Sustained Patient-centered Alcohol Related Care (SPARC) Trial and - - PowerPoint PPT Presentation

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Sustained Patient-centered Alcohol Related Care (SPARC) Trial and - - PowerPoint PPT Presentation

Nov 18, 2023 131 likes •732 views

Sustained Patient-centered Alcohol Related Care (SPARC) Trial and Future Michigan-SPARC Kathy Bradley, MD, MPH AHRQ Panel: Implementing PCOR Evidence PCORI Annual Meeting Washington DC, September, 19 2019 AHRQ R18 HS023173 Sustained

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AHRQ R18 HS023173

Sustained Patient-centered Alcohol Related Care (SPARC) Trial and Future Michigan-SPARC

Kathy Bradley, MD, MPH AHRQ Panel: Implementing PCOR Evidence PCORI Annual Meeting Washington DC, September, 19 2019

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AHRQ R18 HS023173

Sustained Patient-centered Alcohol Related Care (SPARC) Trial

Overview

  • SPARC Trial – recently completed
  • Michigan SPARC recently funded

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SPARC Trial

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AHRQ R18 HS023173

Co-Investigators

  • Amy Lee
  • Jennifer Bobb
  • Julie Richards
  • Evette Ludman
  • Carol Achtmeyer
  • Malia Oliver
  • Chester Pabiniak
  • Ryan Caldeiro
  • Rebecca Parrish
  • Joseph Glass
  • Emily Williams
  • Paula Lozano

Funding Sources: AHRQ – R18 HS023173 – SPARC Trial AHRQ – R18 HS027076– Michigan SPARC Trial K24AA022128 – support for secondary analyses NIAAA R21 AA023037 patient decision aid

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AHRQ R18 HS023173

Sustained Patient-centered Alcohol Related Care (SPARC) Trial

  • Pragmatic implementation trial
  • Kaiser Permanente Washington’s primary care clinics
  • Two evidence-based practices implemented:

 Preventive alcohol screening & brief counseling  Treatment of alcohol use disorders (AUD)

Bobb IJERPH 2017; Glass Implementation Science 2018 USPSTF: Jonas Ann Intern Med 2012; Moyer Ann Intern Med 2013 Jonas JAMA 2014; Bradley & Kivlahan JAMA 2014

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AHRQ R18 HS023173

Sustained Patient-centered Alcohol Related Care (SPARC) Trial

Specific Aims

  • 1. To increase the proportion of PC patients who

have unhealthy alcohol use identified and who are offered brief preventive counseling

  • 2. To increase the proportion of PC patients who

have an AUD recognized and were engaged in alcohol-related treatment

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Overview SPARC Trial & Implementation Intervention

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SPARC Trial: Setting

  • January 2015 - July 2018
  • Kaiser Permanente Washington
  • All 25 primary care clinics: 3 pilot & 22 trial
  • Stepped-wedge trial: 7 waves
  • IRB: waivers of consent & HIPAA

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

SPARC Implementation Intervention

Alcohol-related clinical care

  • 1. Alcohol screening
  • 2. Preventive counseling: unhealthy alcohol use
  • 3. DSM-5 symptom checklist (0-11): high risk
  • 4. Shared decision-making re: options
  • 5. Engagement in treatment

Bobb IJERPH 2017; Glass Implementation Science 2018

A ReThink of the Way we Drink

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AHRQ R18 HS023173

SPARC Implementation Intervention

Implementation Strategies

  • 1. EHR tools
  • 2. Performance monitoring and feedback
  • 3. Practice facilitation (coaching) …

 Quality improvement by local team  Stigma reduction: video & handout  Improved knowledge & understanding

Bobb IJERPH 2017; Glass Implementation Science 2018

A ReThink of the Way We Drink

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AHRQ R18 HS023173

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AHRQ R18 HS023173

For BI

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AHRQ R18 HS023173

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AHRQ R18 HS023173

Stigma Reduction

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AHRQ R18 HS023173

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AHRQ R18 HS023173

SPARC Trial – 25 PC Clinics

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SPARC What Happened?

