Abstract
BACKGROUND: Most studies on adolescent screening, brief intervention, and referral to treatment (SBIRT) have examined substance use outcomes. However, it may also impact service use and comorbidity—an understudied topic. We address this gap by examining effects of SBIRT on health care use and comorbidities.
METHODS: In a randomized trial sample, we assessed 3 SBIRT care modalities: (1) pediatrician-delivered, (2) behavioral clinician–delivered, and (3) usual. Medical comorbidity and health care use were compared between a brief-intervention group with access to SBIRT for behavioral health (combined pediatrician and behavioral clinician arms) and a group without (usual care) over 1 and 3 years.
RESULTS: Among a sample of eligible adolescents (n = 1871), the SBIRT group had fewer psychiatry visits at 1 year (incidence rate ratio [iRR] = 0.76; P = .05) and 3 years (iRR = 0.65; P < .05). Total outpatient visits did not differ in year 1. The SBIRT group was less likely to have mental health diagnoses (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.48–1.01) or chronic conditions (OR = 0.66; 95% CI = 0.45–0.98) at 1 year compared with those in usual care. At 3 years, the SBIRT group had fewer total outpatient visits (iRR = 0.85; P < .05) and was less likely to have substance use diagnoses (OR = 0.64; 95% CI = 0.45–0.91) and more likely to have substance use treatment visits (iRR = 2.04; P < .01).
CONCLUSIONS: Providing SBIRT in pediatric primary care may improve health care use and health, mental health, and substance use outcomes. We recommend further exploring the effects of SBIRT on these outcomes.
- CI —
- confidence interval
- ED —
- emergency department
- EHR —
- electronic health record
- ICD-9 —
- International Classification of Diseases, Ninth Revision
- ICD-10 —
- International Classification of Diseases, 10th Revision
- iRR —
- incidence rate ratio
- KPNC —
- Kaiser Permanente Northern California
- OR —
- odds ratio
- SBIRT —
- screening, brief intervention, and referral to treatment
What’s Known on This Subject:
Research suggests that screening, brief intervention, and referral to treatment (SBIRT) in pediatric primary care may improve patient outcomes, but few studies have examined its effects on health care use or the development of medical or mental health comorbidities over time.
What This Study Adds:
Patients with access to SBIRT had fewer comorbidities, psychiatry visits at 1 year, and substance use diagnoses and lower outpatient use over 3 years. Providing SBIRT in primary care may reduce health care use and improve adolescent health.
Adolescent substance use is a significant public health problem and poses serious health risks. It is closely associated with the top 3 causes of mortality and morbidity among adolescents (injuries, suicide, and homicide1–3), and emerging evidence points to the serious and potentially irreversible effects of exposure to alcohol and drugs on the developing adolescent brain.4,5 Adolescent substance use problems frequently co-occur with medical conditions6 and mental health problems, such as depression and anxiety,7 which in turn are associated with increased health care use,8 particularly costly and potentially avoidable emergency department (ED)9,10 and inpatient care.11 Interventions designed to prevent or reduce substance use and related problems among adolescents could reduce avoidable health care use.
Screening, brief intervention, and referral to treatment (SBIRT) is a public health approach to substance use prevention and early intervention and may reduce mental health symptoms as well.12,13 Although most adolescent SBIRT studies have examined substance use and related consequences,13–21 few have examined its effects on health care use. There is evidence that SBIRT may impact service use, but those studies have largely focused on adults.22 In a study of a cohort of adolescents who had participated in a randomized clinical trial of an ED-delivered brief intervention for substance use, Tait et al23 examined the effects of receiving an intervention on 10-year health care use outcomes. They found reduced substance-related ED use and costs but did not find significant differences in overall health care use and costs, and their analyses were limited because of a small sample size and limited follow-up data.
