Study protocol testing toolkit versus usual care for implementation of screening, brief intervention, referral to treatment in hospitals: a phased cluster randomized approach

Improving screening, brief intervention and referral to treatment for unhealthy alcohol use in diverse, low-resourced primary care clinics

BACKGROUND

Implementation of screening brief intervention and referral to treatment (SBIRT) and medication-assisted treatment for alcohol use disorder (MAUD) remains low in primary care. ANTECEDENT (Partnerships to Enhance Alcohol Screening, Treatment, and Intervention) was a practice-facilitator led implementation study to increase SBIRT and MAUD use in diverse primary care clinics.

METHODS

From November 2019 - April 2023, we conducted a convergent parallel mixed methods evaluation. Participants were small and medium-sized primary care clinics in the Northwestern U.S. Clinics received foundational support (i.e., baseline/exit assessment, access to SBIRT Oregon website) and the option for supplemental implementation support (e.g., practice facilitation, expert consultation) over the 15-month intervention to improve SBIRT and MAUD. Qualitative and quantitative data regarding clinic characteristics, implementation strategies, and SBIRT/MAUD outcomes were collected through practice facilitator interviews, periodic reflections and clinic contact logs, interviews, pre-post surveys, and electronic health record (EHR) queries. Quantitative analyses included descriptive statistics, logistic regression, and the Wilcoxon sign-ranked test. Qualitative analysis took an immersion crystallization approach. Data were reviewed in a matrix to evaluate intervention adoption, implementation, and effectiveness.

RESULTS

We recruited 75 unique clinics; 66 participated and 48 (73%) completed the study. Eight participating clinics chose to receive foundational support only (12%) while 58 chose to engage in supplemental support (88%) activities. Clinics that received supplemental support and completed the intervention (n = 42) engaged in practice facilitation (Mean: 293 min, range: 75-550 min); data review (38%), HIT support (31%), expert consultation (19%), and peer-to-peer learning (5%). Pre- and post-intervention assessments showed significant improvement in self-reported SBIRT process outcomes. Performance data improved among the subset of completing clinics able to produce data (n = 17). Clinics described positive experiences with ANTECEDENT support and highlighted remaining barriers to SBIRT and MAUD implementation.

CONCLUSIONS

Participating clinics engaged in a diverse range of supportive activities. A flexible approach using practice facilitation and implementation support could be helpful for low-resourced primary care clinics in improving SBIRT and MAUD for unhealthy alcohol use.

Impact of brief smoking cessation intervention on quitting rate and glycemic control in patients with diabetes: a randomized controlled trial

OBJECTIVE

We aimed to evaluate the impact of a brief smoking cessation intervention among patients with diabetes.

METHODS

This randomized interventional clinical trial involved patients with diabetes who smoked tobacco and attended the outpatient diabetes clinic at Penang Hospital, Malaysia. Participants were randomized into a control group that usual care for patients with diabetes, or an intervention group that received a 5-minute physician-delivered brief counseling session on tobacco cessation using the 5A's strategy, in addition to usual care. Primary outcome measures were assessed over three visits (every 3-4 months) including mean glycated hemoglobin level, quitting rate, blood pressure, and mean number of cigarettes smoked per day.

RESULTS

In total, 126 participants were finally enrolled in the study, with 63 patients each in the intervention and control groups. There was no significant difference between the two groups with respect to glycemic control, blood pressure, and quitting rate. However, patients in both groups reduced their cigarette consumption.

CONCLUSIONS

The present brief smoking cessation intervention did not result in better glycemic control, blood pressure, or quitting rates among patients with diabetes. This patient group may require more intensive guidance for better outcomes.Trial registration: This study is registered in ClinicalTrials.gov (NCT04864327); https://clinicaltrials.gov/ct2/results?pg=1&load=cart&id=NCT04864327.

Seeking to Understand: Qualitative Research on Sustainability of Evidence-Based Practice in Acute Care

OBJECTIVE

The aim of this study was to describe cultural characteristics, values, and beliefs that influence sustainability of an evidence-based practice (EBP) intervention in the acute care clinical setting.

BACKGROUND

There is an urgent need to identify best practices to sustain EBP to gain efficiencies in nursing care delivery and improve patient outcomes.

METHODS

A focused ethnographic qualitative study was conducted in a community hospital with nurses that used Screening, Brief Intervention, and Referral to Treatment (SBIRT).

RESULTS

Customizing the intervention to the unit culture evolved and was crucial for sustainability. Overlap in responsibilities, time, clinician confidence, and impact to workflow were noted as negative influences. The intervention was primarily viewed as a task to be checked off a list instead of a tool that informs the patient's plan of care.

CONCLUSIONS

Assessing clinician experiences, beliefs, and values of an EBP should be incorporated into a strategic sustainability plan. Clinician understanding of how an EBP can advance the patient plan of care could promote ownership of professional practice and sustainment.

Perceptions of the barriers, facilitators, outcomes, and helpfulness of strategies to implement screening, brief intervention, and referral to treatment in acute care

Background

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a clinical intervention used to address alcohol and illicit drug use. SBIRT use has resulted in positive health and social outcomes; however, SBIRT implementation remains low. Research on implementing interventions, such as SBIRT, lacks information about challenges and successes related to implementation. The Expert Recommendations for Implementing Change (ERIC) provides a framework to guide comprehension, clarity, and relevance of strategies available for implementation research. This framework was applied to qualitative feedback gathered from site coordinators (SCs) leading SBIRT implementation. The purpose of this study was to describe the SCs’ experiences pertaining to SBIRT implementation across a health system.

