AHSR 2008 Meeting-Boston MA Reduced Days of Heavy Drinking After SBIRT Differences in patient outcomes by problem severity and client characteristics InSight Research Group Presenters: Dick Spence, PhD and Tom Bohman, PhD This project was supported by a SAMHSA/CSAT grant through the Texas Department of State Health Services (DSHS), Contract #11618.

AHSR 2008 Meeting-Boston MA InSight Research Group Addcition Research Institute - University of Texas-Austin  Richard Spence▪ Albert Yeung  Thomas Bohman▪ Mary Cook  Lynn WallischAllen Pittman Health Behavior Research Training Institute- University of Texas-Austin  Mary Marden Velasquez  Kirk von Sternberg Baylor College of Medicine & Allied Health Sciences  Vicki Waters  Alicia Kowalchuk  Katie McQueen  James Bray Council on Alcohol and Drugs-Houston  Carol Garza Harris County Hospital District  Cecilia Currier▪ Carnelliue Braden  Beryl Rodrigues Texas Department of State Health Services  Dan Rawlins▪ Tamara Allen H

AHSR 2008 Meeting-Boston MA Intervention Sites  Harris County Hospital District – Fourth largest publicly funded urban health care system  Emergency Center of Level I Trauma Center  Emergency Center of Level III Trauma Center  Hospital Inpatient  Hospital Outpatient  Community Health Centers  School-Based Clinics (adolescents are excluded from analysis)  Council on Alcohol and Drugs-Houston  Free standing community InSight counseling center

AHSR 2008 Meeting-Boston MA Intervention Design Standard of Care for all patients BI and BT interventions based on Motivational Interviewing (MI)

AHSR 2008 Meeting-Boston MA Screening, Assessment, & Services Three Question Generalist Screen During Health Care Encounter 1.Do you smoke or use tobacco products? 2.When was the last time you had more than four (4) drinks on one occasion? 3.Do you use marijuana, cocaine, or other drugs? AUDIT, DAST, K6,* GPRA Results determine level of service needed** Brief Intervention AUDIT 8-15 DAST <3 Brief Treatment*** AUDIT DAST 3-8 Referral to Treatment*** AUDIT >19 DAST >=9 *Patients received mental health services referral if their K6 ≥19, in addition to the referral based on their AUDIT and DAST scores. **All patients received a minimum of BI. ***Some BT and all RT are provided by Council on Alcohol and Drugs - Houston Refer to InSight Specialist

AHSR 2008 Meeting-Boston MA Motivational Interviewing Training (MI)

AHSR 2008 Meeting-Boston MA Comprehensive Training System for Specialists  Motivational Interviewing training  Specialists received a series of training workshops  Standardized Patient training  initial and booster trainings  Quarterly in-service trainings

Treatment Fidelity - Coaching Coaching On-going support from highly skilled MI “Coaches.” Sessions were audio taped Coaches met with Specialists bi-weekly to: discuss cases, practice using role-plays, provide feedback from audiotape review The Specialists proficiency with MI skills was evaluated quarterly by the Coaching team using several criteria including the “Motivational Interviewing Treatment Integrity Skill Coding System (MITI).”

1.Do SBIRT patient outcomes vary by levels of alcohol problem severity? 2.Do SBIRT outcomes vary by age, gender, and race/ethnicity? Research Questions

AHSR 2008 Meeting-Boston MA Evaluation Design  Single group – Pre to Post (6 months) comparison  Follow-up sampling process  Original – Public health model which included all patients receiving services into follow-up  Revised –Random sample of people receiving each level of service  Six-month Follow-up process  HCHD Specialists complete GPRA and obtain contact information  HCHD verification team contacts patients to verify locator information  Council on Alcohol and Drugs-Houston maintained contact and completed the 6 month follow-up

 30,894 patients were screened by generalists between 7/1/05-12/31/06  6,216 (20%) screened positive for potential alcohol or drug abuse and were assessed for level of severity  1,421 were selected for follow-up  921 (65%) completed the follow-up interview Analysis Sample Selection

AHSR 2008 Meeting-Boston MA Follow-up Participant Demographic Comparisons  Very similar to non-follow-up sample on demographics  Patients without successful follow-ups (n=500) were younger, higher-risk AODA, and more likely assessed in ER

Characteristics of Participants

AHSR 2008 Meeting-Boston MA  Outcome: Change in Patient’s Self-reported Heavy Drinking in Past 30 Days  Predictors:  Level of Severity  Time  Age  Gender  Race/Ethnicity  Joint Alcohol/Drug Use  Method: Repeated measures mixed Poisson regression model Analysis

AHSR 2008 Meeting-Boston MA Past 30 Days Heavy Drinking: At least one day versus no days Level of severity by time-point interaction (n=649)

AHSR 2008 Meeting-Boston MA Past 30 Days Heavy Drinking: Mean Days Use Level of severity by time-point interaction (n=440)

AHSR 2008 Meeting-Boston MA Past 30 Days Heavy Drinking: Mean Days Use Ethnicity by time interaction

AHSR 2008 Meeting-Boston MA Summary  Change did not vary by age, gender or joint use.  Patients with higher level of severity showed larger changes in probability of any days heavy drinking and mean days of heavy drinking :  Ethnicity by time interaction showed mean reduction in days of heavy drinking were :

AHSR 2008 Meeting-Boston MA Implications for health services research  Patients with more severe problems report greater reductions in heavy drinking.  Consistent positive outcomes across age, gender, joint use and ethnicity supports implementing SBIRT as a standard of practice for all medical patients.  Differences in changes by ethnicity suggest a need for better understanding of why Anglos and African Americans report higher problem levels at intake.  Positive patient outcomes combined with additional data showing cost offsets lead HCHD to fund continued operation of InSight starting 10/1/2008.

AHSR 2008 Meeting-Boston MA Acknowledgments  This project was supported by a SAMHSA/CSAT grant through the Texas Department of State Health Services (DSHS), Contract #  This presentation does not necessarily reflect the views or policy of SAMHSA/CSAT or DSHS  More information, please contact:  Dr. Richard Spence  Dr. Thomas Bohman