This study used electronic health record (EHR) data to examine subsequent health care use among adolescents from a randomized clinical trial,13,24,25 comparing usual care to 2 modalities of delivering SBIRT in pediatric primary care: by a pediatrician or an embedded behavioral clinician. In this study, we focus on access to brief intervention for substance use and mental health symptoms, regardless of the type of provider delivering it, and its association with health service use. In the main trial, we found no differences between the 2 SBIRT arms in subsequent self-reported substance use, but did find lower rates of depression symptoms13 and higher rates of specialty behavioral health treatment initiation25 and screening and brief intervention24 in the embedded behavioral clinician arm compared with the pediatrician arm. Pediatric primary care practices increasingly employ hybrid models of SBIRT involving both SBIRT-trained pediatricians and behavioral clinicians, such as social workers, integrated into primary care teams.26 To reflect real-world clinical staffing and workflows, in which components of SBIRT may be delivered by both pediatricians and behavioral clinicians, we combined patients in both trial arms providing access to brief interventions into a single brief-intervention group (the SBIRT group) and compared rates of health care service use (overall, ED, inpatient, primary care, and specialty substance use and psychiatry) to those in the usual-care group. We hypothesized that patients in the SBIRT group would have lower rates of ED and inpatient use compared with those in usual care.
Although research provides evidence that substance use problems are correlated with health care use,27 it is important to understand the concomitant changes in substance use, mental health, and medical comorbidities in adolescents (some entering young adulthood) experiencing significant developmental transitions. Therefore, in addition to health care use, we examined the 1- and 3-year prevalence of substance use and mental health conditions, including attention-deficit/hyperactivity disorder, anxiety, bipolar disorder, depression, and substance use disorders. Because substance use and mental health problems are frequently comorbid with medical conditions6,28 and preventing the development of the former could potentially forestall or prevent development of the latter, we also examined the prevalence of pediatric medical conditions such as asthma, arthritis, diabetes, irritable bowel syndrome, migraine, rhinitis, and sinusitis. We hypothesized that patients in the SBIRT group would have lower rates of substance use, mental health, and medical conditions compared with those in usual care.
Methods
Setting and Design
The study was conducted at Kaiser Permanente Northern California (KPNC), an integrated health care–delivery system serving a diverse population of >4 million members. The sample was drawn from a pragmatic, randomized clinical trial at KPNC’s Oakland Pediatrics Department of implementation and patient outcomes of 3 different modalities of delivering SBIRT for adolescents ages 12 to 18 years, including 2 brief-intervention arms: (1) a pediatrician-only arm consisting of pediatricians who were trained to screen and (when indicated) deliver brief interventions and refer to specialty substance use or mental health treatment; (2) an embedded behavioral clinician arm in which pediatricians administer the initial assessment and (if needed) refer patients to an embedded behavioral clinician for further assessment, brief intervention, and referral to treatment; and (3) a usual-care arm in which pediatricians had access to the EHR screening tools but no formal SBIRT training. SBIRT training of the pediatricians and behavioral clinicians in the original trial was similar and has been described previously in detail elsewhere.13
Study Sample
The sample consists of a subset of adolescents aged 12 to 18 years who endorsed either the substance use or mental health symptoms on the Teen Well Check Questionnaire between November 1, 2011, and October 31, 2013, or were deemed eligible for further assessment, brief intervention, and/or referral to treatment by their pediatricians (n = 1871). The index date was defined as the date on which the adolescent screened positive during this period. Additional details of the study protocol and the Teen Well Check Questionnaire are given elsewhere.13,24,25
Measures
Treatment Groups
To examine associations between comorbidity and health care use between patients who had access to brief interventions for problems (if needed) and those who did not, we created a dichotomous indicator (SBIRT group = 1; usual care = 0).
Patient Characteristics
We obtained sex, age at index date, race and/or ethnicity (coded as white, African American, Hispanic, Asian American, and other), and length of enrollment in the health plan in the 3 years after the index date from the EHR.
Health Care Use
The EHR was used to obtain all outpatient and inpatient (medical and psychiatric) service use for 1-year before and up to 3 years after the index date. Counts of visits made to the ED, primary care, substance use treatment, and psychiatric services and inpatient uses as well as a count of all outpatient visits were created for baseline and 1- and 3-year follow-up periods.