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AHRQ R18 HS023173

SPARC Trial

  • Primary care leader who partnered left
  • Mental health leaders willing to support trial if …

Depression and suicidality Alcohol cannabis and other drug use

  • Implemented as Behavioral Health Integration
  • 7-item paper screener – MA into EHR
  • Assess on paper: depression, suicide, DSM-5

symptom checklists alcohol & other substance use

  • Only pilot approved initially

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

SPARC: Lessons from Pilot Phase

Health system financially stressed

  • Decreased staffing
  • Leadership changes
  • Morale low
  • No QI practices in primary care
  • End of Pilot Year, acquisition announced
  • Leaders only agreed to Year 1 of trial

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

Implementation: 4 Phases Each Site

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AHRQ R18 HS023173

Implementation: 4 Phases Each Site

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AHRQ R18 HS023173

Implementation: 4 Phases Each Site

Usual Care

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AHRQ R18 HS023173

Implementation: 4 Phases Each Site

Intervention

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AHRQ R18 HS023173

SPARC: Lessons from Pilot Phase

Intensive Practice Coaching

  • Weekly scheduled meetings required – 6 months
  • Video and handout: big success
  • DSM-5 Alcohol Symptom Checklists helpful
  • Positive stories – huge positive impact
  • But only 1 hour provider training

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

No, we can’t do this month. How about never? Is never good for you?

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AHRQ R18 HS023173

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AHRQ R18 HS023173

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AHRQ R18 HS023173

SPARC Trial

EHR tools

  • Prevention: prompts for MA

 Screening and assessment  Give provider alcohol handout  No PCP prompt for brief alcohol counseling

  • Alcohol treatment

 Best Practice Alert: need to initiate treatment  No prompt for engagement visits

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AHRQ R18 HS023173

SPARC Trial

Performance metrics

  • Prevention:

 Weekly screening/assessment  Not brief counseling

  • Treatment:

 NCQA Alcohol and/or drug HEDIS measures

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

SPARC Trial

Strong partnership with mental health service

  • Social workers

 Transitioned to integrated MH clinicians  Warm hand-offs key to success  Number expanded during trial

  • PC leaders not actively engaged
  • Years 2-3: permission to randomize 1 month prior

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SPARC Trial Methods

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AHRQ R18 HS023173

SPARC Trial Evaluation Methods

  • Sample: all patients seen in primary care
  • Measures: secondary electronic data
  • Two main outcomes

Prevention: brief alcohol counseling (NLP & codes) Alcohol treatment (ICD codes based on HEDIS)

  • Assessed in entire PC sample
  • GLMM: compares Usual Care vs Intervention
  • Descriptive treatment cascades
  • Consistent with consort requirements

Bobb IJERPH 2017; Glass Implementation Science 2018

  • J. Bobb et. al. Designing to avoid identification bias, NIH Collaboratory ltextbook

https://rethinkingclinicaltrials.org/chapters/design/experimental-designs-randomization- schemes-top/designing-to-avoid-identification-bias/

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SPARC Trial Results

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Where we started

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We don’t have enough time or resources to do this. Whose idea was this? This is opening up Pandora’s box. This is a research project that

  • thers committed to … now we are

being forced to prioritize it.

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Where we ended

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I wouldn’t go back to providing care the way I used to if they asked me to. The best roll-out of any program I’ve experienced. I felt empowered to help this patient when she was in need. This is one of the best things that has happened to my primary care practice…this is just how we do primary care now.

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AHRQ R18 HS023173

What we achieved

Alcohol screening rates: 22 primary care sites

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Main Outcome: Prevention

Prevention Usual Care vs Intervention per 10,000 PC patients

UC Intervention

p

Screened* 2081 8319

< 0.0001

Most recent screen positive 502 1802

< 0.0001

High Positive 54 148

< 0.0001

Brief alcohol counseling 11 57

< 0.0001

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AHRQ R18 HS023173

Results: Prevention

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AHRQ R18 HS023173

Main Outcome: Treatment

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Alcohol Treatment Usual Care vs Intervention per 10,000 PC patients