Methods

Within the context of a larger parent study, a semi-structured interview guide was used to capture 14 SCs’ perceptions of the barriers, facilitators, and outcomes pertaining to SBIRT implementation. Qualitative data were analyzed using standard content analytic procedures. A follow-up survey was developed based on 14 strategies identified from qualitative data and was administered electronically to determine the SC’s perceptions of the most helpful implementation strategies on a scale of 1 (least helpful) to 5 (most helpful).

Results

All 14 invited SCs participated in the SBIRT implementation interview, and 11 of 14 (79%) responded to the follow-up survey. Within the categories of barriers, facilitators, and outcomes, 25 subthemes emerged. The most helpful implementation strategies were reexamining the implementation (M = 4.38; n = 8), providing ongoing consultation (M = 4.13; n = 8), auditing and providing feedback (M = 4.1; n = 10), developing education materials (M = 4.1; n = 10), identifying and preparing champions (M = 4; n = 7), and tailoring strategies (M = 4; n = 7).

Conclusion

SCs who led implementation efforts within a large healthcare system identified several barriers and facilitators to the implementation of SBIRT. Additionally, they identified clinician-related outcomes associated with SBIRT implementation into practice as well as strategies that were helpful in the implementation process. This information can inform the implementation of SBIRT and other interventions in acute care settings.

Implementation of screening, brief intervention, and referral to treatment (SBIRT) by nurses on acute care units: A qualitative descriptive study

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based intervention for patients with substance use disorders, but this intervention is under-utilized. Little is known about the implementation of SBIRT in acute care facilities. The purpose of this study is to describe implementation of SBIRT by nurses in acute care hospitals. Methods: A qualitative descriptive design was used for this study. Registered nurses who agreed to participate in the study completed a 1:1 interview using a semi-structured interview guide. Interviews were audio recorded and transcribed and then data were analyzed using qualitative content analysis. Results: When implementing SBIRT in an acute care setting, participants identified several factors that affect implementation. Some nurses felt that it is "one more thing to do" but other nurses feel that it was a "good, simple" screening tool that does not take long to do and can "plant the seeds of change" for patients. Additionally, participants mentioned barriers and facilitators related to the patients' responses to SBIRT and organizational factors. Conclusions: This study identified several barriers and facilitators to SBIRT implementation related to the nurses, patients, and organization. By understanding the factors that influence implementation, healthcare providers can develop strategies to support effective implementation of SBIRT.

Development and use of a toolkit to facilitate implementation of an evidence-based intervention: a descriptive case study

Background

Implementation of evidence-based clinical interventions in real-world settings becomes a futile effort when effective strategies to foster adoption are not used. A toolkit, or a collection of adaptable documents to inform and facilitate implementation, can increase the use of evidence-based interventions. Most available toolkits provide resources about the intervention but lack guidance for adaptation to different contexts or strategies to support implementation. This paper describes the development and use of a toolkit to guide the implementation of an evidence-based intervention to identify and intervene for people with risky substance use.

Methods

A descriptive case study describes the development and use of a toolkit throughout a two-year study. Investigators and site coordinators from 14 acute care hospitals developed tools and engaged external stakeholders as they prepared for implementation, integrated the clinical intervention into practice, and reflected on implementation.

Results

The final toolkit included 54 different tools selected or created to define the intervention, engage and communicate with stakeholders, assess for readiness and plan for implementation, train clinical nurses and other stakeholders, evaluate training and implementation effectiveness, create policies and procedures for different contexts, and identify opportunities for reimbursement. Each tool corresponds to one or more implementation strategies.

Conclusion

The approach used to develop this implementation toolkit may be used to create resources for the implementation of other evidence-based interventions.

Screening, Brief Intervention, and Referral to Treatment in a Retail Pharmacy Setting: The Pharmacist's Role in Identifying and Addressing Risk of Substance Use Disorder

OBJECTIVE

This study determined the feasibility of interviewing and screening patients presenting to a retail pharmacy using Screening, Brief Intervention, and Referral to Treatment (SBIRT) interview protocols, and to compare SBIRT results to a risk score calculated from Prescription Drug Monitoring Program (PDMP) data.

METHODS

Using the NIDA Quick Screen and NIDA Modified-ASSIST (NM-ASSIST) and the Alcohol Use Disorder Identification Test (AUDIT), retail pharmacy customers were screened for substance and alcohol use disorder and tobacco use. PDMP reports were collected on subjects and a PDMP-risk score was calculated based on the numbers of Schedule II-V prescriptions and prescribers over the previous 12 months.

RESULTS

A total of 24 patients were included in this study (67% response rate). SBIRT screening revealed that 20.8% were at-risk for substance use disorder (SUD), 16.7% for alcohol use disorder, and 37.5% used tobacco. Overall, 33.3% of subjects were at-risk for SUD or alcohol use disorder. Fifty percent of subjects required education and/or brief intervention based on their responses, 37.5% of all subjects were deemed at-risk based on their PDMP-risk score, and 60% of patients who were risk-positive by SBIRT screening were also PDMP-risk positive.

CONCLUSIONS

This study demonstrates the feasibility of performing SBIRT-based screenings in a retail pharmacy setting and combining these with PDMP-risk analysis to screen patients for prescription and illicit drug misuse. Findings from this study will inform the design of larger multisite studies, which should validate these findings and include follow-up analysis to assess the efficacy of intervention on this patient population.