Teaching residents screening, brief intervention, and referral to treatment (SBIRT) skills for alcohol use: Using chart-stimulated recall to assess curricular impact

Factors associated with intention to implement SBI and SUD treatment: a survey of primary care clinicians in Texas enrolled in an online course

BACKGROUND

Substance use disorder (SUD) presents a range of public health challenges and consequences. Despite the prevention potential of screening and brief intervention (SBI) in the primary care setting, implementation is low. The purpose of this study was to assess associations of primary care clinicians' knowledge of SBI and SUD treatment, subjective norms, and perceived behavioral control with intention to incorporate SBI and SUD treatment into regular clinical practice.

METHODS

This online survey was administered to primary care clinicians who practice in Texas between March 1, 2021, and February 5, 2023. Survey questions were mapped to factors in the Theory of Planned Behavior and included measures of knowledge, subjective norms, and perceived behavioral controls related to SBI and SUD treatment. Intention to engage in SBI and SUD treatment was assessed as the outcome.

RESULTS

Of 645 participants included in this study, 59.5% were physicians. Knowledge was low, with less than half correctly reporting what was considered a standard drink (39.6%) and only 20% knew the correct number of alcoholic beverages considered risky drinking in 21-year-old non-pregnant women. Subjective norms, such as having colleagues within their practice support addressing SUDs, and perceived behavioral control such as having SUD screening routinized within clinic workflows, were positively associated with intention to implement SBI and SUD treatment in primary care settings.

CONCLUSIONS

Modifying knowledge gaps, subjective norms, and perceived behavioral control requires a multipronged interventional approach that blends accessible clinician training with systemic workplace enhancements and a collective shift in professional norms.

Use of Epic Electronic Health Record System for Health Care Research: Scoping Review

BACKGROUND

Electronic health records (EHRs) enable health data exchange across interconnected systems from varied settings. Epic is among the 5 leading EHR providers and is the most adopted EHR system across the globe. Despite its global reach, there is a gap in the literature detailing how EHR systems such as Epic have been used for health care research.

OBJECTIVE

The objective of this scoping review is to synthesize the available literature on use cases of the Epic EHR for research in various areas of clinical and health sciences.

METHODS

We used established scoping review methods and searched 9 major information repositories, including databases and gray literature sources. To categorize the research data, we developed detailed criteria for 5 major research domains to present the results.

RESULTS

We present a comprehensive picture of the method types in 5 research domains. A total of 4669 articles were screened by 2 independent reviewers at each stage, while 206 articles were abstracted. Most studies were from the United States, with a sharp increase in volume from the year 2015 onwards. Most articles focused on clinical care, health services research and clinical decision support. Among research designs, most studies used longitudinal designs, followed by interventional studies implemented at single sites in adult populations. Important facilitators and barriers to the use of Epic and EHRs in general were identified. Important lessons to the use of Epic and other EHRs for research purposes were also synthesized.

CONCLUSIONS

The Epic EHR provides a wide variety of functions that are helpful toward research in several domains, including clinical and population health, quality improvement, and the development of clinical decision support tools. As Epic is reported to be the most globally adopted EHR, researchers can take advantage of its various system features, including pooled data, integration of modules and developing decision support tools. Such research opportunities afforded by the system can contribute to improving quality of care, building health system efficiencies, and conducting population-level studies. Although this review is limited to the Epic EHR system, the larger lessons are generalizable to other EHRs.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research

PURPOSE

To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula.

METHOD

The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability.

RESULTS

Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula.

CONCLUSIONS

SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

A Video- and Case-Based Curriculum on the Management of Alcohol Use Disorder for Internal Medicine Residents

INTRODUCTION

Alcohol use disorder (AUD) is commonly undertreated. Physicians cite discomfort with AUD medication as a barrier to treatment. While several curricula teach and assess screening and brief interventions, few teach and assess learner knowledge of treatment options.

METHODS

We created a video- and case-based curriculum for internal medicine residents delivered by 16 internal medicine faculty in three 30-minute sessions at four clinic sites. Learner knowledge, attitudes, and confidence were assessed before and after the curriculum. We used qualitative methods to evaluate learner reflections. We also assessed faculty satisfaction with the curriculum.

