Gentilello, Larry M. MD
The efficacy of brief alcohol interventions has been demonstrated in varied populations including primary care patients, adolescents, older adults, and pregnant women. Four prospective randomized trials have also been conducted among injured patients. Although procedures and patient populations differed among the four trials, all demonstrated clinical benefit and a decreased risk of injury recurrence.1–4 Despite this success, alcohol screening and intervention in trauma centers is currently not routine because of a number of obstacles. These obstacles can and should be overcome because alcohol and drugs play such a significant role in trauma that efforts to reduce injuries and their recurrence are unlikely to be successful if they are not addressed.
Lack of Knowledge
The typical medical school curriculum devotes only about 4 hours total toward education on the treatment of alcohol problems.5–10 Thus, medical schools foster the notion that alcohol problems are peripheral issues for practicing physicians of all specialties.
A survey of members of the American Association for the Surgery of Trauma revealed that 83% of trauma surgeons had no training in either screening or detecting alcohol problems;11 more than 75% of trauma surgeons were unfamiliar with any of the commonly used alcohol screening questionnaires, such as the CAGE or MAST alcohol screening questionnaires,12,13 and 13% were not familiar with the term BAC (blood alcohol concentration) within the context of screening for alcohol problems.11 Lack of knowledge is a major reason why trauma surgeons tend to overlook alcohol problems in their patients.14 This presents a compelling obstacle to instituting screening and intervention programs in trauma centers.
To overcome this lack of knowledge, trauma fellowship programs should include a brief rotation that provides trainees with the basic skills needed to screen patients and to perform brief interventions. Using a simple questionnaire to identify those at risk, trauma surgeons can motivate patients to accept the need for change through brief intervention by capitalizing on the effects of a recent major injury.15 The rationale for screening trauma patients for the presence of alcohol and drug problems should also be part of the educational curriculum of Advanced Trauma Life Support to provide an effective link between subsequent chapters within the of Advanced Trauma Life Support curriculum that discuss the importance of injury prevention programs.
It is unlikely that trauma surgeons will advocate for intervention services if they are unaware of the potential benefits of treatment. For example, few are familiar with the magnitude of the treatment effect found in Project MATCH, a large, prospective, randomized trial involving 1,635 patients at 30 sites. Three different types of relatively brief interventions were studied: cognitive behavioral therapy, motivation enhancement therapy, and 12-step orientation. Each was found to significantly reduce alcohol intake (Figs. 1 and 2).16
The belief that alcohol treatments have not been proven effective is partially attributable to the expectation that alcohol- or drug-use problems should respond to treatment just as infections or other acute disorders respond to treatment.17 For example, some would consider an intervention ineffective if the patient reduces alcohol intake but does not stop drinking completely, or if the patient resumes alcohol intake after 6 to 12 months of abstinence.
Trauma surgeons should consider substance-use problems as chronic rather than acute disorders. Hypertension, diabetes, and asthma are considered lifelong diagnoses that can be rendered asymptomatic but cannot always be cured by treatment. Frustration in managing these conditions is reduced or eliminated by the expectation that subsequent life events and stressors will likely result in periodic exacerbations of symptoms that require additional treatment. Even though there is a substantial likelihood of relapse, patients with chronic disorders usually benefit from assistance designed to control or eliminate symptoms.
Similarly, patients who were drinking heavily but who are asymptomatic for 1 year after an intervention have substantially reduced their risk of adverse health consequences during that 1-year period. This was demonstrated in a prospective study that used brief interventions with injured adolescents treated in an emergency department. Patients with an alcohol-related injury were randomized to receive a 35- to 40-minute intervention or to receive standard care. At 6 months, the intervention group had a 75% reduction in drunk-driving episodes. A review of motor vehicle department records indicated that only 3% of intervention patients had a moving violation compared with 23% of the control group. Intervention reduced the rate of alcohol-related injuries from 50% to 21%. All of these reductions were statistically significant.18 However, it is unlikely that intervention will have a lifelong effect on the drinking patterns of these patients.
The level of evidentiary support for brief interventions exceeds that of most clinical protocols adopted by trauma centers. Studies to determine whether or not treatment works for trauma patients are therefore unnecessary. Instead of additional foundational studies to prove that interventions are effective, translational studies are needed on how to adapt interventions for the appropriate patients within the trauma care setting. Data on effectiveness are already available.
