Don’t we already know enough? Can’t we take what we have and apply it to both practice and policy in a way that effectively eliminates impaired driving? We know plenty about the roots of impaired driving and how effective various interventions are and are not. Unfortunately, this knowledge is not being applied consistently in practice or in policy, and the ultimate research question is the one that asks why that is the case. We need a new way of integrating the research that we have.
One of the barriers to be crossed in improving the care of injured alcohol-impaired drivers is the mindset of practitioners who think in too narrow terms as to what they can do to help solve this problem. The research is related to practice or advocacy or both and can be organized into several categories, including the following areas:
Effectiveness and Influence of Insurance Statutes and Policies on Reimbursement
for Emergency Care
The development of trauma centers in the United States has been extraordinarily successful. The preventable death rate from injuries has been reduced from 40 percent to 2-4 percent. This means that further significant reductions in mortality are not likely to occur as a result of improvements in trauma care. Also, over one-half of all trauma deaths occur at the scene of the injury, before anyone has a chance to respond. These deaths are also not responsive to improvements in care. Further reductions in mortality are therefore more likely to occur as a result of improvements in injury prevention programs. A public health approach to injuries is centered on addressing the underlying causes of injuries. Trauma centers have always known that alcohol use is by far the leading risk factor for injury in the United States, and is a factor in nearly half of all trauma center admission. This makes addressing alcohol problems the most obvious potential target for injury prevention programs.
Each year over 20.5 million adults in the United States sustain injuries requiring ED care. Published studies indicate that approximately 7.4 percent of these patients are intoxicated by alcohol. An additional 19.6 percent of patients who present to the ED for trauma care screen positive on an alcohol screening questionnaire, even though they are not intoxicated at the time. Overall, 25 percent of injured adult patients treated in the ED, or over five million patients, are potential candidates for an alcohol screening and intervention program designed to reduce the risk of injury recurrence, and other alcohol-related morbidity and mortality.
The potential benefits of addressing alcohol problems in this setting are profound. Including alcohol screening and interventions into treatment protocols for injured patients results in a physician patient interaction occurring at a time when the consequences of excessive drinking are most salient to the patient, resulting in a “teachable moment.” Furthermore, patients with an alcohol problem are more likely to require a visit to a doctor for treatment of an injury than for any other medical problem, making EDs the most logical place to initiate contact between patients and needed counseling services. Finally, the type of doctor most frequently seen by a problem-drinking patient is an ED physician.
In recent years a variety of federal, expert, and consensus panels have recommended routine screening and intervention in injured patients. From almost no interest a decade ago, according to a recent survey, 83 percent of trauma surgeons believe that trauma centers are an appropriate place to initiate alcohol treatment. However, despite the interest and opportunity, many physicians are reluctant to screen patients for an alcohol problem because of the potential impact of measuring a BAC on patients, hospitals, and health care providers.
Currently in 36 states, if a doctor documents in the medical record that an injured patient was intoxicated, the insurance company is allowed to deny payment for all charges. A recent survey of ED BAC screening practices for injured patients was conducted to evaluate specific barriers to implementation of intervention programs. Most centers did not provide this service at their center. Of those who did not, 41 percent cited the threatened impact of screening on reimbursement as a key factor. The threat of insurance denials was a greater concern than cost, time, confidentiality, or the potential for offending patients.
The UPPL statute that provides insurers with the right to deny coverage for treatment of alcohol related. The UPPL was drafted in 1947 and adopted as policy by 38 states and provisionally by four others (e.g., narcotics only). The states with insurance laws that allow this provision are shown in Figure 1.
(National Conference of State Legislators/Health Policy Tracking Service)
These statutes were passed decades ago, prior to the development of trauma and emergency medicine programs and at a time when there were few treatment opportunities available to patients with alcohol and drug problems. If the purpose of the statute was to reduce insurance costs, it has not had that effect because physicians simply avoid measuring and documenting alcohol use in jurisdictions where the UPPL is in effect and enforced. Therefore, insurers pay for the costs of alcohol-related injuries anyway, and the only effect of the law is to sweep the problem under the rug.
There are multiple stakeholders in favor of repealing the UPPL, including trauma and emergency medicine clinicians, alcohol and drug treatment providers, public safety officials, law enforcement groups, and anti-drunk driving advocacy groups. The National Association of Insurance Commissioners (NAIC), the originators of model legislation upon which the UPPL is based, have revised the model, and now recommends excluding medical coverage from exclusionary provisions. Whether the revision of the model is adopted by states will depend on the interest and activities of these multiple stakeholders.
(See Dr. Gentilello’s paper, Effectiveness
and Influence of Insurance Statues and Policies on Reimbursement for Emergency
Care, in the Appendix.)
Our culture has a schizoid view of alcohol consumption; it is good and bad, enjoyable and destructive. There are elements/businesses/interests of the environment that struggle with this dichotomy. For example, taverns (alcohol distribution sources) are faced with competing interests; they want people to consume alcohol, but they want patrons to drink safely and responsibly. Happy hours that offer free or low cost drinks encourage customers to drink more at the risk of over consumption. Yet most people arrive at taverns driving their cars, motorcycles, and snowmobiles.
