Alcohol Screening and Intervention:

1. The Trauma Surgery Perspective Alcohol Screening and Intervention: Larry Gentilello, MD Professor of Surgery, Management, Policy, and Community Health University of Texas Dallas, Texas

3. Alcohol-Related Mortality 40,933 Injuries (CDC - MMWR, 2004)

4. Years of Potential Life Lost - YPLL’s Alcohol - Related Diseases 2,279,322 Chronic Disease Injuries (CDC - MMWR, 2004)

5. Alcohol and Trauma (Gentilello, Am J Surg 1988)

6. Positive Alcohol Screens

8. (Gentilello, Am J Surgery, 1988)

10. Standard Practice instrument “not familiar with” • 87% reported no prior training in substance abuse • 18% routinely screen BAC • < 15% use questionnaires • intervention or referral is rare (Danielson, Gentilello, et al, Archives of Surgery, 1999)

12. 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)

15. Severity of Alcohol Problems Dependent drinking/Alcoholism Harmful drinking/Abuse severity Risky/Hazardous drinking Safe drinking abstinent

16. Brief Intervention Outcomes 1,735 patients percent days abstinent drinks per drinking day

17. (Miller WR, 1995)

18. Cost-Effectiveness effectiveness cost

19. (Miller WR, 1995)

20. Drinking Pyramid Goals Types of Drinkers Prevalence in US . Referral to treatment ~ 5 % Alcohol Dependent Brief Intervention Risky or Harmful ~ 25% Low Risk or Abstinent No intervention ~ 70%

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

22. 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?”

23. Hypothesis Alcohol interventions as a routine component of trauma care will reduce subsequent alcohol intake, and decrease the rate of trauma recidivism

24. 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

25. 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

27. Patient Enrollment eligible trauma patients 3,358 screened 2,524 screened negativescreened positive 1,371 (54%) 1,153 (46%) randomized 762 (66%) controlintervention 396 366

28. Baseline Characteristics

29. Trauma Recidivism - HMC injury recurrence days follow-up

30. Trauma Recidivism - Statewide injury recurrence days follow-up

31. Changes in Alcohol Intake (p = 0.01) 6 month follow-up 12 month follow-up

32. Changes in Alcohol Use at One Year

33. Other Outcomes .83 .84 .77 .56 .50 0.00 0.50 1.00 1.50 2.00 less frequent more frequent

36. Trauma Center Requirements • Physical therapy • Occupational therapy • Vocational therapy • Speech therapy • Spinal chord therapy • Nutritional therapy • Play therapy • Alcohol therapy?

38. 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.

42. Financial Costs in Colorado Failure to do SBIRT in ER’s 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.org.

44. 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

45. New CMS Codes for SBI • New codes Medicaid codes • H0049 Screening • H0050 Brief Intervention • New Medicare codes • G0396 SBI > 15 minutes • G0397 SBI > 30 minutes

46. Reimbursement for SBI

47. Medicaid Code Adoption UPPL Status as of 2000 WASHINGTON WASHINGTON NORTH NORTH MINNESOTA MINNESOTA MAIN MAIN MONTA MONTA N NA DAK DAK OTA OT E E A A V V OREGON OREGON T T N N WISCONSIN WISCONSIN MASS MASS H H SOUTH SOUTH IDAHO IDAHO DAK DAK OT OTA NEW NEW MICHIGAN MICHIGAN WYOMING WYOMING RI RI YO YORK RK CONN CONN IOWA IOWA PE PE N N NE NE NEBR NEBRA A SK SKA JERSE JERSE N N W W NEVADA NEVA D OHIO OHIO A Y Y DELAWA DELAWA R R A INDIAN INDIAN ILLINOIS ILLINOIS E E UT UT AH A A A COLORADO COLORADO MARY MARY L L A A N N W W D D V V KANS KANS A AS VIRGINIA VIRGINIA MISSOURI MISSOURI S KEN KEN T T U U CK CK CALIFOR CALIFORNIA NIA NORTH NORT H Y Y CAROLI CAROLI N N TENNESS TENNESS E E A A ARIZO ARIZO N NA ARK ARK A A NS NS A A E E OK OK L L AHO A MA SOU SOU T T A S S CAROLI CAROLI N N H H NEW MEXICO NEW MEXICO A A MISS MISS GEORGIA GEORGIA AL AL A A BA BA M M A A TEX TEX AS A S FLORIDA FLORIDA LOUISIANA LOUISIANA ALA ALA SK SK A A HAWAII HAWAII States that have adopted H codes States considering adoption of H codes

48. 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.

49. 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

50. 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