, or mental health risk, who are assessed further using the CRAFFT tool. | Within 2 weeks following index well-visit date | 
| Brief Intervention rate | The proportion of patients who receive an intervention within 14 days, among those who are identified with AOD risk (based on CRAFFT score). Documented in EHR by clinicians, using an ICD-9 Administrative V-code for substance use counseling or behavioral counseling. | Within 14 days of assessment at index well visit | 
| Referral to specialty treatment rate | The proportion of patients who receive referrals to specialty behavioral health treatment, among those identified through the CRAFFT as needing such treatment. Documented in the EHR. | Within 6 months of index well-visit | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Specialty Behavioral Health Treatment Initiation | Defined as the percent referred, who have at least one specialty behavioral health visit among those identified with a behavioral health problem. Documented in the EHR. | Within 2 years post-intervention | 
| Alcohol and other drug use | Alcohol and drug use: The items in the EHR measure past 30-day and 6-month use of alcohol, marijuana and other drugs and tobacco, including days of use, quantity consumed (any, 3+ and 5+ drinks), and days of binge drinking (3+ and 5+). | Use in past 6 months, at 1 and 2 years post-intervention | 
| Substance Use-related outcomes | AOD-related legal, school, and family problems: The EHR questions also include measures from the Comprehensive Adolescent Severity Inventory (CASI),148 a semi-structured questionnaire which measures adolescent health and functioning across education, legal, and family relations domains. | in past 6 months, at 1 and 2 years post-intervention |