The advertising industry is also caught in this schizoid view. They promote alcohol products and their success is measured by consumption of alcohol products. However, the advertising industries, in their attempts to enhance their success, link the alcohol product to driving and sexual conduct. Both of these activities have bad effects with at-risk alcohol use.
Hospital EDs also have competing interests related to alcohol consumption effecting their patients. Emergency physicians and nurses are focused on addressing their patients’ immediate problems but do not effectively address their patients’ basic issues related to at-risk alcohol use and abuse. One reason for this is due to the vagaries of insurance payments for alcohol-related car crashes. Some insurance companies will not pay for hospital/physician services if the patient was intoxicated at the time of the car crash.
It is very challenging to solve these behavioral and privacy issues and effectively address these competing interests of businesses that comprise parts of the environment of alcohol-related injuries and devise constructive measures to balance them for the public’s health. It is imperative that physicians and nurses remain patient-centered AND reframe the problem of alcohol-related injury as a public health issue. By broadening the discussion to the public’s health, everyone’s interests can be balanced to better manage these behavioral and privacy challenges.
In order to effectively address and balance these competing interests, a public health paradigm is needed. We should recognize a spectrum of alcohol consumption: moderate use, at-risk use, abuse, and alcoholism. Since the environment (home, roadway, tavern, hospital) is a key component of public health strategies, definitions of alcohol-related problems should be clear so that strategies can be aligned with the person’s health, as well as with the public’s health.
Health care professionals need to have a thorough understanding of HIPAA and the rights of patients to privacy. Health care professionals are agents of the patient and screening for alcohol-related problems does not violate that contract as long as it is in the best interest of the patient. However, disclosure of a patient’s behavior and alcohol over consumption to law enforcement is a challenging issue that must balance the needs of the patient’s health and the health and safety of the public.
Recommendations that merit further exploration are:
Brief intervention works for patients who present to the ED with alcohol problems. However, ED practitioners fail to incorporate screening and intervention for alcohol problems into their daily practice. There are multiple and complex barriers that contribute to this failure to act, including factors related to the individual practitioner as well as the system as a whole.
To begin the process of changing health practitioner behavior, we need to utilize the principles of motivational intervention, which include creating cognitive dissonance, decreasing ambivalence by reflection on conflicting motivations, and negotiating strategies for change. The components of any brief intervention can be used to change practitioner behavior. These steps include: (1) raise the subject, (2) provide feedback, (3) enhance motivation, and (4) negotiate and advise. We should remember, as in the National Institute on Drug Abuse (NIDA) principles, treatment does not need to be voluntary. Incentives, which are negative or positive, may be helpful in bringing about change. Most importantly, system changes will need to occur so that the change is feasible and sustainable.
Changing practitioner behavior can be approached in a variety of ways. The following describes different approaches along with their associated assumptions. (From Grol, R. Improving the quality of medical care: Building bridges among professional pride, payer profit and patient satisfaction. JAMA. 2001:28:2578-86.)
Approaches to Quality Improvement and Their Assumption
Strategies that can be used to approach practitioner behavioral change include the following:
The dictionary defines culture as: a: “the integrated pattern of human knowledge, belief, and behavior that depends upon man’s capacity for learning and transmitting knowledge to succeeding generations, b: the customary beliefs, social forms, and material traits of a racial, religious, or social group, c: the set of shared attitudes, values, goals, and practices that characterizes a company or corporation.” The first definition relates mostly to patients, while the last one describes health care staff in an ED.
As we look at how culture affects care, understanding factors that influence behavior change in both patients and ED staff may be helpful. Keller’s Learning Paradigm describes four areas that affect behavior change.
To explore cultural factors that can help us understand at-risk patients, we can look at six major groups or sub-cultures based on age (youth, college, and geriatrics), gender (women at-risk) and ethnicity (Native Americans). Gaining an understanding of each sub-culture’s environment and what affects them helps to understand their risks.
Youth (11-14 years of age)
Women at high risk
To help ameliorate these factors, several approaches
could be considered. Providing education on brief intervention and the
cultural factors that influence patients’ behaviors is one approach that can help. Mentoring ED colleagues
on how to “let go” is also an effective approach. To help staff,
referral information should be provided.
Emergency medical services are faced with several issues when providing care for alcohol-impaired patients.
Specific barriers in caring for alcohol-impaired patients as they relate to EMS include the following:
To impact the care of alcohol-impaired patients, the attitudes of EMS providers need to change. To accomplish this, EMS providers need access to the data (and need to help gather data) regarding alcohol involvement with injuries and illnesses. They need to know which health care interventions are effective. And, importantly, they need to be a part of solving the alcohol problem one patient at a time.
EMS can make a contribution because they are on the scene of the injury, but they need to make sure information is documented and communicated. Strategies that can lead to change for EMS providers focus on: