Hungerford, Daniel W. PhD
In an effort to broaden research and to increase the role of brief interventions for alcohol and drug problems in trauma centers, investigators at the Centers for Disease Control and Prevention collaborated with other agencies to convene a national conference from May 28 to 30, 2003, in Arlington, Virginia. Participants included clinicians and researchers from emergency medicine and trauma surgery, psychiatrists, psychologists, alcohol researchers, epidemiologists, policy advocates, and representatives from various federal and state agencies involved in alcohol-related research and substance treatment efforts. Intensive interaction between presenters and participants occurred during each session. On the final day of the conference, participants were given draft recommendations for review and discussion. Final recommendations incorporate feedback from this discussion and were approved by the conference steering committee. For the convenience of the reader, these recommendations summarize the conference results.
The recommendations will be more useful if readers use a common definition of screening, brief intervention, and referral to treatment (SBIRT). Screening is different from case finding. In case finding, a clinician evaluates patients who appear to have a medical or psychological condition to arrive at a diagnosis. The goal is diagnosis and the target is the individual patient. In screening, program staff use a screening instrument with every member of a predefined group of patients to identify and measure risk factors for a condition. Screen-positive patients receive an intervention to decrease that risk. Depending on the condition and risk factors of interest, screen-positive status may or may not lead to a diagnostic evaluation. The goal is quantifying risk and the target is a predefined group.
The prevailing practice in most medical clinics is to address patients with obvious alcohol-related problems: case finding. However, case finding does not identify most patients with alcohol problems because the role of alcohol is not readily evident, or the screening instrument may not be appropriate for the condition of interest. For example, blood alcohol concentrations are appropriate to identify the degree to which patients are intoxicated; self-report questionnaires are appropriate to identify the level of usual alcohol consumption, alcohol-related harm, or symptoms of alcohol dependence.
The term “brief intervention” is defined many ways in the published literature and, historically, can include three or four separate counseling sessions. However, for the purposes of these recommendations, a brief intervention is defined as a postscreening interaction between a patient and staff during the medical visit or hospitalization and can last from 5 minutes to 20 minutes or more. Staff do not usually have advanced professional counseling credentials, but are specially trained to provide brief interventions. For a patient with less severe problems, the goal of the brief intervention is for the patient to decrease or stop drinking. For a patient who has problems severe enough to warrant more extensive treatment, the goal is to increase the patient’s motivation to seek more intensive treatment. The brief intervention may also include efforts to ensure patient access to appropriate specialized treatment.
Final conference recommendations are listed below. Immediately after the list is text that provides the background and rationale for each recommendation.
1. Disseminate evidence about intervention efficacy and effectiveness.
2. Make SBIRT for substance use disorders routine practice in trauma centers even as appropriate implementation studies are being conducted.
3. Fund implementation research that involves the trauma community.
4. Make SBIRT for substance use disorders an essential component of trauma care.
5. Develop better systems of reporting substance use problems to improve surveillance.
6. Change insurance regulations.
7. Insurers should reimburse trauma center staff for SBIRT for substance use disorders.
Recommendation 1: Disseminate Evidence about Intervention Efficacy and Effectiveness
Expert and consensus panels have evaluated the body of evidence on the efficacy and effectiveness of SBIRT on substance use problems. There is clear evidence that much can be done to reduce substance use problems and their consequences. The American College of Surgeons Committee on Trauma (COT) should disseminate this evidence and the panel’s recommendations throughout the field of trauma surgery.
Researchers who study the treatment of substance use disorders already know that brief interventions in health care settings can improve health outcomes for injured patients by reducing repeat injuries, emergency department and trauma center readmissions, subsequent alcohol use, health care costs, and other negative consequences. Although the Institute of Medicine (IOM), medical professional panels, and other authoritative groups have recommended that brief interventions be implemented in a variety of medical settings—including emergency departments and trauma centers—many physicians and nurses are unaware of these recommendations and the body of evidence supporting brief interventions, or are not convinced that these services actually help patients. Trauma staff cannot be expected to support these services unless they have been fully informed of the evidence.
The need to address substance use problems among trauma patients is great. Research studies have found that up to 50% of patients who present for treatment at trauma centers screened positive for alcohol or drugs. However, trauma centers cannot address the problem because these patients are not routinely identified. Fewer than one in seven hospitalized trauma patients have any medical record notation that they underwent blood alcohol testing or were administered an alcohol screening questionnaire.