One such translational study modified the motivational intervention used in Project MATCH (described earlier) for trauma center use by reducing it to a single 30-minute session. In this prospective, randomized trial, the intervention group showed a 48% reduction in return visits to the emergency department and a 47% reduction in readmissions to the trauma center (compared with the control group) after up to 3 years' follow-up (Fig. 3).1 The success of this trial led to the adoption of the intervention program as a hospital-funded service by a Level I trauma center in Seattle.
Lack of Collaboration with Trauma Surgeons
There have been significant advances in the treatment of alcohol problems in the past decade. However, these advances have had little impact on trauma care because alcohol treatment specialists and researchers have rarely disseminated their findings to specialists in trauma surgery. Addiction medicine specialists typically practice in an office setting and see patients who have accepted a referral or who are actively seeking treatment. Treatment does not have to be sought to be effective. Many patients who are not actively seeking alcohol treatment present to the health care system for treatment of disorders related to their substance use. Admission to a trauma center may be the only opportunity to provide these patients with an intervention.
Successful implementation of intervention programs in trauma centers will depend on several factors. Specialists in treating substance-use disorders must be willing to seek out and collaborate with trauma surgeons; to integrate their services into a hospital practice rather than a clinic-based environment; to help surgeons design screening and intervention programs; and to provide the necessary oversight, training, and quality review. Alcohol treatment specialists should know that their patients are more likely to die as a result of an injury than from cirrhosis, hepatitis, or pancreatitis. More than 95% of trauma patients are willing to discuss their alcohol intake with a counselor, and a recent life-threatening injury substantially increases their motivation to reduce or stop drinking.19,20
It is equally important for trauma surgeons to learn about brief interventions (i.e., validation of interventions in multiple randomized trials, the development of simple screening questionnaires, and how intervention techniques can easily be incorporated into trauma center routines at minimal cost). Both the alcohol treatment and trauma care fields should include education about substance-use problems and injuries at their respective professional and continuing medical education meetings.
Trauma surgeons may not view prevention of alcohol-related injuries as a key responsibility. This perception presents another obstacle to interventions. Treatment of alcohol use disorders in trauma settings differs from other specialty environments such as coronary care units, where acceptance of the responsibility to prevent repeat cardiac events has led to routine screening for hypertension, hypercholesterolemia, and other risk factors. In respiratory clinics, it is common for pulmonary specialists to ask their patients whether they use tobacco. Advice, assistance, and motivation are routinely offered in an effort to help them quit. Reducing the risk of alcohol-related injuries should be of similar vital interest to trauma surgeons.
Unlike coronary artery disease that cripples or kills only the patient, more than one third of the deaths attributed to drunk driving include other drivers, passengers, or pedestrians, which further increases the rationale for screening and intervention. Injury prevention should be a core responsibility for the trauma surgeon because alcohol use is the most common cause of injury in trauma center patients.
Trauma Center Verification Criteria
Studies of strategies to change physician behavior suggest that standards set by professional organizations and opinion leaders are an effective means of producing positive changes.21 There is clear evidence that acceptance of screening and intervention programs is increasing within trauma professional societies.
A recent survey of American Association for the Surgery of Trauma members found that over 80% of trauma surgeons agree that it is important to discuss alcohol problems with their patients, and a similar percentage believe that a trauma center is an appropriate place to address alcohol problems.22 Unless trauma professional organizations, opinion leaders, and trauma directors advocate prevention of alcohol problems, implementation of screening and intervention programs will be slow, uneven, and dominated by attitudinal obstacles; plus, hospital administrators will balk at providing the resources.
The American College of Surgeons (ACS) has a long history of supporting activities designed to improve care of the injured patient. Even though most trauma centers are verified by a state or regional process, most designating authorities require that trauma centers provide all resources required by the ACS Committee on Trauma. Even in states lacking a formal system of care, hospitals voluntarily seek verification by the ACS Committee on Trauma.
