Wieschhaus K, Ghodrati S, Martin B, McIntyre J. Evaluation of Physician Attitudes, Perceptions, and Current Practice regarding SBIRT as a clinical tool in the Chicagoland Primary Care setting. Harvard Public Health Review. 2021; 34.
Background and Objectives: To assess physician attitudes and current practice surrounding a substance use intervention tool, Screening, Brief Intervention, and Referral to Treatment (SBIRT) in order to gain insight into the feasibility of SBIRT in the primary care setting.
Methods: A survey consisting of 35 Likert-scale questions was administered to primary care physicians at departmental meetings over 3 months. Survey questions aimed to address the attitudes/perceptions/practice surrounding current SBIRT usage in Chicago area primary care clinics.
Results: Female providers are more confident in their ability to use standardized screening tools and ask patients about their substance use, asking their patients about the quantity/frequency of their substance use more often than their male counterparts.
Urban providers were found to strongly agree that PCP’s should discuss substance use with their patients, be more confident in their ability to ask patients about their substance use, and express comfort discussing alcohol consumption with their patients. By contrast, their suburban counterparts were neutral or disagreed that they are effective in reducing illicit drug use in their patients.
Overall, 82% of providers agreed that at-risk substance use in patients is common enough to warrant systematic screening, 84% agreed that screening can result in early intervention, and even more (86%) ultimately believe this leads to improved outcomes.
Conclusion: The significant trends elicited from this study suggest implementation may be very feasible in urban primary care clinics and clinics with a female provider predominance, with a need for more robust education and preparation prior to implementation in practice settings where providers feel less comfortable.
According to the 2014 Healthy Chicago Survey Report, prepared by the Chicago Department of Public Health, 18.4% of adults in Chicago smoke tobacco. In the span of the 12 months prior to the administration of this survey, 71.2% of current smokers had stopped smoking for one day or more in an attempt to quit permanently. As of 2010, the prevalence of binge alcohol use within the previous month among Chicago-Joliet-Naperville adults, was 26.5%. The prevalence of any illicit drug in the past year was 14.8% among Chicago-Joliet-Naperville area adults, 10.9% of that 14.8% being Marijuana, and 4.2% use of prescription-type pain relievers.13
Among Chicago teens, the prevalence of tobacco use was 16.5% as of 2011. Approximately thirty-eight percent of teens drank alcohol in the past month, and 19.7% engaged in binge drinking. Twenty-five percent of Chicago teens used Marijuana in the past month as of 2011, and 9.8% used prescription drugs without a doctor’s order.14
SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment, is a clinical tool that is intended to elicit “change talk” and healthier behaviors in patients who screen positive for at risk alcohol and substance use. It can be implemented by physician or non-physician providers. The SBIRT method in a medical office setting involves administering a screening survey, such as the AUDIT or DAST-10, which is often given in the waiting room. For those patients who screen positive, a physician or provider then conducts a Brief Negotiated Interview, which is a structured motivational interviewing technique that encourages the patient to reflect on their risky alcohol or substance use. Depending on the patient’s readiness for change, this 5-15 minute long intervention culminates with a plan for change or referral to treatment.
It is known that SBIRT has been sanctioned by the United States Preventive Services Task Force as an evidence-based approach to identify risky alcohol use amid adults in the primary care setting.8 Per the National Household Survey on Drug Use and Health, it is approximated that only 1 in 10 individuals in the United States with a substance use disorder will receive treatment.6 Of those who do not receive treatment, roughly 95% (over 20 million people, and growing) are not even aware that they have a problem.7 Standardized implementation of SBIRT in primary care settings crucial to addressing this treatment gap. However, before large-scale implementation can take place, assessment of the current state of physician perceptions, attitudes, and practice, as it pertains to substance use and the practice of SBIRT, is an important first step.