This knowledge must be disseminated to individuals and groups who control funding and set policies governing routine practice—federal agencies and leaders of professional groups such as the American Association for the Surgery of Trauma, the Society of Trauma Nurses, the American Trauma Society (ATS) and its Committee on Trauma (COT), the American Hospital Association, the Joint Commission on Accreditation of Healthcare Organizations, and other organizations devoted to trauma care.
Dissemination can be accomplished by presentations that lead to continuing medical education credits, peer-reviewed articles in journals such as The Journal of Trauma, the Journal of the American College of Surgeons, Annals of Emergency Medicine, the Journal of Emergency Nursing, and other publications read by health professionals and administrators working in trauma centers. Researchers of substance use disorders should be invited to partner with trauma specialists to produce presentations, training materials and sessions, and journal articles.
Recommendation 2: Make SBIRT for Substance Use Disorders Routine Practice in Trauma Centers Even as Appropriate Implementation Studies Are Being Conducted
To facilitate broad acceptance of SBIRT for trauma patients with substance use disorders, all trauma centers—academic and nonacademic—should focus on making protocols more efficient, helping trauma services overcome barriers, and developing flexible practice models. Randomized clinical trials in trauma centers and other medical settings consistently demonstrate that brief interventions can help such patients reduce alcohol intake and related consequences such as injury. However, demonstrated efficacy does not automatically lead to changes in routine practice. Despite the proven efficacy of brief interventions in diverse clinical settings, few studies have focused on methods to adapt treatment protocols or to optimize them for delivery in trauma centers. Such implementation research would encourage the adoption of brief interventions as part of routine trauma care.
Protocols developed for efficacy studies are generally too complicated for use in real-world clinical settings. Implementation studies are needed to evaluate protocols modified for use by non-research staff. The objectives of such studies are to improve the outcomes of brief interventions for trauma patients, decrease implementation cost, and develop protocols that are effective in varied trauma centers settings—urban and rural, academic and nonacademic, or county and private hospitals. Protocols that accommodate variations in operational realities and patient populations are more likely to be accepted by trauma center staff, and patients, and be adopted as part of routine trauma care.
Implementation studies also can pave the way for widespread use of new practices by developing and evaluating training tools, start-up manuals, practice guidelines, and performance metrics for measuring and maintaining quality services. For example, implementation studies can identify protocol components that improve patient outcomes, increase efficiency of screening and intervention programs in trauma centers, and reduce injury recidivism. This knowledge will allow trauma centers to make protocols more efficient and to tailor them to a specific center’s needs.
In short, implementation studies are essential if SBIRT is to become part of routine trauma care. It would be a fundamental misunderstanding of the concept of implementation research if trauma centers delayed implementation of SBIRT until after such research is completed. Instead, implementation studies should help evaluate, improve, and adapt SBIRT at the same time it is being implemented as routine practice.
Recommendation 3: Fund Implementation Research that Involves the Trauma Community
Federal agencies and private foundations should fund research in trauma centers to find more effective ways to implement screening, brief interventions, and referral to specialized alcohol and drug treatment. To ensure that the resulting research products are feasible, effective, and likely to be adopted by trauma centers, research projects should include members of the trauma community on teams that design and conduct implementation studies.
Federal agencies and other funding groups have not supported brief alcohol interventions in trauma centers with the same level of funding as that provided in primary care settings. Trauma surgeons either have had difficulty competing for available funding or they are unaware that such funding exists. Nonetheless, trauma centers provide a particularly promising setting for brief alcohol interventions. Every year, these centers admit more than 3.5 million seriously injured patients. Compared with primary care patients, trauma center patients have a much higher prevalence of alcohol and drug problems, and they are particularly receptive to interventions. Furthermore, the types of patients typically seen in trauma centers are generally not likely to visit primary care practitioners. Consequently, admission to a trauma center may offer the only opportunity to provide interventions for these patients.
Compared with practices in other medical settings such as primary care clinics, trauma care tends to be more uniform because the services offered in trauma centers must be in accordance with standards provided by the COT in Resources for Optimal Care of the Injured Patient. This document describes all practices and components that the COT considers essential for trauma centers to achieve or maintain trauma center status. As a result, integrating new services and protocols into routine trauma care throughout the country is much easier than integrating new practices in other medical settings. Furthermore, to maintain trauma center status, hospitals must maintain a trauma registry that contains data on every patient. This provides each trauma center with a repository of information for research and quality improvement projects. The registry also provides the COT with a structure for quality assurance and for monitoring institutional compliance with COT care standards.
