Health Care Utilization After Paraprofessional-administered Substance Use Screening, Brief Intervention, and Referral to Treatment: A Multi-level Cost-offset Analysis.

BACKGROUND: Authorities recommend universal substance use screening, brief intervention, and referral to treatment (SBIRT) for all (ie, universal) adult primary care patients. OBJECTIVE: The objective of this study was to examine long-term (24-mo) changes in health care utilization and costs associated with receipt of universal substance use SBIRT implemented by paraprofessionals in primary care settings. RESEARCH DESIGN: This study used a difference-in-differences design and Medicaid administrative data to assess changes in health care use among Medicaid beneficiaries receiving SBIRT. The difference-in-differences estimates were used in a Monte Carlo simulation to estimate potential cost-offsets associated with SBIRT. SUBJECTS: The treatment patients were Medicaid beneficiaries who completed a 4-question substance use screen as part of an SBIRT demonstration program between 2006 and 2011. Comparison Medicaid patients were randomly selected from matched clinics in Wisconsin. MEASURES: The study includes 4 health care utilization measures: outpatient days; inpatient length of stay; inpatient admissions; and emergency department admissions. Each outcome was assigned a unit cost based on mean Wisconsin Medicaid fee-for-service reimbursement amounts. RESULTS: We found an annual increase of 1.68 outpatient days (P=0.027) and a nonsignificant annual decrease in inpatient days of 0.67 days (P=0.087) associated with SBIRT. The estimates indicate that the cost of a universal SBIRT program could be offset by reductions in inpatient utilization with an annual net cost savings of $782 per patient. CONCLUSIONS: Paraprofessional-delivered universal SBIRT is likely to yield health care cost savings and is a cost-effective mechanism for integrating behavioral health services in primary care settings.

PREPARING HEALTH PROFESSIONS VOLUNTEERS TO SERVE GLOBALLY.

Scant literature exists to describe the global health and collaboration competence of international healthcare professional volunteers. An educational program to prepare volunteers for short-term service in resource-poor settings was developed. Pre- and post- program competence and team collaboration levels were assessed in 18 healthcare professionals. A significant improvement (p < .05) occurred in global health competence after education. Formal educational preparation of international health volunteers can enhance their overall effectiveness when serving in resource-poor settings. Extensive resources for global health education are referenced.

Measuring the health-related quality of life (HRQoL) of young children in resource-limited settings: a review of existing measures.

PURPOSE: This review sought to identify and summarize the instruments adapted or developed for measuring HRQoL among young children (<8 years) living in resource-limited settings. METHODS: A review of the literature was conducted in two phases. Phase one searched the PubMed, PsycInfo, Web of Knowledge (Web of Science), African Index Medicus, and SocINDEX databases and identified widely used child HRQoL instruments. Phase two reviewed the articles using the selected HRQoL instruments and extracted information on their use in resource-limited settings including adaption processes. RESULTS: Seven instruments were identified that measured the HRQoL of young children. Six had been used in resource-limited settings. Of the 452 articles using these instruments, a total of 23 (5 %) studies used one of the identified HRQoL instruments in a resource-limited setting. Among these studies, 39 % employed an adaptation process for the use of that instrument. No instruments had been developed specifically for measuring the HRQoL of young children in resource-limited settings. CONCLUSIONS: If pediatric HRQoL instruments are to be used in resource-limited settings, it is critical that they be developed and adequately adapted to those settings. Only then will interventions lead to larger increases in the overall HRQoL and well-being of children.

Evaluating Community Readiness to Implement Environmental and Policy-Based Alcohol Abuse Prevention Strategies in Wisconsin.