This project (LU #209834) received “Notice of Exemption of a Research Project” from Loyola University Chicago’s Institutional Review Board on 6/21/2017, with the committee having reviewed the project protocol on 5/22/2017, determining that it qualify for “EXEMPT” action with no further reporting requirements due to its categorization as an anonymous survey study.
The study was designed as a cross-sectional, human research study assessing the prevalence of existing attitudes, perceptions, and current usage of SBIRT as a clinical tool by Chicagoland primary care physicians.
SBIRT attitudes/perceptions/practice among physician and non-physician New York State care providers was assessed in a 2016 study11. This approached served as the template for this inquiry. Hard copy surveys consisting of 35 Likert scale questions were administered to PCPs at departmental meetings over the course of 3 months. Drawing our sample from these meetings was suggested by the Director of Primary Care at our institution, on the basis of having the highest density and regularity of PCP attendance within reasonable proximity.
There were 6 qualitative questions inquiring about professional role, gender, age, race/ethnicity, geographical setting, and practice type, accompanied by 29 questions comprising a total of 7 sub-sections.
Likert scores were graded 1 through 5, with each number correlating to a distinct interpretation in the following 7 sub-sections listed below:
Attitude toward substance use screening
(1 = Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)
Perceived role responsibility for addressing substance use
(1 = Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)
Perceived self-efﬁcacy for addressing substance use
(1 = Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)
Comfort discussing substance use
(1 = Very Uncomfortable, 3 = Neutral, 5 = Very Comfortable)
Perceived effectiveness at reducing substance use
(1 = Strongly Ineffective, 3 = Neutral, 5 = Strongly Effective)
SBIRT model practice
(1 = Never, 2 = Less than ½ the time, 3 = Half the time, 4 = More than ½ the time, 5 = Always)
Frequency and regularity of model component practice
(1 = Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)
In total, all forty-four physicians who attended select primary care divisional meetings over a three-month period responded to this survey. Subgroup comparisons (female v. male, urban v. suburban, etc.) were made to evaluate for significant differences in attitudes, perceptions, and current practice of SBIRT, among several other components involving the integration of addiction medicine into primary care. Due to the small sample size and the inherent non-normal distribution of the ordinal scales used for each question, exact Wilcoxon Rank Sum tests were used to determine significance. All statistical analyses were conducted using SAS 9.4 (Cary, NC).
Respondents are, on average, 46 years old (SD: 9.3) and nearly all are physicians (42/44, 95.5%). One respondent each self-identified as a medical assistant or nurse practitioner. Additionally, respondents were 70.5% (31) white, 27.3% (12) non-white, and 2.3% (1) unidentified. Nearly half (20, 45.5%) work in academic/teaching institutions and 54.5% (24) in outpatient settings. Geographically, 86.4% (38) of respondents worked in suburban settings, 13.6% (6) in urban ones. Finally, 70.5% (31) were female, while 29.5% (13) were male.
The results of the comparisons by physician sex are presented in Table 1. Significant differences emerged when comparing male versus female provider responses on the “Perceived Self-efficacy” and “Frequency and Regularity” sections of the survey. Female providers are significantly more likely (p= .002) to be STRONGLY CONFIDENT in their ability to ask patients about substance use and are significantly more likely (p= .03) to STRONGLY AGREE that they ask patients about their substance use greater than half the time.
Female providers are also significantly more likely (p= .04) to STRONGLY AGREE that they ask patients about the quantity and frequency of their substance use greater than half the time. By comparison, male providers are more likely (p= .07) to be NEUTRAL when assessing their ability to screen patients for substance use using a standardized tool. The remaining survey sections yielded no significant results for the sex cross-tabulation.
Differences also emerged based on provider Race/Ethnicity (Table 2). Compared to non-white providers, white physicians are significantly more likely (p= .03) to STRONGLY AGREE that screening for at-risk substance use can result in early intervention. White providers are also significantly more likely (p= .02) to AGREE that they feel they know enough about substance use problems to carry out their role when working with at-risk substance users. By contrast, non-white providers are significantly more likely to be NEUTRAL on the topic.