Alcohol screening and intervention should be an essential prevention activity required by the ACS for trauma center verification. Ignoring alcohol problems should be considered the medical equivalent of treating a hypertensive 55-year-old patient with a myocardial infarction while ignoring the underlying hypertension, or of treating patients with emphysema without asking whether they smoke. Hospital administrators will not provide the needed resources if the ACS Committee on Trauma does not insist that trauma patients deserve the same preventive interventions provided to patients with other types of medical problems.
Some trauma surgeons are concerned that requiring trauma centers to provide alcohol interventions constitutes an “unfunded mandate.” To be verified as a Level I or II trauma center, a hospital must offer physical, occupational, and speech therapy and a multidisciplinary rehabilitation team that offers nutritional counseling, pain management, psychology, psychiatry, and vocational counseling. Personnel for trauma registry maintenance, educational activities, community education, monitoring of prevention programs, outreach, and coordination with community prevention activities are also required.
A trauma center typically obtains these resources from the hospital because all are requirements of the ACS Committee on Trauma. Most trauma directors look toward these requirements not as a source of financial burdens but as the primary means of obtaining the support needed from their hospital administration. Hospitals have traditionally provided these resources rather than relinquish status as a trauma center. Overall, since 1991, the number of trauma centers in the United States has increased by 245%.23 Although some hospitals have dropped out of the system, the cause is invariably a lack of commitment by personnel who refuse to provide surgical coverage, rather than the amount of resources required by the ACS Committee on Trauma.
A recent study on the feasibility of alcohol screening and intervention was conducted at four busy trauma centers: Grady Hospital in Atlanta (Emory University), Denver Health (University of Colorado), the University of California at San Diego Medical Center, and the University of New Mexico Health Science Center. At each center, only one half-time employee was needed to provide the service.24 The nominal costs of such a program suggest that the current lack of interventions in trauma centers may be related to the level of importance attached to providing this service relative to competing cost concerns.
New therapies in trauma care are routinely implemented, even if the cost of providing the new therapy does not pay for itself. Unlike some new practices, there is evidence that addressing alcohol problems in trauma centers is cost-effective. Cost-benefit analysis of alcohol interventions for injured patients demonstrates a savings of nearly four dollars in direct injury-related medical costs for every dollar invested in screening and intervention for injured patients.25 Other studies confirm this and show that most savings are attributable to reductions in motor vehicle crashes and reduced use of hospital and emergency department resources.26
Lack of Reimbursement
Trauma surgeons cannot bill insurance providers for alcohol interventions. If they provide advice or an intervention that results in spending more than the usual time allotted for a patient visit, they can bill for a higher level of service using a prolonged service evaluation and management code (99356 and 99357). When counseling or coordination of care takes more than 50% of the time spent with a patient, time becomes the controlling factor when billing for a particular evaluation and management service. For example, if a trauma patient requires 35 minutes for that day's care, including 18 minutes of counseling and coordination, the service can be billed using a time-based code.
Social workers cannot bill extra for screening and intervention because it is usually bundled into their overall fee. However, psychologists, chemical dependency counselors, and other staff with alcohol counseling credentials can bill for their services. In trauma centers with a favorable mix of insured patients, an intervention service is likely to be self-supporting, and most trauma centers can generate revenue to cover the costs.
Insurance Laws and Regulations
Insurance companies are allowed to deny payment for medical bills for injuries that occur while a patient is under the influence of alcohol. In a recent survey, 41% of trauma surgeons who do not screen patients for blood alcohol level cited the potential for denial of payment by the insurance company as a disincentive to providing interventions. The threat of insurance denials was a greater concern than cost, time, confidentiality, or the potential for offending patients.22
The National Association of Insurance Commissioners (NAIC) is an organization dedicated to streamlining the business practices of multistate insurers by maintaining uniformity of insurance laws across states. The primary instrument for doing so are model laws, which are drafted by the NAIC for adoption by the states. In 1947, the NAIC drafted the Uniform Accident and Sickness Policy Provision Law (UPPL), a model law.27 That permits the denial of insurance payments for injuries sustained by persons if they are found to be under the influence of alcohol or drugs. Thirty-eight states adopted the UPPL; four others adopted it provisionally (narcotics only).
