152. Substance Use Screening, Brief Intervention, And Referral To Treatment (SBIRT) In Pediatric Practice: A Quality Improvement Project In The Maryland Adolescent And Young Adult Health Collaborative Improvement And Innovation Network

Abstract

The Adolescent and Young Adult Health Collaborative Improvement and Innovation Network (AYAH CoIIN) is a national initiative, composed of states including Maryland, designed to improve adolescent preventive services. The Maryland AYAH CoIIN recognized that there is limited data on how pediatric practices in Maryland have integrated evidence-based practice models. The purpose of this Quality Improvement (QI) project was to evaluate the impact of an SBIRT (Screening, Brief Intervention & Referral to Treatment) training intervention on provider knowledge, confidence, adoption of a validated screen for substance use, delivery of a brief intervention, and screening for associated behaviors such as sexual activity. This project implemented the evidence-based SBIRT model of screening for adolescent substance use using the “CRAFFT” screening tool. A “Plan/Do/Study/Act” approach to QI was utilized. This human subjects’ approved project was conducted in a large 9-provider multidisciplinary pediatric practice serving a diverse patient population with a high Medicaid payer mix in a community with higher than national substance use. Prior to the intervention, no standardized screening tool for substance use was being used. To prepare the intervention, baseline data was collected and the CRAFFT was integrated into the practice’s electronic medical records system to screen for substance use at all well adolescent visits for adolescents aged 13-20 years. The Phase 1 training for providers focused on integration of SBIRT into a busy clinical session, management of positive screens, and referral resources. Phase 2 training reviewed Phase 1 performance, motivational interviewing, and trouble-shooting for the next cycle. Process measures included a pre- and post-Phase 1 provider survey (provider knowledge and comfort with screening/motivational interviewing) and chart review (socio-demographic data, substance use and sexual risk behaviors, service delivery). Data were analyzed using bivariate analyses using SPSS 24. Eighty charts were reviewed (40 pre-training, 40 post-Phase 1), and 9 providers were surveyed. Patients were predominantly white (71%), female (55%), Medicaid-insured (51.3%), with a mean age of 15.7 (STD 2.1). Pre-intervention, 12.5% of adolescents were identified as using substances, and 20% post-intervention. The most commonly used substance was marijuana (11.3%), followed by alcohol (6.3%), tobacco (2.5%), opioids (1.3%), and benzodiazepines (1.3%). From pre-intervention to post, the practice increased their frequency of screening with a validated tool (0% to 67.5%, p<0.001), providing any screening for substance use (85% to 97.5%, p=0.048), and providing a brief intervention (7.5% to 27.5%, p=0.019). From pre- to post-intervention, providers’ confidence improved (58.3% to 78.3%, p=0.005), and providers’ percent correct on the knowledge questions of the survey trended towards improvement (48.2% to 63.9%, p=0.082). Documentation regarding sexual health, a related, but non-targeted screening task, did not significantly improve (72.5% to 85%, p=0.17). Among the 31.5% of patients asked about sexual health, sexual activity was associated with substance use (45% versus 6.8%, p<0.001). Pediatric primary care providers trained in SBIRT and motivational interviewing can improve their screening and management of adolescent substance use. Expansion to pediatric practices in Maryland with a 3rd module focused on the relationship of substance use and sexual behavior is warranted.