UC Intervention

p

New AUD diagnosis at visit 29 34

0.003

New AUD dx and initiated Tx 6.1 7.8

0.042

AUD treatment engagement 1.8 1.4

0.30

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AHRQ R18 HS023173

Descriptive Results: Treatment

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AHRQ R18 HS023173

SPARC Trial

Successful approaches

  • Breadth of the effort: depression, suicidality, etc.
  • Weekly scheduled practice coaching
  • Using positive stories tipping point

Bobb IJERPH 2017; Glass Implementation Science 2018

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AHRQ R18 HS023173

SPARC Trial

Challenges

  • No performance feedback on main outcomes
  • Inadequate PCP training for many
  • Provider discomfort

Bobb IJERPH 2017; Glass Implementation Science 2018

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Michigan- SPARC

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AHRQ R18 RFA – Fall 2018

Alcohol-related prevention and treatment in…

  • 125 PC practices (< 10 PCPs)

 Not in an integrated system  Not already screening  No collocated behavioral health clinicians  High needs area

  • 3 years: Lower resources and less time
  • Due January 4th …

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AHRQ R18 RFA – Fall 2018

Cold Call from Altarum

  • Anya Day (MPI/PD)
  • Emily Erlich
  • Tom Taylor
  • Christine Stanik

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Altarum

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AHRQ R18 RFA – Fall 2018

Altarum

  • Quality improvement with practice coaches
  • Performance feedback (0, 3, & 5 months)
  • EHR tech support
  • MOC credit, CME and P4P
  • Documented quality improvements

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AHRQ R18 RFA – Fall 2018

SPARC Michigan

  • 3 years
  • 6 wave stepped wedge trial
  • Practice coaches
  • 2 in-person coaching sessions
  • Then telephonic, biweekly

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MI SPARC

Figure 10. Timeline of MI-SPARC YEAR 1 YEAR 2 YEAR 3 Month of study

1 2 3 4 5 6 7 8 9 1 1 1 1 2 1 2 3 4 5 6 7 8 9 1 1 1 1 2 1 2 3 4 5 6 7 8 9 1 1 1 1 2

Start-up Pilot Period 1 recruitment Wave 1 implements Wave 2 implements Wave 3 implements Period 2 recruitment Wave 4 implements Wave 5 implements Wave 6 implements Formative Evaluation Data management Evaluation Dissemination

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AHRQ R18 RFA – Fall 2018

SPARC Michigan

  • Recommend: 7 item screener all assessments
  • Performance feedback

 Manual (0, 3, & 5 months)  Electronic data incentivized (more often)

  • Add CME and MOC
  • 50% randomized patient decision aid for AUD

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Options Study: Patient Decision Aid

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Stories Destigmatize & Engage Option Grid: 5 Types of Treatment Worksheet Share with PCP

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Options Study: 5 Dyads

Woman, mid-60s

Result of visit: Left with plan to receive counseling and naltrexone Patient: The DA “gave us a guideline….It’s hard to negotiate this sticky subject and it made it a lot easier....I think this would be a good thing to hand out to people….It gives you a lot of

  • ptions, too.”

Her PC provider: "This was the most comfortable appointment I’ve ever had talking to someone about alcohol….She was driving the conversation.…I felt set up for success.”

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Options Study: Decision Aid

Patients and providers reported …

  • Supported comfort & optimism
  • Increasing awareness of options
  • Increased efficiency
  • New knowledge
  • Built motivation
  • Supported PCP-patient partnership

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Summary

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AHRQ R18 HS023173

MI-SPARC Trial: Summary

Lessons from SPARC …

  • Successful implementation

Spectrum of alcohol-related care As part of behavioral health integration Patient-centered approaches: symptom

checklist, shared decision-making

Using positive stories

  • Need for improvement

Performance measures for outcomes More provider training

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AHRQ R18 HS023173

MI-SPARC Trial: Summary

New in MI-SPARC…

  • EHR tools and performance metrics aligned w/ P4P
  • Increased alcohol-related training time (CME)
  • 50%: patient decision aid
  • New challenges

Timeline Telephonic coaching Manual extraction of metrics Linkage to community resources

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Thank You! Questions and Comments?

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Sustainment: July 2019

Performance metrics 1 year after trial ended

  • Alcohol screening: 89% average
  • Alcohol Symptom Checklist: 71% average

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