The intent of the UPPL was to reduce insurance costs by excluding coverage for injuries that result from “putting oneself in harm's way.” It has not had the desired effect. Trauma surgeons avoid screening for alcohol problems in jurisdictions where the UPPL is or has been enforced. Consequently, insurers wind up paying for treatment because doctors do not perform screening to identify the patients who are intoxicated. Failure to document alcohol use for insurance purposes results in lost opportunities for identifying patients who might benefit from intervention.
Until this law is repealed, trauma centers can overcome the obstacle of nonpayment by using a screening questionnaire to detect alcohol or drug problems. These questionnaires can, and should, be excluded from the medical record to protect patient confidentiality.
There are a number of stakeholders in favor of repealing this anachronistic insurance law. Mothers Against Drunk Driving (MADD) considers repeal of the UPPL to be one of its legislative priorities.28 A drunk driver who is stopped by the police most likely faces at least one night in jail, loss of their driver's license, and a substantial fine. If the same individual has a car crash and is transported to a trauma center, unless law enforcement officers accompany the ambulance to the emergency department and wait until evidence is collected, the intoxicated driver usually escapes all legal and civil consequences. Studies demonstrate that 85% to 96% of drunk drivers involved in a crash avoid detection if they are transported to a trauma center.29 This “safe haven” effect has been called the Achilles heel of efforts to prosecute drunk drivers.
In 2001, the NAIC unanimously voted to amend the UPPL.30 The current model law prevents insurers from denying payment on the basis of patient intoxication. It is up to states to adopt the new model, as was recently done in Maryland, Vermont, North Carolina, North Dakota, Washington, Iowa, Nevada, and Rhode Island. Trauma surgeons, emergency medicine physicians, addiction treatment specialists, and other stakeholders should collaborate to ensure that policy makers are aware of the effects of the UPPL on alcohol screening, obtain legislative sponsorship to adopt the amendment, and be willing to testify in support of this legislative change.
Patient Privacy and Confidentiality
Many trauma surgeons believe that asking patients about alcohol and drug use is an invasion of privacy. Nearly one third of surgeons who do not screen cite this belief as a factor.11,22 However, trials of alcohol screening in primary care, general medical clinics, trauma centers, and emergency departments all demonstrate a high rate of patient acceptance.1,2 Patient surveys indicate that satisfaction with the quality of care is increased when physicians ask questions about alcohol.31
Because there are risks of stigma and discrimination against patients who use drugs or alcohol, confidentiality must be ensured. Federal regulations ensuring patient confidentiality (42 CFR Part 2) were adopted over 20 years ago. The regulations were designed to encourage individuals to seek alcohol and drug treatment. However, confidentiality regulations apply only to specialized alcohol treatment programs; hospitals that have a specialized alcohol treatment program; or medical personnel whose primary function is to provide alcohol and drug abuse diagnosis, treatment, or referral for treatment.
In 1990, the Department of Health and Human Services amended the regulations to specifically exclude records generated by trauma and emergency department physicians.32 The congressional testimony stated, “We do not foresee that the elimination of hospital emergency rooms or surgical wards from coverage will act as a significant deterrent to patients seeking assistance for alcohol and drug abuse” because trauma patients do not come to the hospital to receive alcohol or drug treatment. Therefore, a BAC or screening questionnaire obtained during routine emergency department or trauma center care is not under special protection.
Some trauma centers are now screening and have staff whose primary function is to provide alcohol and drug abuse diagnosis, treatment, or referral for treatment. The reason for obtaining a BAC determines the level of confidentiality required. A trauma surgeon who obtains a BAC or drug toxicology screen to better manage the patient's injuries is not required to protect information identifying the individual as an alcohol or drug user. If a trauma surgeon obtains a BAC or administers a screening questionnaire specifically to provide alcohol screening, counseling, or a referral for counseling, and has specialized staff who will provide this service, the results should be kept confidential under CFR 42 and not be made part of the general medical record.
Release of information about alcohol and drug use requires written permission from the patient using a specialized CFR 42 release form. A general medical consent form is insufficient. This information can only be released against the patient's wishes by issuance of a subpoena. During any subsequent judicial hearing, the patient must be represented by an attorney (or provided an attorney if one cannot be afforded); the hearing must take place in closed chambers; disclosure must document involvement in a crime that is “extremely serious”; and there must be reasonable likelihood that disclosure will provide substantial value to the investigation. Thus, trauma centers that establish a screening and intervention service can keep screening and intervention information separate from the medical chart and can provide patients with considerable confidentiality protections.