Despite the compelling reasons for providing SBIRT programs to injured patients, most studies have been conducted in primary care clinics and did not result in intervention protocols suitable for use in trauma centers. Trauma centers have different types of patients and different operational demands; therefore, different protocols are required. Because emergency departments and trauma centers are particularly busy, complicated clinical settings, flexible protocols must be tailored to the varying operational requirements of different institutions.
Furthermore, most grants on brief intervention in medical settings are awarded to researchers who specialize in alcohol treatment research. These researchers have primarily focused on demonstrating treatment efficacy, comparing the relative efficacy of different types of treatments, and on identifying the effects of various elements of the treatment process. Many of the intervention studies were lengthy and involved multiple sessions. Consequently, few studies produced protocols suitable for trauma centers.
To conduct implementation studies that will support screening and brief intervention for routine use in trauma centers, a different mix of investigators will be required. Substance use treatment professionals are a necessary part of that mix, but just as necessary are trauma surgeons and emergency physicians, nurses, social workers, hospital administrators, health services researchers, health economists, legal experts, and professional organizations such as the COT. These stakeholders are in the best position to help develop and evaluate the utility and practicality of proposed implementation studies and resulting practice models.
Currently, the study sections that decide which proposals will be funded are usually composed of people who have little or no experience with trauma centers. Likewise, they are not familiar with implementation study goals or methods. Therefore, selection processes should encourage interdisciplinary collaborations between basic and clinical investigators involved in trauma care. To facilitate such collaborative efforts, federal and private agencies should target funding for implementation research projects in trauma centers, include trauma surgeons and emergency physicians who have conducted this type of research in study sections, and solicit proposals that foster interdisciplinary collaboration.
Recommendation 4: Make SBIRT for Substance Use Disorders an Essential Component of Trauma Care
The COT’s ‘Resources for Optimal Care of the Injured Patient’ should adopt language stating that SBIRT is an essential component of care in Level I and Level II trauma centers.
By offering preventive intervention services, trauma centers position themselves to participate in a larger public health strategy. In its Guide to Clinical Preventive Services, the U.S. Preventive Services Task Force notes “the majority of deaths among Americans below age 65 are preventable, many through interventions best provided in a clinician’s office.” Although this document was intended for use in primary care settings, it also applies to specialists. For example, cardiologists offer blood pressure management, and pulmonologists offer smoking cessation programs. Not only do these specialists treat specific diseases, they also help to prevent those diseases by managing underlying risk factors.
The COT already requires Level I and Level II trauma centers to be engaged in injury prevention activities. Because alcohol and drug use are the principal risk factors leading to serious injury, identifying patients with these risk factors and providing interventions should be an essential part of a trauma center’s mission.
By requiring SBIRT as a routine component of care, trauma centers can address the most prevalent risk factors for trauma patients and thereby reduce injuries and other consequences related to substance use. This service will enhance the trauma center’s value to the community because its expanded mission will share common elements with the goals of organizations such as Mothers Against Drunk Driving (MADD), the American Society for Addiction Medicine, law enforcement agencies, and the recovery community. These links not only communicate the importance of trauma centers to local and regional communities, but also garner support for their existence and funding from outside the medical community.
Substance use problems consume a large proportion of trauma resources. The trauma community’s response should be commensurate with the magnitude of the problem. Although providing SBIRT services is not the primary mission of trauma centers, requirements should be defined so that trauma centers can provide effective services without being overburdened.
Screening and brief intervention programs often focus on patients with mild to moderate alcohol problems. However, these programs should also include referrals to more extensive alcohol treatment for patients whose screening results indicate more severe problems such as alcohol dependence. The COT should consider these factors in the language of its requirement.
Recommendation 5: Develop Better Systems of Reporting Substance Use Problems to Improve Surveillance
Although many trauma patients experience alcohol and drug problems, population-based surveillance data about these problems are not available. Therefore, reporting substance use problems to public health or other appropriate authorities should be mandatory. The COT and the American College of Emergency Physicians should request that appropriate federal agencies form an advisory panel representing affected stakeholders to explore ways to improve surveillance estimates.
In addition to the value of blood alcohol concentration testing in clinical management, routine testing can bolster important public health objectives. Data obtained by testing has a number of uses: to facilitate screening and brief interventions and entry into treatment; to design programs to prevent alcohol- and drug-related medical problems and trauma; to monitor emerging trends in alcohol and drug use; to provide policy makers and governmental agencies with more accurate and representative information about the magnitude of substance use problems in specific communities; to document the need to address substance use problems, which can facilitate funding decisions; and to evaluate the effectiveness of impaired driving prevention efforts.