Comorbidity
We examined 2 sets of comorbidities recorded in the EHR during each patient’s visits at baseline and over the 1- and 3-year postindex visits. These comorbidities included the prevalence of any behavioral health conditions (International Classification of Diseases, Ninth Revision [ICD-9] codes 290, 293–302, and 306–319; International Classification of Diseases, 10th Revision [ICD-10] codes F01–F09, and F20–F99) and any of the 7 most common or chronic medical conditions found in this age group, including asthma (ICD-9: 493; ICD-10: J45), arthritis (ICD-9: 710–719; ICD-10: M01, M02, M05–M08, and M11–M25), diabetes (ICD-9: 250; ICD-10: E08–E13), irritable bowel syndrome (ICD-9: 555, 560.89, and 5641; ICD-10: K50, K58, and K566), migraine (ICD-9: 346; ICD-10: G43), rhinitis (ICD-9: 477; ICD-10: J30 and J31), and sinusitis (ICD-9: 461 and 473; ICD-10: J01 and J32).28 Two dichotomous indicators, 1 to denote the presence of any behavioral health condition and 1 for the presence of any of the medical conditions (any of the conditions was recorded = 1; otherwise = 0), were created for each time period. We also created indicators for the most common behavioral health conditions from the subset of behavioral health conditions noted above: depression (ICD-9: 296.2, 296.3, 296.82, 298.0, 300.4, 301.12, 309.0, 309.1, 309.28, and 311; ICD-10: F32, F33, F34.1, F43.21, and F43.23), anxiety (ICD-9: 300.00, 300.02, 300.09, 309.21, 309.24, 309.81, F41.1, F41.3, F41.8, F41.9, F43.22, and F43.1), attention-deficit/hyperactivity disorder (ICD-9: 314; ICD-10: F90), bipolar disorder (ICD-9: 296 [except 296.1 and 296.3], 301.13, and 301.11; ICD-10: F30, F31, F34.0, F34.8, F34.9, and F39), and substance use disorders (ICD-9: 291, 292, and 303–305; ICD-10: F10–F19).
Statistical Analysis
We used χ2 and Student’s t tests to examine differences in demographic characteristics (age, sex, and race and/or ethnicity) and medical and behavioral health comorbidities between the SBIRT and usual-care groups. Multivariate logistic regression models were used to examine the dichotomous outcomes (any mental health or substance use comorbidities and any common or chronic medical comorbidities), and negative binomial regression models were used to examine visit counts (number of ED, primary care, substance use treatment, psychiatry, and all outpatient visits). In these models, the exponent of the coefficient for the treatment variable represents the odds ratio (OR) and the incidence rate ratio (iRR) for logistic and negative binomial regressions, respectively, for the SBIRT group relative to the usual-care group. Multivariate use models adjusted for age, sex, race and/or ethnicity, and previous use of similar services (eg, ED visits in the 12-month preindex period were included in the model for postindex ED visits). Similarly, we adjusted for corresponding preexisting diagnoses in the models for postindex comorbidity (eg, previous-12-month mental health diagnoses in the model for mental health comorbidity). Length of membership was accounted for by creating a variable whose coefficient is constant. All analyses were performed by using SAS 9.3 (SAS Institute, Inc, Cary, NC).
Results
Demographics
The SBIRT group had significantly more girls (59.5% vs 48.1%; P ≤ .05) and multiracial adolescents and adolescents of color (77.9% vs 68.3%; P ≤ .05) than the usual-care group (Table 1); there was no difference in the mean age at index date (15.8 years [SD = 1.5] vs 15.9 years [SD = 1.5]; P > .10). More than 93% of the sample had continuous membership for the 1-year postindex period, and >80% were continuous members up to 3 years postindex. At 1 year postindex, the usual-care group had more continuous members than the brief-intervention group (95.6% vs 92.3%; P ≤ .05); there were no differences in membership length at 3 years (data not shown).
Demographic Characteristics by SBIRT Group
Use Rates
Although this was a randomized trial, we examined differences in service use and comorbidities between the SBIRT and usual-care groups in the year before the index date (Fig 1). We found no baseline or postindex differences in any of the health service measures (Table 2).
Analytical sample. BC, behavioral clinician; BI, brief intervention.