BACKGROUND: Matching evidence-based alcohol prevention strategies with a community's readiness to support those strategies is the basis for the Tri-Ethnic Community Readiness Model (CRM). The purpose of this evaluation was to assess the association of a community's readiness to address alcohol abuse in their community with the implementation of environmental and policy-based strategies. METHODS: Twenty-one substance abuse prevention coalitions in Wisconsin participated in a pre-post intervention group-only evaluation using the CRM. As part of a Substance Abuse and Mental Health Services Administration (SAMHSA) grant, all grantees were obligated by the Wisconsin Department of Health Services to implement environmental and policy-based strategies focused on one of three priority areas: young adult binge drinking, underage drinking, and alcohol-related motor-vehicle injuries and fatalities. RESULTS: At baseline, all communities (n=21) scored at or below a Stage 4 (on a scale of 1-9) readiness level ("preparedness"). The mean change in community readiness over the three-year period (2009-2011) was significant, but was less than one complete CRM stage (0.77, p=<0.001; 95% CI: 0.49, 1.05). CONCLUSION: These findings suggest that implementation of environmental and policy-based strategies may improve a community's progression in perceived readiness to address alcohol abuse regardless of the community's baseline level of readiness to address alcohol abuse. RECOMMENDATION: An assessment specific for measuring community readiness for policy-related strategies should be developed. The assessment would include community-level factors (e.g. community climate) for implementing policy-related prevention strategies, and not assume a linear readiness model.

Clinical Recognition of Substance Use Disorders in Medicaid Primary Care Associated With Universal Screening, Brief Intervention and Referral to Treatment (SBIRT).

OBJECTIVE: Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs. METHOD: SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses. RESULTS: SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services. CONCLUSIONS: The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis.

BACKGROUND: Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective. METHODS: Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança's previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability-adjusted life year. RESULTS: Esperança's surgical missions' program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate. CONCLUSIONS: The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations.

Self-reported cannabis use and biomarkers of inflammation among adults in the United States.

BACKGROUND: Cannabis is among the most frequently used substance in United States (U.S.). Studies evaluating the association between cannabis use and inflammation in humans have been few and have not explored potential sex-dependent effects. OBJECTIVE: To examine the relationship between self-reported cannabis use and high-sensitivity C-reactive protein (hsCRP), Interleukin 6 (IL-6) and fibrinogen. METHODS: We used Wave 1 of the Population Assessment of Tobacco and Health (PATH) - a nationally representative sample of adults in the U.S. Weighted linear regression models were used to determine associations of self-reported cannabis use with natural log-transformed hs-CRP, IL-6 and fibrinogen adjusting for sociodemographic and psychosocial factors. RESULTS: Self-reported cannabis use, particularly cannabis use within the past 30 days, was associated with lower levels of each biomarker of systemic inflammation, although findings were imprecise. Specifically, in multivariable models, the associations between respondents who self-reported cannabis use in the past 30 days compared to never use was imprecise for hs-CRP (ß= -0.15, 95% confidence interval (CI): -0.32, 0.00), IL-6 (ß= - 0.02, 95% CI: -0.10, 0.05) and fibrinogen (ß= - 0.01, 95% CI: -0.04, 0.02). We did not find that these associations differed significantly by sex. DISCUSSIONS: Data from this nationally representative study suggest potential anti-inflammatory effects of recent cannabis use. Additional studies that biologically measure the THC and CBD concentrations of the cannabis used and employ prospective and or experimental study designs investigate cannabis and inflammation associations are needed.

Substance Use Screening, Brief Intervention, and Referral to Treatment Among Medicaid Patients in Wisconsin: Impacts on Healthcare Utilization and Costs.

Unhealthy substance use in the USA results in significant mortality and morbidity. This study measured the effectiveness of paraprofessional-administered substance use screening, brief intervention, and referral to treatment (SBIRT) services on subsequent healthcare utilization and costs. The pre-post with comparison group study design used a population-based sample of Medicaid patients 18-64 years receiving healthcare services from 33 clinics in Wisconsin. Substance use screens were completed by 7367 Medicaid beneficiaries, who were compared to 6751 randomly selected treatment-as-usual Medicaid patients. Compared to unscreened patients, those screened changed their utilization over the 24-month follow-up period by 0.143 outpatient days per member per month (PMPM) (p < 0.001), -0.036 inpatient days PMPM (p < 0.05), -0.001 inpatient admissions PMPM (non-significant), and -0.004 emergency department days PMPM (non-significant). The best estimate of net annual savings is $391 per Medicaid adult beneficiary (2014 dollars). SBIRT was associated with significantly greater outpatient visits and significant reductions in inpatient days among working-age Medicaid beneficiaries in Wisconsin.