Translating research findings into practice: example of treatment services for adolescents in managed care.

An important question in the alcoholism treatment field is how research findings can be translated into real-world clinical practice. Researchers have developed a new research-practice integration (RPI) model that can both drive the formulation of studies and new research questions and promote improvements in treatment quality. The hallmark of this model is a collaborative relationship between the key stakeholders in both alcohol and other drug (AOD) treatment and research, including health plan administrators and clinicians, treatment program administrators, psychiatry and primary care departments, patients and their families, purchasers, and researchers. The issue of technology transfer is especially relevant in the realm of adolescent AOD treatment. The implementation and feasibility of the RPI model are illustrated by a case study of a managed health care plan's treatment services for adolescents with AOD dependence. In this setting, key research findings are being used to shape the plan's adolescent health services

Barriers to and Facilitators of Implementation of Screening, Brief Intervention and Referral to Treatment for Risky Substance Use for Adolescents in Pediatric Primary Care: A Qualitative Interview Study

Alcohol and other drug problems can be devastating to adolescents’ health, mental health and well-being, and early detection and intervention are critically important.1-3 Pediatric primary care, with its emphasis on health promotion is an opportune setting in which prevention and early intervention for substance use problems can occur.4,5 Screening, brief intervention and referral to treatment (SBIRT) for alcohol and drug use problems is a public health approach to early intervention for substance use problems endorsed by the National Institutes of Health, and the Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration,6-9 and recommended by major medical organizations.10-15 SBIRT for adolescents has not been widely implemented in pediatric health care settings however, and there is little research on factors contributing to its implementation in pediatric primary care.16,17 This dissertation uses qualitative data from Key Informant interviews with Kaiser Permanente Northern California (KPNC) and community-based pediatric and specialty mental health and substance abuse treatment clinicians, policymakers and clinical staff to examine feasibility and factors – environmental, organizational, provider- and patient-level, and the nature of the intervention itself – which may inhibit or facilitate implementation of SBIRT in pediatric primary care. The dissertation culminates in a Plan for Change focused on pragmatic steps to facilitate the implementation of adolescent SBIRT in a large integrated healthcare delivery system, KPNC. The qualitative analysis and resulting implementation plan are informed by the findings on implementation outcomes from a cluster-randomized, hybrid implementation and effectiveness trial of different modalities of delivering SBIRT in pediatric primary care, conducted in KPNC.Doctor of Public Healt

Substance abuse and HIV risk behaviours amongst primary health care service users in Cape Town

Objective: To document prevalence of, and association between, substance use and HIV risk behaviours among primary care patients.Method: Cross-sectional survey. Four primary care clinics in Cape Town. We selected clinics using stratified sampling, and systematically selected 131 patients from attendance logs. We assessed substance use with the Alcohol, Smoking and Substance Involvement Screening Test, and HIV risk with items addressing injection drug use, blood-sharing rituals, and sexual risk behaviours. Results: Substances most used at hazardous levels were tobacco (28.2%) and alcohol (14.8%). Among possible HIV risk factors, highest prevalence was participation in blood-sharing rituals (25%), and having had an STI (19.8%). An association between substance use and sexual risk behaviours was only found among those aged 18-24. Conclusion: In younger patients, presence of substance use or HIV risk behaviours increases the probability that the other is present

Substance abuse and HIV risk behaviours amongst primary health care service users in Cape Town

Objective: To document prevalence of, and association between, substance use and HIV risk behaviours among primary care patients.Method: Cross-sectional survey. Four primary care clinics in Cape Town. We selected clinics using stratified sampling, and systematically selected 131 patients from attendance logs. We assessed substance use with the Alcohol, Smoking and Substance Involvement Screening Test, and HIV risk with items addressing injection drug use, blood-sharing rituals, and sexual risk behaviours. Results: Substances most used at hazardous levels were tobacco (28.2%) and alcohol (14.8%). Among possible HIV risk factors, highest prevalence was participation in blood-sharing rituals (25%), and having had an STI (19.8%). An association between substance use and sexual risk behaviours was only found among those aged 18-24. Conclusion: In younger patients, presence of substance use or HIV risk behaviours increases the probability that the other is present. Keywords: substance abuse, HIV risk behaviours, primary care South African Psychiatry Review Vol. 8(4) 2005: 160-16

Challenges of Population-based Measurement of Suicide Prevention Activities Across Multiple Health Systems

Suicide is a preventable public health problem. Zero Suicide (ZS) is a suicide prevention framework currently being evaluated by Mental Health Research Network investigators embedded in six Health Care Systems Research Network (HCSRN) member health systems implementing ZS. This paper describes ongoing collaboration to develop population-based process improvement metrics for use in, and comparison across, these and other health systems. Robust process improvement metrics are sorely needed by the hundreds of health systems across the country preparing to implement their own best practices in suicide care. Here we articulate three examples of challenges in using health system data to assess suicide prevention activities, each in ascending order of complexity: 1) Mapping and reconciling different versions of suicide risk assessment instruments across health systems; 2) Deciding what should count as adequate suicide prevention follow-up care and how to count it in different health systems with different care processes; and 3) Trying to determine whether a safety planning discussion took place between a clinician and a patient, and if so, what actually happened. To develop broadly applicable metrics, we have advocated for standardization of care processes and their documentation, encouraged standardized screening tools and urged they be recorded as discrete electronic health record (EHR) variables, and engaged with our clinical partners and health system data architects to identify all relevant care processes and the ways they are recorded in the EHR so we are not systematically missing important data. Serving as embedded research partners in our local ZS implementation teams has facilitated this work