Current estimates of the prevalence of substance use problems among trauma patients are inadequate. Most published estimates come from single-institution studies and therefore cannot be generalized to the total U.S. population of trauma patients. Studies based on multiple institutions may not be valid or reliable because methods of identifying substance use problems are not uniform across practitioners and institutions. Another problem with current estimates is that biochemical tests or self-report screening instruments are not routinely ordered for all or even for a statistically valid sample of patients. Therefore, the patients tested likely represent a biased sample because trauma staff test only patients they suspect are intoxicated or have alcohol problems.
Estimates based on national databases are also problematic. The Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network (DAWN) collects data on drug-related visits to a representative sample of U.S. emergency departments. However, it only captures data when the drug-related visit is the primary or secondary diagnosis and only records alcohol-related visits when the visit is also drug related. The American College of Surgeons’ National Trauma Data Bank (NTDB) is also inadequate as a surveillance system for substance use problems—as of 2002, approximately two thirds of trauma centers were not participating, and the majority of patient entries into the database (64%) did not include a blood alcohol concentration measurement. Generally, testing is infrequent and usually performed only when the physician believes the patient is under the influence of one or more intoxicants. Studies have shown that the use of clinical suspicion to detect the presence of alcohol intoxication in trauma patients is inaccurate, especially in patients who are brain injured or in shock, and results in underreporting. Moreover, because the NTDB alcohol variable reports only the presence or absence of alcohol—not the level of blood alcohol—it is not possible to evaluate a trauma patient’s level of intoxication.
A mandatory reporting system that is both feasible and capable of producing valid estimates would require careful planning and support from a variety of stakeholders. To develop a pilot program, critical questions must first be addressed. What are the primary goals of the system? Are they to estimate the prevalence and trends of substance use conditions among trauma patients; to facilitate further substance use treatment; to support legal or administrative action? To whom should the data be reported? The answers to these questions will help determine what data will be collected. Arriving at valid and feasible answers will require an ongoing process that involves all affected stakeholders. The process would have two main goals: to evaluate whether existing data collection systems can be modified to achieve surveillance goals and to design a system—new or modified—that can balance competing interests, operational realities, and surveillance goals. We have described the need and the potential goals and benefits of such a system. Rather than recommend a specific process, we recommend that the Committee on Trauma and the American College of Emergency Physicians initiate the process.
Recommendation 6: Change Insurance Regulations
Statutes in most states allow medical insurance policies to exclude coverage for treatment if a patient’s injuries are alcohol or drug related. This exclusion poses a major barrier to routine blood alcohol testing and screening of trauma patients for substance use disorders. It also stigmatizes patients and impedes best management practices of a treatable disease. State laws should be changed to prohibit insurance companies from denying payment for treatment of patients based on documented use of alcohol or drugs. Trauma centers, surgeons, and hospital administrators should use their influence to call for changes in legislation in their states.
In 1947, the National Association of Insurance Commissioners (NAIC) created a model law called the Uniform Accident and Sickness Policy Provision Law (UPPL). The relevant part of that law reads: “The insurer shall not be liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.”
The NAIC’s intent was to promote uniform insurance legislation throughout the country by creating a model law on which states could base their own insurance legislation. Most states adopted the model. Consequently, insurance companies in these states can deny payment for medical services provided to patients with alcohol- or drug-related injuries. The statutes neither specify a level of intoxication nor require proof of a causal link. Prevailing societal attitudes may have led to widespread adoption of these laws as a morals clause, as a method to reduce drunk driving by increasing the associated financial risks, or as a means of reducing insurance costs.
Some states did not adopt the 1947 UPPL model and have no statutory law addressing insurance payment for alcohol- or drug-related injuries. In these states, courts have ruled that insurers can write such clauses into their policies. For example, consider a Connecticut court case. In September 2003, an underage intoxicated driver was involved in a motor vehicle crash and was taken to a Level I trauma center for treatment, generating a $245,235 medical bill. The insurance company’s refusal to pay this medical claim was upheld by the 2nd U.S. Court of Appeals. Court decisions such as this and prevailing UPPL laws have broad negative consequences for dealing with a major public health problem.
In trauma centers, the prevailing methods for identifying patients with alcohol and drug problems are testing blood for alcohol concentrations and urine for drug levels. These tests enhance diagnostic sensitivity, objectively validate self-reported alcohol or drug use, and can be implemented with minimal cost. However, if information on alcohol or drug use becomes part of the patient’s medical record, insurance companies can use this information as a basis for denying payment. Consequently, trauma surgeons have valid concerns regarding the potential financial impact of participation in screening and brief intervention programs.
