Implementing electronic substance use disorder and depression and anxiety screening and behavioral interventions in primary care clinics serving people with HIV: Protocol for the Promoting Access to Care Engagement (PACE) trial

Abstract

Background: Substance use disorders (SUDs) and psychiatric disorders are common among people with HIV (PWH) and lead to poor outcomes. Yet these conditions often go unrecognized and untreated in primary care.

Methods: The Promoting Access to Care Engagement (PACE) trial currently in process examines the impact of self-administered electronic screening for SUD risk, depression and anxiety in three large Kaiser Permanente Northern California primary care clinics serving over 5000 PWH. Screening uses validated measures (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]; and the Adult Outcomes Questionnaire [AOQ], which includes the Patient Health Questionnaire [PHQ-9] and Generalized Anxiety Disorder [GAD-2]) delivered via three modalities (secure messaging, tablets in waiting rooms, and desktop computers in exam rooms). Results are integrated automatically into the electronic health record. Based on screening results and physician referrals, behavioral health specialists embedded in primary care initiate motivational interviewing- and cognitive behavioral therapy-based brief treatment and link patients to addiction and psychiatry clinics as needed. Analyses examine implementation (screening and treatment rates) and effectiveness (SUD, depression and anxiety symptoms; HIV viral control) outcomes using a stepped-wedge design, with a 12-month intervention phase implemented sequentially in the clinics, and a 24-month usual care period prior to implementation in each clinic functioning as sequential observational phases for comparison. We also evaluate screening and treatment costs and implementation barriers and facilitators.

Discussion: The study examines innovative, technology-facilitated strategies for improving assessment and treatment in primary care. Results may help to inform substance use, mental health, and HIV services.

Trial registration: NCT03217058.

Keywords: Alcohol; Anxiety; Cognitive behavioral therapy; Depression; Drug use; HIV; Motivational interviewing; Patient portal; Primary care; Suicidal ideation.

Copyright © 2019 Elsevier Inc. All rights reserved.

Figures

Figure 1.

Stepped-wedge design to evaluate outcomes in the PACE Trial. Notes: *Each time period represents six months. Observational period cells are light gray. Intervention period cells are dark gray. Rollout of the study intervention (computerized screening + BHS-delivered treatment) occurs sequentially at the 3 HIV primary care clinics, starting with Oakland. The observational periods are also sequential.

Figure 2.

Conceptual model of factors associated with successful intervention implementation in health care settings. Notes: Conceptual model is based on the Practical, Robust Implementation and Sustainability Model (PRISM) [48]. BHS= behavioral health specialist; SUD = substance use disorder.

Figure 3.

PACE intervention approach to computerized substance use, depression and anxiety screening and treatment in HIV primary care clinics. Notes: TAPS/AOQ = Tobacco, Alcohol, Prescription Medication and other Substance Use/Adult Outcomes Questionnaire; PCP = primary care provider; BHS = behavioral health specialist; EHR = electronic health record. KP.org is Kaiser Permanente’s electronic patient portal.