Global Assessment of Screening and Intervention for Unhealthy Substance Use at the Primary Care Annual Visit

CONTEXT: Tobacco, alcohol and drug use are among the top 10 causes of preventable death in the United States, but unhealthy substance use is often under-recognized and under-treated. In primary care, screening, brief intervention, and referral to treatment (SBIRT) contributes to improved patient outcomes. While many barriers exist to implementing SBIRT, the annual or new patient visit is often a critical touchpoint for many patients.

OBJECTIVE: The purpose of this study was to assess, at the population level, our department’s rates of screening, risk identification and intervention for tobacco, alcohol and other substance use.

STUDY DESIGN/SETTING/POPULATION: Monocentric multisite retrospective chart review over the calendar year 2019. We conducted secondary data analysis of 18,420 patients (Mean age = 43 years, SD = 13; range: 18-65 years old), with a health maintenance exam in this 12 month period who received care at six Family Medicine clinics.

PROCESS AND OUTCOME MEASURES: The primary process measures examined screening rates for tobacco, alcohol, and other substance use. The primary outcome measures examined evidence of intervention (dx, medication prescription, referral) among those with and without positive screen.

RESULTS: The percent of patients identified at risk for unhealthy use: 9.4% tobacco, 7.3% alcohol, and 6.15% other substance use. Of those who screened positive for tobacco use, 54.7% with evidence of intervention (50% associated diagnosis code; 17% CPT code cessation counseling; less than 2%, with a referral; 14% medication prescription). Of those who screened positive for unhealthy alcohol use, 7.2% with evidence of intervention (7% associated diagnosis code; 1% referral; 0.3% medication prescription). Of those who screened positive for substance use, 7.4% with evidence of intervention (7.4% associated diagnosis code; 0.1% referral). Few statistically significant differences identified by patient or provider demographics or care site.

CONCLUSIONS: Overall, patients who were screened and were positive were more likely to have evidence of intervention, supporting efforts to complete at least annual screens. The department is strongest at identifying and intervening on tobacco use. Brief assessment and intervention with alcohol and substance use are areas in need of additional focus. The use of validated tools, systematic survey implementation, and population level data storage provide avenues for improvement.