Benzodiazepine and Unhealthy Alcohol Use Among Adult Outpatients

OBJECTIVES: Concomitant excessive alcohol consumption and benzodiazepine use is associated with adverse health outcomes. We examined associations of unhealthy alcohol use and other patient characteristics with benzodiazepine use. STUDY DESIGN: A cross-sectional analysis of 2,089,525 Kaiser Permanente of Northern California outpatients screened for unhealthy alcohol use in primary care between November 1, 2014, and December 31, 2016. METHODS: We fit multivariable generalized linear models to estimate the associations between unhealthy alcohol use and benzodiazepine dispensation and, among patients who were dispensed a benzodiazepine, mean doses (in mean lorazepam-equivalent daily doses [LEDDs]) and prescription durations. We controlled for patient sex, age, race/ethnicity, estimated household income, Charlson Comorbidity Index (CCI) score, anxiety disorder, alcohol use disorder, insomnia, musculoskeletal pain, and epilepsy. RESULTS: In the 12 months centered around (6 months before and 6 months after) the first alcohol-screening visit, 7.5% of patients used benzodiazepines. The following characteristics were independently associated with higher rates of benzodiazepine use, higher LEDD, and longer prescription duration: older age, white race/ethnicity, lower estimated household income, higher CCI score, and the presence of an anxiety disorder, insomnia, musculoskeletal pain, or epilepsy. Women and patients with an alcohol use disorder or unhealthy alcohol use, compared with men and patients with low-risk drinking or abstinence, were more likely to use a benzodiazepine; however, their LEDDs were lower and their prescription durations were shorter. CONCLUSIONS: Benzodiazepine use in primary care was associated with older age, female sex, white race/ethnicity, lower socioeconomic status, and unhealthy alcohol use. These findings may be applied to develop policies and interventions to promote judicious benzodiazepine use

Accounting for quality improvement during the conduct of embedded pragmatic clinical trials within healthcare systems: NIH Collaboratory case studies

Embedded pragmatic clinical trials (ePCTs) and quality improvement (QI) activities often occur simultaneously within healthcare systems (HCSs). Embedded PCTs within HCSs are conducted to test interventions and provide evidence that may impact public health, health system operations, and quality of care. They are larger and more broadly generalizable than QI initiatives, and may generate what is considered high-quality evidence for potential use in care and clinical practice guidelines. QI initiatives often co-occur with ePCTs and address the same high-impact health questions, and this co-occurrence may dilute or confound the ability to detect change as a result of the ePCT intervention. During the design, pilot, and conduct phases of the large-scale NIH Collaboratory Demonstration ePCTs, many QI initiatives occurred at the same time within the HCSs. Although the challenges varied across the projects, some common, generalizable strategies and solutions emerged, and we share these as case studies. KEY LESSONS: Study teams often need to monitor, adapt, and respond to QI during design and the course of the trial. Routine collaboration between ePCT researchers and health systems stakeholders throughout the trial can help ensure research and QI are optimally aligned to support high-quality patient-centered care

Border Insecurity: Reading Transnational Environments in Jim Lynch’s Border Songs

This article applies an eco-critical approach to contemporary American fiction about the Canada-US border, examining Jim Lynch’s portrayal of the British Columbia-Washington borderlands in his 2009 novel Border Songs. It argues that studying transnational environmental actors in border texts—in this case, marijuana, human migrants, and migratory birds—helps illuminate the contingency of political boundaries, problems of scale, and discourses of risk and security in cross-border regions after 9/11. Further, it suggests that widening the analysis of trans-border activity to include environmental phenomena productively troubles concepts of nature and regional belonging in an era of climate change and economic globalization. Cet article propose une lecture écocritique de la fiction étatsunienne contemporaine portant sur la frontière entre le Canada et les États-Unis, en étudiant le portrait donné par Jim Lynch de la région frontalière entre la Colombie-Britannique et Washington dans son roman Border Songs, paru en 2009. L’article soutient que l’étude, dans les textes sur la frontière, des acteurs environnementaux transnationaux – dans ce cas-ci, la marijuana, les migrants humains et les oiseaux migratoires – jette un jour nouveau sur la contingence des limites territoriales politiques, des problèmes d’échelle et des discours sur le risque et la sécurité des régions transfrontalières après les évènements du 11 septembre 2001. Il suggère également qu’en élargissant l’analyse de l’activité transfrontalière pour y inclure les phénomènes environnementaux, on brouille de façon productive les concepts de nature et d’appartenance régionale d’une époque marquée par les changements climatiques et la mondialisation de l’économie