A proposal to include screening and brief intervention for addictions in national quality and accreditation standards for hospitals could be one of the most important developments ever for addiction treatment -- or wind up being something far less significant, depending upon the outcome of ongoing discussions and feedback from the medical community.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently released for public comment a list of proposed new hospital performance measures for screening, brief intervention, referral and treatment (SBIRT) of alcohol, tobacco, and other drug use. JCAHO accredited nearly 16,000 U.S. healthcare facilities, accounting for 95 percent of the country's hospital beds.

"These would be standardized measures, so every hospital would be expected to do it the same way," said Nancy Lawler, assistant project director and clinical lead for SBIRT at JCAHO. The SBIRT measures could become part of the JCAHO accreditation manual in late 2011 or 2012, assuming they survive review by the organization's advisory board, pilot testing and analysis procedures and are endorsed by the National Quality Forum, which helps set national healthcare performance standards and measures.

If the JCAHO decides that all hospitals should be required to report their outcomes on SBIRT as part of the accreditation process, it could "do more to medicalize substance-abuse problems than all the urging and pleading we've undertaken for the past 25 to 30 years," said SBIRT pioneer and trauma surgeon Larry Gentilello, M.D., a professor at the University of Texas Southwestern Medical Center.

That's because such a requirement would essentially compel all U.S. hospitals to implement programs to screen their patients for addiction problems, potentially providing a huge boost in the numbers of individuals referred to treatment and, advocates say, saving money for the healthcare system in the process. Currently, just 4 percent of hospital patients receive evidence-based interventions for alcohol, tobacco or other drug use, according to researchers. Since 2006, the American College of Surgeons has required the 100-plus Level 1 trauma centers in the U.S., to conduct SBIRT, but the programs are rarely implemented in other hospitals.

"If it goes as we hope, it will require every patient admitted to the hospital to be screened for alcohol, tobacco and other drug abuse," said Eric Goplerud, Ph.D., co-chair of the Joint Commission's technical advisory group and director of Ensuring Solutions to Alcohol Problems, a project of the George Washington University Medical Center.

Feedback is Crucial

However, feedback from hospital administrators, treatment advocates and others will help determine the scope of the changes, and the final outcome could be something far less dramatic.

"The present thinking regarding the draft measure set on the topic of assessing and treating tobacco, alcohol and other drug use is that it will be offered to Joint Commission accredited hospitals as a set of core measures available for hospitals to choose in order to meet their performance measure accreditation requirement (most hospitals are required to collect data and report data on 4 core measure sets)," said Ann Watt, associate director of the Center for Performance Measurement at JCAHO's Division of Quality Measurement and Research. "There has been some discussion as to whether reporting should be required on this set (should it move forward) by all hospitals, but it is certainly much too early to speculate as to whether that will be the case."

Why you should submit comments (letter from David Rosenbloom)

In other words, SBIRT performance measures -- if implemented at all -- could just become one choice on a menu of indicators that hospitals can choose from (known as JCAHO's Oryx measures) in order to meet their accreditation requirements. That would be a significant step towards acceptance of SBIRT by the mainstream medical community: "Even if this is among the performance measures that hospitals can choose, it is a big deal," said David Rosenbloom, president and CEO of the National Center on Addiction and Substance Abuse at Columbia University. "They constitute a remarkable and complete validation that tobacco, alcohol and drug addiction are chronic diseases that must be identified, treated, and followed after discharge in virtually all hospital patients. I think even the publication of the standards is a huge advance."

Such a limited implementation would not be likely to prompt widescale adoption of screening and brief intervention by U.S. hospitals, however. "The measures could become global and mandatory, but that decision has not been made and will be influenced by the strength of responses from the field to the initial descriptions of the measures," said Goplerud.

Comments on the proposed performance measures are being accepted by JCAHO through Sept. 30.

Cost, Outcomes Data Favor Broad Adoption, Advocates Say

JCAHO is seeking feedback on eight proposed process and outcome measures: Tobacco Use Assessment; Tobacco Use Treatment; Tobacco Use Treatment at Discharge; Tobacco Use Follow-up; Alcohol and Other Drug Use Screening; Alcohol and Other Drug Use and Dependence - Brief Intervention or Treatment; Alcohol and Other Drug Use and Dependence – Treatment Management at Discharge; and Alcohol and Other Drug Use and Dependence – Follow-up for Unhealthy Use and/or Disorders.

Advocates said that the measures, if adopted, could address some of the greatest unmet healthcare needs in U.S. hospitals. An estimated one in four hospital admissions is related to alcohol, tobacco, or other drug use.

If broadly construed, the JCAHO measures could require that all admitted patients be screened for excessive alcohol use, use of illicit drugs, misuse of prescription drugs, or tobacco use; that those who screen positive receive a brief intervention; that those found to have a dependence problem get treated in the hospital or referred to treatment at discharge; and that followups be conducted within two weeks of discharge, according to Goplerud.

The jury is still out on how the medical community will view the SBIRT proposal, but advocates say that providers can expect to yield $4 in reduced healthcare costs for every $1 invested in SBIRT. Goplerud noted that Medicaid and Medicaid now allows providers to seek reimbursement of SBIRT expenses. Also, recent research from the Center for Substance Abuse Treatment found that SBIRT "was feasible to implement and the self-reported patient status at 6 months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of healthcare settings and a range of patients."

"Hospital administrators may balk at this, but they haven't seen the data," said Gentilello. "There was no disruption of hospital routines, and SBIRT was well accepted by patients. There was a 34 percent reduction in alcohol use and a 64 percent reduction in drug use."

The pairing of alcohol and other drug screening with tobacco screening in the proposed JCAHO measures also could help win over skeptics, advocates said. "Tobacco-cessation interventions are so inexpensive that even if only the occasional patient stops smoking it will more than pay for itself," said Gentilello, who said that the cost of 1,000 tobacco screenings is easily outweighed by the cost of treating one cancer patient.