Assessing the relationship between medical residents' perceived barriers to SBIRT implementation and their documentation of SBIRT in clinical practice

Abstract

Of the 17.9 million adult Americans who have an alcohol use disorder, most (89%) are unaware of their condition.1 The Centers for Disease Control and Prevention (CDC) lists more than 30 specific immediate and long-term health risks associated with excessive alcohol use,2 suggesting that identifying and addressing alcohol use is an important component of primary medical care. Screening, brief intervention, and referral to treatment (SBIRT) is an integrated and validated approach to identifying risky or problematic alcohol use and providing services to those who need them.3 In 2009, Indiana University School of Medicine (IUSM) reached a cooperative agreement with the Substance Abuse and Mental Health Services Administration (SAMHSA) to begin training its medical residents in SBIRT. The training curriculum focuses on delivery of SBIRT services using motivational interviewing techniques (MI). In addition to developing this curriculum and integrating it into the first year of medical residency at IUSM, we developed a protocol for implementing SBIRT services at an internal medicine continuity clinic. This clinic is part of a larger safety-net health system in Indianapolis at which some residents are assigned a small panel of patients during their internal medicine residency. At the time of the study, the continuity clinic was classified as a community health centre, though it since has received federally qualified health center (FQHC) designation. Medical conditions presenting in the clinic vary, with a predominance of adult chronic diseases such as hypertension, heart failure, diabetes, and chronic obstructive lung disease. At each visit, all adult patients were screened for alcohol, drug, and tobacco use by a medical assistant (MA) using the AUDIT-C tool and single drug and tobacco screening questions. These data were given to care providers, both medical residents and staff physicians, to enable delivery of targeted SBIRT services. At the conclusion of each clinical encounter, providers were then asked to document the components of SBIRT that they completed by responding to four yes/no statements, such as ‘I referred the patient to a substance abuse counselor.’ However, across 9954 initial physician visits with unique patients that occurred between 1/31/2011 and 6/29/2012 (hereafter ‘the study period’), we observed a high frequency of incomplete SBIRT encounter forms (83.8%), meaning that the physicians generally were not documenting whether they completed SBIRT. While this was seen as a cause for concern, logically, we could not conflate incomplete forms with a failure to provide SBIRT services. We therefore were moved conceptually to separate two distinct behaviours: actually performing SBIRT, and documenting that SBIRT was completed. In order for SBIRT to be an integrated part of primary medical care, all associated processes and results need to be recorded. Since we have access to evaluative data collected during their SBIRT training that assesses residents’ anticipated barriers to utilizing SBIRT and MI in their medical practice, we examined whether medical residents’ self-reported barriers to performing SBIRT or using MI in their clinical practice predicted appropriate SBIRT documentation in their clinical practice.