Furthermore, white providers are significantly more likely (p= .03) to STRONGLY AGREE that they feel they can appropriately advise their patients about substance use and its effects, while non-white providers are significantly more likely to be NEUTRAL on the topic. White primary care physicians are also marginally more likely (p= .07) to AGREE that preventive health should be the patients’ responsibility not theirs compared to their non-white counterparts.
Non-white providers are significantly more likely (p= .04) to STRONGLY AGREE that it is their responsibility to refer patients with substance use problems to specialty treatment. They are also significantly more likely (p= .03) to believe they are INEFFECTIVE in reducing alcohol consumption amongst their patients. The remaining survey sections yielded no significant results for the race/ethnicity cross-tabulation.
On the basis of geographic setting (Table 3), urban providers were significantly more likely (p= .004) to STRONGLY AGREE that PCP’s should discuss substance use with all patients.They are also significantly more likely (p= .03) to STRONGLY AGREE that it is their responsibility to ask patients about their substance use. Urban providers were also marginally more likely to be STRONGLY CONFIDENT in their ability to ask patients about their substance use, as well as marginally more COMFORTABLE in their ability to ask patients about their alcohol consumption(both p= .08). The remaining survey sections yielded no significant results for the geographic setting cross-tabulation.
Comparisons by practice type are presented in Table 4. Positive trends emerged when Outpatient Clinic versus Academic/Teaching Institution were compared, specifically in the “Comfort Discussing” and “SBIRT Model Practice” sections of the survey.
Academic/Teaching Institution providers were found to be marginally more (p= .07) NEUTRAL regarding their comfort discussing illicit drug use in their patients. By comparison, outpatient clinic providers were significantly more likely (p= .046) to state that they ALWAYS screen their patients for drug and alcohol use. The remaining survey sections yielded no significant results for the practice type cross-tabulation.
Based on trends elicited from this study, the existing literature, and the current climate of drug/alcohol prevalence and misuse, it can be concluded that although SBIRT is recommended as a beneficial, evidenced-based practice universally in primary care, there are in certain sub-settings where successful implementation maybe more feasible, based on the existing providers’ attitudes and knowledge.
A recent 2017 study examined the keys for successful implementation of SBIRT into the primary care setting by awarding 10 primary care practices small community grants to implement and evaluate an SBIRT program in their location. Through this evaluation, the research team was able to complete 36,394 pre-screens and 21,635 full screens, ultimately allowing them to describe 8 “best practices” for using SBIRT in primary care: (1) Have a practice champion, (2) Utilize an inter-professional team, (3) Define and communicate the details of each SBIRT step, (4) Develop relationships with referral partners, (5) Institute ongoing SBIRT training, (6) Align SBIRT with the primary care office flow, (7) Consider using a pre-screening instrument, and (8) Integrate SBIRT into the electronic medical record.15What our study has done, aside from assessing the general conceptions and practice surrounding SBIRT in the Chicagoland area, is help to identify which settings are likely to have clinicians with a high likelihood of being the “practice champion” for implementing an SBIRT program into their primary care location, thereby facilitating the remaining steps of successful implementation.
From this study, the two variables that seem to predict highest likelihood of successful SBIRT implementation and usage would be female sex and an urban setting.
White and non-white providers both possessed skills and attitudes that could allow for successful use of SBIRT and early intervention in their clinics, although the data was not as robust in this cross-tabulation as it was for the sex and geography break-downs.
The results certainly warrant further investigation, with possible next steps including a similar study with larger sample size, studies exclusively focusing on the urban division of primary care clinics, or a potential pilot study assessing the efficacy of actual SBIRT implementation into a local primary care clinic, using the 8 best practices noted above, in addition to information gleaned from this study as resources to guide where and how to implement an SBIRT program.
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