Baseline Through 3 Years Use and Comorbidity Rates
Comorbidity
The prevalence of mental health and substance use diagnoses was similar between the groups at baseline through 1 year postindex (Table 2). Among those with a behavioral health diagnosis 1 year postindex (6.8% of adolescents), depression (43.7%) and anxiety (36.7%) were the most common; there were no differences between the treatment groups. The prevalence of any behavioral health conditions in the 3 years postindex was 28.7%; fewer adolescents in the SBIRT group had a depression diagnosis than those in usual care (45% vs 54%; P < .05). All other diagnoses did not differ significantly. There was no difference in substance use rates at baseline through 1 year postindex between the 2 groups; by 3 years postindex, the SBIRT group was less likely to have a substance use diagnosis (2.1% vs 3.7%; P < .05). Eighteen percent of all adolescents had at least 1 of the 7 common or chronic medical conditions at baseline; there was no difference between the treatment groups. At 1 year postindex, the SBIRT group was less likely to have any chronic medical condition (5.4% vs 7.8%; P < .05); this trend was also observed at 3 years postindex, although the difference was narrower (31.6% vs 32.6%; P < .10).
Multivariate Analyses of Use
In the 1-year postindex period, there were only 6 inpatient stays and 6 adolescents with a substance use treatment visit, 5 of whom were in the SBIRT group; therefore, these outcomes could not be modeled. There was no significant difference in the likelihood of ED visits, but there was a declining trend in the number of ED visits in the postindex period (iRR = 0.87; P > .05). Adolescents in the SBIRT group were also likely to have 24% fewer psychiatry department visits (iRR = 0.76; P = .05). There were no differences in primary care or total outpatient visits (Table 3).
Multivariate Analyses of Health Service Use by SBIRT Group: 1 Year Postintake
Three years postindex, adolescents in the SBIRT group were likely to have had more substance use treatment visits (iRR = 2.04; P < .01) and fewer psychiatry department visits (iRR = 0.65; P < .05) and total outpatient visits (iRR = 0.85; P < .05) over the 3 years compared with those in usual care (Table 4).
Multivariate Analyses of Health Service Use by SBIRT Group: 3 Years Postintake
Multivariate Analyses of Comorbidities
Less than 1% of all adolescents had a substance use diagnosis during the 1-year postindex period; therefore, this outcome could not be modeled. In multivariable models adjusted for patient characteristics and the presence of previous diagnoses, adolescents in the SBIRT group were less likely to have a mental health diagnosis (OR = 0.69; 95% confidence interval [CI] = 0.48–1.01; P = .05) or a common or chronic medical condition (OR = 0.66; 95% CI = 0.45–0.98) in the 1 year postindex compared with patients in the usual-care group (Table 5).
Mental Health, Substance Use, and Medical Comorbidities by SBIRT Group: 1 Year Postintake
In multivariate models adjusted for patient characteristics and previous diagnoses, we found that adolescents in the SBIRT group were less likely to have a substance use diagnosis (OR = 0.64; 95% CI = 0.45–0.91) than those in usual care over the 3-year postindex period. There were no statistically significant differences in the prevalence of mental health diagnoses or common or chronic medical conditions between groups over the 3 years (Table 6).
Mental Health, Substance Use, and Medical Comorbidities by SBIRT Group: 3 Years Postintake
Discussion
This study examined the association between access to SBIRT and health care use and comorbidities for adolescents at risk for substance use and other behavioral health problems. As in adult studies,29 we observed that adolescents with access to brief interventions for behavioral health risks had fewer ED visits in the subsequent 12 months compared with those in usual care. This finding echoes those of Tait et al,23 who also found lower ED use associated with the receipt of a brief intervention for substance use. In that study, however, the adolescents presented in the ED for substance-related problems and represented a more severe population than this primary care sample. That we found a trend toward lower ED use even in this lower-severity population underscores the potential of offering SBIRT in primary care to reduce ED use among adolescents.
The SBIRT group also had lower psychiatric service use in both the 1- and 3-year follow-up periods. There were no differences in use or comorbidities between the SBIRT and usual-care groups in the year before participants’ index screening. Therefore, it appears that the lower ED- and psychiatric service–visit rates we found could be attributable to having access to SBIRT in primary care. This premise is supported by our finding that the SBIRT group had lower likelihood of medical and mental health comorbidity during the 1-year follow-up period relative to the usual-care group.