Despite CFR 42, insurance contracts typically require the patient to agree to release all medical information to the insurer. The patient effectively signs away the federal right to confidentiality as a condition of the policy. To overcome confidentiality barriers, trauma centers can use questionnaires and keep the results separate from the general medical record as a matter of privacy under CFR 42.
Research Priorities and Funding
For the past two decades, funding priorities for screening and brief intervention research have focused on exporting these procedures to primary care settings. However, many patients with an alcohol problem do not have access to a primary care physician and only interface with the health care system when they come to an emergency department or trauma center for an injury or other acute problem.
Most urban and suburban areas are served by hundreds of primary care practitioners. Implementing screening and intervention services in primary care will require changing the practices of many individuals. Most metropolitan areas are served by only one or two major trauma centers. Changing practice within a few trauma centers offers a more practical means of widely expanding alcohol screening and intervention services in a given community.
Changes in a specialty are more likely to occur if they are supported by research conducted by individuals within the same specialty. Trauma surgeons do not read articles published in journals devoted to psychiatry or substance abuse, so publications in these journals are not likely to have an impact on the practice of trauma care. Consequently, it is important for trauma surgeons to be involved in conducting this type of research and in publicizing their findings within their own specialty journals.
Current funding sources do not foster the development of surgical investigators in this cross-disciplinary area. It is difficult to obtain funds from study sections that review grants for trauma research because peer reviewers in surgery do not view alcohol-related research as being part of their research agenda. There are equally formidable obstacles when attempting to obtain funding from study sections that focus on alcohol research. Reviewers are generally unfamiliar with the operating environment in trauma centers and prefer the use of highly controlled diagnostic and demographic groups to obtain unambiguous answers to questions about treatment. Although this approach has led to great strides in understanding how treatment works, studies conducted by alcohol research specialists may not provide trauma centers with clinically relevant intervention protocols.
The design and peer review of studies on alcohol interventions in trauma centers should embrace the perspectives of trauma specialists. Trauma surgeons understand what research questions are relevant and what types of programs are feasible in trauma care settings. Although grant applications from trauma surgeons may not use the study methods used by alcohol research specialists, funding such research will lead to the growth and development of research methodologies appropriate for trauma centers.
Lack of Collaboration with Partners
Trauma centers have many potential partners among advocacy groups that have an interest in reducing the societal burden imposed by alcohol and drugs. As previously mentioned, one of MADD's legislative priorities is to ensure that “State laws do not allow exclusionary coverage provisions in health insurance policies that would exclude payment of benefits of trauma patients for alcohol screening including BAC testing and alcohol treatment.”33
If trauma centers performed functions that extended beyond the provision of surgical care, federal agencies and private groups that focus on treatment and prevention of alcohol and drug problems would support further development and funding of trauma systems. For example, by providing additional services such as screening, intervention, and referral for its patients, a trauma center could promote its role in the community and help other organizations accomplish their own goals and objectives. This could garner support from such organizations as the National Council on Alcoholism and Drug Dependence, the Center for Substance Abuse Treatment, the National Association of State Alcohol and Drug Abuse Directors, Join Together, the National Association of Addiction Treatment Providers, Physicians and Lawyers for National Drug Policy, and the American Society of Addiction Medicine. By identifying drunk drivers and facilitating interventions to reduce future risk of drunk-driving episodes, trauma centers also could earn support from organizations with an interest in traffic safety such as MADD, the National Commission Against Drunk Driving, and the Governor's Highway Safety Association. Partnerships with these organizations can influence hospital administrators as they consider how to allocate resources for funding intervention programs.
There are obstacles to implementing alcohol screening and intervention programs in trauma centers. These include relative lack of training, knowledge, and collaboration with related specialties in addiction medicine. There are also potential roadblocks in the form of funding and insurance financing.