When trauma surgeons do not adequately document substance use by patients involved in motor vehicle crashes, valuable impaired-driving data are lost. This not only hampers prosecutors’ investigations of crashes, but also affects prevention efforts. Even in states with mandatory testing laws, alcohol use is tested in fewer than half of those drivers involved in crashes resulting in death, injury, or property damage. Insurance laws that threaten reimbursement to physicians and hospitals may contribute to this low testing rate. Changing those laws to prohibit exclusionary language would encourage routine blood alcohol concentration and urine toxicology testing.
Trauma surgeons sometimes need information about a patient’s alcohol and drug use for optimal clinical management. They may need it to determine the cause of an altered mental status, detect patients at risk for withdrawal symptoms, ensure that patients are competent to provide consent for medical procedures, or determine the reliability of physical symptoms such as abdominal or spinal column pain. Consequently, trauma surgeons are on the horns of a dilemma: test for substance use and risk financial repercussions or avoid testing and proceed with treatment without potentially important information. The net result is that the insurance practice of denying payment in these cases penalizes both patients and trauma centers. In addition, it hinders widespread adoption of screening and brief intervention programs in trauma centers.
In June 2001, after a year of meetings, NAIC members decided unanimously to amend the 1947 UPPL model law. The amendment recommends that states write laws prohibiting medical expense policies from excluding coverage for treatment of alcohol- and drug-related injuries. Furthermore, a medical expense policy was defined as “…an accident and sickness insurance policy that provides hospital, medical, and surgical expense coverage. …”
States are not required to adopt the amendment. However, the National Conference of Insurance Legislators (NCOIL) passed a resolution supporting this amendment and sent letters to insurance commissioners and key state legislators recommending its adoption. The endorsement by these two organizations has had an impact. As of April 2005, six states—Maryland, Iowa, North Carolina, South Dakota, Vermont, and Washington—either have repealed UPPL-related statutes or have passed new laws based on the current NAIC amendment. In addition, bills to repeal or change UPPL-related laws are being considered in four states—California, Nevada, Rhode Island, and Texas.
Recommendation 7: Insurers Should Reimburse Trauma Center Staff for SBIRT for Substance Use Disorders
Doctors, nurses, and other health care practitioners who work in trauma centers and are trained to address patients’ alcohol and drug problems should be able to bill for their services and be reimbursed by health care payers. The COT and the ACEP should take the lead in developing billing codes and actuarial studies of SBIRT to foster changes in routine insurance practices.
Currently, insurers (the federal government, health maintenance organizations, and private health insurance companies) pay for treatment of injuries in trauma centers, but do not reimburse trauma surgeons or their surrogates for providing prevention interventions.
When more than 50% of the surgeon’s time during a patient encounter is spent on “counseling and coordination of care,” a time-based billing code that reimburses at a higher level can be used to cover the cost of the intervention. However, trauma surgeons, trauma nurses, and others cannot bill specifically for providing SBIRT services. Only psychologists, psychiatrists, alcohol treatment specialists, and other individuals with mental health specialty credentials can bill for this type of service.
In Broadening the Base of Treatment for Alcohol Problems, the IOM states that the responsibility to provide SBIRT does not rest solely on substance use treatment specialists. The IOM recommends expanding the responsibility for screening and counseling to physicians and other health care specialists who work in medical settings where alcohol problems are frequently encountered (e.g., trauma centers). Consensus panels, professional organizations, and task forces have reiterated this recommendation. However if these services must be donated because healthcare organizations refuse to reimburse for them, the base of treatment is not likely to broaden significantly.
Some trauma centers may wish to hire mental health or addiction specialists specifically to provide SBIRT, but this may not be the optimal model for all centers. The establishment of billing and reimbursement procedures for SBIRT will facilitate its widespread adoption in trauma centers.
The lack of reimbursement for interventions by staff who are trained to provide SBIRT, but are not certified substance abuse treatment specialists, is also contrary to IOM recommendations in Crossing the Quality Chasm: A New Health System for the 21st Century. Those recommendations state that reimbursement should align with recommended practice patterns, evidence-based medicine, and optimal treatments. Because billing codes have not been developed to allow nonspecialists to bill for these services, current reimbursement practices provide no financial incentive for trauma surgeons and trauma centers to incorporate interventions into their daily practice. The COT, ACEP, and other clinical professional societies involved with trauma care should take the lead in developing billing codes and actuarial studies of SBIRT that would be positive incentives to change routine insurance practices.
© 2005 Lippincott Williams & Wilkins, Inc.