Over the longer 3-year period, the SBIRT group had lower use of psychiatric services and total outpatient services, a lower likelihood of a substance use diagnosis, and a slightly lower likelihood of a mental health diagnosis. The SBIRT group was more likely to use substance use treatment services than the usual-care group. This suggests that although fewer patients in this group over time develop substance use problems that are serious enough to warrant specialty substance use treatment, the referral-to-treatment component of SBIRT available to them might be operative in getting those who do to treatment.
We also observed that the prevalence of mental health, substance use, and medical conditions increased over time among the adolescents in both groups; almost one-third of all adolescents had a common or chronic medical condition in the 3 years postindex. Together with the findings on service use, this underscores the importance of screening for substance use problems and brief intervention or referral to treatment as necessary, occurring at every visit as for other health conditions, particularly in light of the developmental changes and environmental exposures experienced by adolescents. This also suggests the need for patients to be given brief interventions in a timely manner and, if needed, more than once so that their substance use and other psychiatric problems do not escalate, resulting in worsening morbidity and critical life events that lead to costly ED visits or hospital stays. Access to SBIRT, by helping to reduce substance use and initiation and/or emotional distress, may also bolster physical health through the encouragement of healthier behavior choices (eg, not smoking, not drinking, and stress reduction), reducing the prevalence of medical comorbidities and ultimately contributing to lower health care use.
Consistent with the adolescent mental health literature,28 we found that depression and anxiety were the most common mental health diagnoses recorded in the EHR, emphasizing the need for early screening and timely intervention. Although we acknowledge that comorbidities impact service use, we did not control for these in our analyses of use because the prevalence of comorbidities over time are in and of themselves important outcomes of interest. Instead, we included corresponding health care use, which serves as both a proxy for comorbidity as well as accounting for regression to the mean.
This study has several limitations. It was conducted in an integrated health care system with an insured population and may not be generalizable to uninsured populations. This was a pragmatic trial that did not recruit patients but relied on EHR-based clinical information collected during regular care. This strengthened the study by allowing us to examine the population base of adolescents with pediatric visits in the clinic, increasing its generalizability to pediatric primary care populations. This was an intent-to-treat analysis in which outcomes were examined among all eligible patients in both groups, regardless of whether they received a brief intervention. However, post hoc analyses showed that the receipt of brief intervention was associated with significantly lower rates of ED services at 1 year, which speaks to the potential value of SBIRT in helping to avert problems necessitating emergency medical care.
Conclusions
This study is among the first to examine associations between access to brief intervention and health care service use. Among those in the SBIRT group, we found lower use of psychiatry services at both 1 and 3 years and lower overall outpatient use at 3 years. These lower use rates are particularly notable because they serve as important proxy indicators of health and well-being. Importantly, we also found that the adolescents in the SBIRT group were less likely to have a mental health or a medical diagnosis at 1 year and less likely to have a substance use or depression diagnosis at 3 years, suggesting that offering SBIRT in pediatric primary care may have an enduring impact on both health and health care use during this critical developmental period. Future research is needed on the effects of SBIRT for adolescents on these important outcomes.
Acknowledgments
We thank the KPNC Adolescent Chemical Dependency Coordinating Committee, the KPNC Adolescent Medicine Specialists Committee, and Thekla Brumder Ross, PsyD, Derek Satre, PhD, and Jennifer Mertens, PhD, for their guidance. We also thank David Bacchus, MD, and all the physicians, medical assistants, nurses, receptionists, managers, and especially the patients and parents of KPNC’s Oakland Pediatrics clinic for their participation in the activities related to this study. All contributing authors have been included above.
Footnotes
- Accepted February 1, 2019.
- Address correspondence to Stacy Sterling, DrPH, MSW, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403. E-mail: stacy.a.sterling{at}kp.org
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the National Institute on Alcohol Abuse and Alcoholism (grant R01 AA016204). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
- Copyright © 2019 by the American Academy of Pediatrics