The maturation of trauma systems has increased awareness of the need to focus on injury prevention in addition to acute care. Because alcohol and drugs are the leading causes of injuries, there is a compelling need for specialists in trauma care, addiction medicine, and public health to develop formal strategies to address these obstacles.
1.Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–483.
2.Monti PM, Colby SM, Barnett NP, et al. Brief intervention for harm reduction with alcohol positive older adolescents in a hospital emergency department. J Consult Clin Psychol. 1999;67:989–994.
3.Longabaugh R, Woolard RF, Nirenberg TD, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. J Stud Alcohol. 2001;62:806–816.
4.Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004;61:498–506.
5.Geller G, Levine DM, Mamon JA, et al. Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism. JAMA. 1989;261:3115–3120.
6.Lewis DC. The role of internal medicine in addiction medicine. J Addict Dis. 1996;15:1–7.
7.Moore RD, Bone LR, Geller G, et al. Prevalence, detection and treatment of alcoholism in hospitalized patients. JAMA. 1989;261:403–407.
8.Gerbert B, Maguire BT, Bleecker T, et al. Primary care physicians and AIDS: attitudinal and structural barriers to care. JAMA. 1991;266:2837–2842.
9.Isaacson JH, Fleming M, Kraus M, et al. A national survey of training in substance use disorders in residency programs. J Stud Alcohol. 2000;61:912–915.
10.D'Onofrio, G. Screening and brief intervention for alcohol problems: what will it take? Acad Emerg Med. 2000;7:69–71.
11.Danielson PE, Rivara FP, Gentilello LM, et al. Reasons why trauma surgeons fail to screen for alcohol problems. Arch Surg. 1999;134:564–568.
12.Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–1123.
13.Selzer ML. The Michigan Alcoholism Screening Test: the quest for a new diagnostic instrument. Am J Psychiatry. 1971;127:1653–1658.
14.Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410–418.
15.American Association for the Surgery of Trauma and the Committee on Trauma of the American College of Surgeons. Guidelines for trauma care fellowships. J Trauma. 1992;33:491–494.
16.Project Match Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH post treatment drinking outcomes. J Stud Alcohol. 1997;58:7–.
17.McLellan AT, Lewis DC, O'Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689–1695.
18.Monti PM, Colby SM, Barnett NP, et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consult Clin Psychol. 1999;67:989–994.
19.National Institute on Alcohol Abuse and Alcoholism. Fourth Special Report to the US Congress on Alcohol and Health. Washington, DC: U.S. Government Printing Office; 1981:83.
20.Apodaca TR, Schermer CR. Readiness to change alcohol use after trauma. J Trauma. 2003;54:990–994.
21.Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–705.
22.Schermer CR, Gentilello LM, Hoyt DB, et al. National survey of trauma surgeons' use of alcohol screening and brief intervention. J Trauma. 2003;55:849–856.
23.MacKenzie EJ, Hoyt DB, Sacra JC. National inventory of hospital trauma centers. JAMA. 2003;289:1515–1522.
24.Schermer CR, Bloomfield LA, Lu SW, Demarest GB. Trauma patient willingness to participate in alcohol screening and intervention. J Trauma. 2003;54:701–706.
25.Gentilello LM, Ebel BE, Wickizer TM, et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005;241:541–550.
26.Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26:36–43.
27.National Association of Insurance Commissioners. Uniform Individual Accident and Sickness Policy Provisions Law in NAIC Model Laws Regulations and Guidelines. Vol II. Kansas City, MO: Model Regulation Service; 2004:180–181.
29.Biffl WL, Schiffman JD, Harrington DT, et al. Legal prosecution of alcohol-impaired drivers admitted to a level I trauma center in Rhode Island. J Trauma. 2004;56:24–29.
30.National Association of Insurance Commissioners. Discussion of alcohol and drug exclusion provision in the Uniform Individual Accident and Sickness Policy Provision Model Act. Minutes from: meeting at NAIC executive headquarters: March 2001, Kansas City, MO.
31.Steven ID, Thomas SA, Eckerman E, Browning C, Dickens E. The provision of preventive care by general practitioners measured by patient completed questionnaires. J Qual Clin Pract. 1999;19:195–201.
32.52 Fed. Reg. 21796, 21797, 1990.
© 2005 Lippincott Williams & Wilkins, Inc.