Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care

A Preamble to Prevention of Adolescent Substance Use: Pediatric Resident Screening for Caregiver Substance Use

BACKGROUND

Caregiver problematic substance use (SU) is a common adverse childhood experience that is associated with the development of SU disorders in adolescence and poor health outcomes. Most pediatricians do not currently screen for caregiver SU, missing an opportunity to provide targeted prevention counseling to at-risk youth and their families. The objective of this study was to assess whether pediatric residents' screening-related competencies, beliefs, and training were associated with current screening practices and/or preparedness to screen in the future.

METHODS

Baseline surveys from a quality improvement initiative to increase screening for household SU in pediatric primary care were e-mailed to all pediatric residents at an academic medical center. Surveys assessed residents' current screening practices, preparedness to screen in the future, screening-related competencies, receipt of SU training, beliefs about screening, perceived caregiver acceptability of screening, and stigma about caregiver SU.

RESULTS

Residents agreed screening for household SU is a pediatrician's responsibility and beneficial for patients and families, yet only 5% universally screened. Preparedness to screen in the future was positively associated with reported screening-related competencies and receipt of training on SU screening during residency.

CONCLUSIONS

Most residents did not universally screen for household SU, thereby missing opportunities for targeted secondary prevention of adolescent SU. Trained residents who reported competence in addressing families' concerns were more likely to feel prepared to screen in the future, suggesting education that addresses caring for affected families, reviews available resources, and improves pediatrician confidence may be particularly impactful.

Addressing India's alcohol misuse crisis: The urgent need for screening and brief intervention to bridge the healthcare gap

India faces a significant challenge with alcohol misuse, as evidenced by the national survey revealing that 57 million out of 160 million persons with alcohol use exhibit harmful or dependent patterns, necessitating professional assistance. The Global Status Report on Alcohol and Health (2018) indicates a rising per capita alcohol consumption in the Southeast Asian Region, with India contributing substantially. To address this, implementing policies and programs to curb hazardous alcohol use is crucial. Despite a shortage of mental health professionals in India, they remain the primary caregivers for those with alcohol-related issues. Only one in five individuals with problematic alcohol use can access professional help. I argue for adopting Screening and Brief Intervention (SBI) to bridge this healthcare gap. SBI is a concise, structured counseling approach that proves effective and scalable. It can be delivered by various healthcare providers, including doctors, nurses, counselors, and paramedics. Hence, it can be seamlessly integrated into primary care, emergency, and nonclinical settings. The efficacy of SBI extends to electronic formats, providing a scope of expansion through telehealth. The WHO advocates SBI by its SAFER initiative aimed at reducing negative alcohol-associated health and social consequences. SBI is effective across age groups, including adolescents and young adults, constituting most of India's population. Emerging evidence suggests that SBI is acceptable, feasible, and effective in the Indian context. Universal or targeted SBI can be a pivotal tool in achieving the Sustainable Development Goals (2030) and global commitments for noncommunicable diseases, fortifying efforts to prevent and treat alcohol misuse.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial

BACKGROUND

Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures.

OBJECTIVE

This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities.

METHODS

The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses.

RESULTS

This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027.

CONCLUSIONS

SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54486.

Economic evaluations performed alongside randomized implementation trials in clinical settings: a systematic review

BACKGROUND

Economic evaluations alongside implementation trials compare the outcomes and costs of competing implementation strategies to identify the most efficient strategies. The aims of this systematic review were to investigate how economic evaluations are performed in randomized implementation trials in clinical settings and to assess the quality of these evaluations.

METHODS

A systematic literature review was conducted on 23 March 2023 to identify studies that reported on economic evaluations embedded in randomized implementation trials in clinical settings. A systematic search was applied across seven databases, and references of relevant reviews were screened for additional studies. The Drummond Checklist was used to assess the quality and risk of bias of included economic evaluations. Study characteristics and quality assessments were tabulated and described.

RESULTS

Of the 6,550 studies screened for eligibility, 10 met the inclusion criteria. Included studies were published between 1990 and 2022 and from North America, the United Kingdom, Europe, and Africa. Most studies were conducted in the primary and out-patient care setting. Implementation costs included materials, staffing, and training, and the most common approach to collecting implementation costs was obtaining expense and budget reports. Included studies scored medium to high in terms of economic methodological quality.

CONCLUSIONS

Economic evidence is particularly useful for healthcare funders and service providers to inform the prioritization of implementation efforts in the context of limited resources and competing demands. The relatively small number of studies identified may be due to lack of guidance on how to conduct economic evaluations alongside implementation trials and the lack of standardized terminology used to describe implementation strategies in clinical research. We discuss these methodological gaps and present recommendations for embedding economic evaluations in implementation trials. First, reporting implementation strategies used in clinical trials and aligning these strategies with implementation outcomes and costs are an important advancement in clinical research. Second, economic evaluations of implementation trials should follow guidelines for standard clinical trial economic evaluations and adopt an appropriate costing and data collection approach. Third, hybrid trial designs are recommended to generate evidence for effective and cost-effective implementation strategies alongside clinical effectiveness and cost-effectiveness.

TRIAL REGISTRATION

The review was prospectively registered with PROSPERO (CRD42023410186).