RESULTS

Of 153 residents receiving the curriculum, 35 (23%) completed both pre- and postsurveys. Median percent correct on knowledge questions improved from 67% pre- to 80% postcurriculum (p < .001). Confidence increased for all three items assessing it, with a notable increase in confidence with pharmacotherapy (2.9 pre- vs. 4.5 postcurriculum on a 7-point Likert scale with high scores indicating greater confidence, p < .001). Positive attitudes toward people with AUD increased from 3.4 pre- to 3.9 postcurriculum (p < .001) on a 7-point Likert scale. Learners continued to express concerns about prescribing logistics, the role of primary care, and management of ongoing use. Thirteen of 16 faculty (83%) completed the postcurricular survey; all said they would be happy to facilitate again.

DISCUSSION

Implementation of this curriculum for the management of AUD improved resident knowledge, attitudes, and confidence in AUD treatment. The curriculum was acceptable to faculty and is ideal for programs looking to expand teaching about AUD.

A Sequential Implementation Model for Workforce Development: A Case Study of Medical Residency Training for Substance Use Concerns

PROBLEM

In graduate medical education, residency programs are often educationally isolated from each other, with varying needs and patient populations, so strategies are needed when attempting to implement training in evidence-based practices across multiple residencies.

INTERVENTION

Using implementation science as a guide, we adapted a community development model to sequentially implement an evidence-based intervention, Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and drug use problems, across internal medicine, pediatrics, emergency medicine, psychiatry, and obstetrics and gynecology residency programs.

CONTEXT

A grant-funded "executive" team coordinated the implementation, enrolled a new residency program annually, and served as the consultative team to span the programs. The team was attentive to aligning implementation with the needs of each program. To assist in planning, the team included a program champion 1 year prior to SBIRT implementation to provide the opportunity to develop resources and work with peers. We evaluated this model through an implementation science lens using a case study approach that included interviews and quantitative tabulation of products and resident perceptions.

OUTCOME

We successfully instituted SBIRT training in all 5 residency programs through the use of a supported local champion model. Teams developed 90 curricular products and had 57 presentations and publications. Residents reported satisfaction with the SBIRT activities. Champions reported that SBIRT was a useful approach and that they gained valuable knowledge and relationships from working with the executive team when designing learning materials appropriate for their residency. Champions successfully incorporated SBIRT into routine clinical practice.

LESSONS LEARNED

Having a strong team to support subsequent SBIRT champions was essential for implementation. The champions needed financial support to have the necessary time to implement training. The strategy of building a peer network across programs was critical for sustaining the implementation. Collecting and sharing resources aided the champions in developing their materials.

A Digital Tool to Promote Alcohol and Drug Use Screening, Brief Intervention, and Referral to Treatment Skill Translation: A Mobile App Development and Randomized Controlled Trial Protocol

BACKGROUND

Translation of knowledge and skills from classroom settings to clinical practice is a major challenge in healthcare training, especially for behavioral interventions. For example, screening, brief intervention, and referral to treatment (SBIRT) is a highly-promoted approach to identifying and treating individuals at risk for alcohol or drug problems, yet effective, routine use of SBIRT has lagged.

OBJECTIVE

The objective of this paper is to describe the development, pilot testing, and trial protocol of a mobile app based on the theory of planned behavior (TPB) to promote SBIRT skill translation and application.

METHODS

Intended for use after classroom training occurs, the mobile app has three primary functions designed to increase behavioral intent to deliver SBIRT: (1) review skills (ie, address knowledge and beliefs about SBIRT), (2) apply skills with patients (ie, build confidence and perceived behavioral control), and (3) report performance data (ie, increase accountability and social norms and/or influence). The app includes depression and anxiety screening tools due to high comorbidity with substance use. A randomized controlled trial (RCT) is in progress among health and social service learners (N=200) recruited from 3 universities and 6 different training programs in nursing, social work, internal medicine, psychiatry, and psychology. Participants are randomized to SBIRT classroom instruction alone or classroom instruction plus app access prior to beginning their field placement rotations. TPB-based data are collected via Qualtrics or via the mobile app pre-post and SBIRT utilization, weekly for 10 weeks. Key outcomes include the frequency of and self-reported confidence in delivery of SBIRT.

RESULTS

Beta testing with advanced practice nursing students (N=22) indicated that the app and its associated assessment tools were acceptable and useful. The system usability scale (SUS) mean was 65.8 (n=19), which indicated that the SBIRT app was acceptable but could benefit from improvement. Indeed, modifications were implemented prior to starting the trial. Enrollment of trial participants began in September 2016. Results are expected by December 2017.

CONCLUSIONS

This report describes the process of TPB-based app development and testing, and the protocol for a RCT to determine the effectiveness of the app in enhancing skill translation. If effective, this approach could improve SBIRT implementation, fidelity, and clinical outcomes.