Reducing harm through quality improvementBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39520.730370.94 (Published 24 April 2008) Cite this as: BMJ 2008;336:952
- Brenda Reiss-Brennan, mental health integration director1,
- Lucy A Savitz, senior scientist2,
- Pascal Briot, analyst2,
- Wayne Cannon, medical director1
- 1Primary Care Clinical Programs, Intermountain Healthcare, 36 South State Street, Salt Lake City, UT 84111, USA
- 2Institute for Health Care Delivery Research, Intermountain Healthcare
- Correspondence to: B Reiss-Brennan
The concept of harm reduction has evolved over nearly 90 years from its beginnings in the 1920s, when it applied to drug misuse in adult populations.1 Applying the concept to adolescent groups at risk is relatively new, requiring that the concept be adapted appropriately. “The harm reduction approach, taking social context and developmental stage of the individual into account, may also be applied to adolescents at the less extreme end of the substance abuse spectrum.”2
Adolescent harm reduction spans a wider array of harmful behaviours than are discussed in the literature: substance misuse, multiple sexual partners, violence and weapon carrying, non-use of helmets when cycling, skating, or snowboarding, riding with a driver who has been drinking, and suicide plans. But the main contributor to death from injuries in people in the United States under the age of 21 is underage drinking.3
Young women are “outdrinking” their male counterparts of the same age and are more likely to experience adverse health consequences.4 Such behaviour may undermine neurological brain development, predispose to adult dependency, and increase mortality.5 The strong association between drinking and having multiple sexual partners “underscores the need to educate young people about the effects of alcohol on partner choice and the risk of infection with sexually transmitted diseases.”6 Harm from drinking often involves others; among young women this other will often be an unborn child. Fetal alcohol syndrome is the leading cause of brain damage in children in the United States.7 Young girls are now drinking and smoking like boys and are more likely to be depressed and to attempt suicide.3 In primary care the complexity of these risky behaviours among young people often goes undetected, owing to lack of time, of access to effective treatment, and of coordinated and adequately funded resources in the community to reduce harm.
A growing number of patients with serious mental illness and substance misuse report being treated in primary care or emergency rooms.8 Despite the availability of evidence based treatment for these disorders, many patients and families do not receive effective treatment in real world settings.9 One strategy to help remove such barriers is to re-engineer the processes of care delivery, using an evidence base of changes that lead to improvements in the quality and efficiency of care.
Our organisation, the non-profit Intermountain Healthcare (http://intermountainhealthcare.org/xp/public/about-intermountain/), became increasingly concerned that primary care resources were not being used effectively to treat patients with mental health conditions. Its medical leaders were influential in establishing the mental health integration (MHI) quality improvement programme. Over the last decade Intermountain has implemented MHI throughout 68 primary care clinics to identify patients with mental health or substance use disorders and to treat them and refer them to additional services. MHI makes available a clinical team and offers financial support to the primary care doctor. Sustained results show that MHI leads to improved functional status in patients and improved satisfaction and confidence among physicians in managing mental health problems as part of routine care at a neutral cost.10
The primary care environment presents opportunities and challenges for reducing harm in young female drinkers. Alcohol dependence and underage drinking are complex family health problems and are intensely personal and isolating issues for girls and young women. It is an opportune consultation in which teenagers’ health risks are uncovered and wellness can be promoted. Although guidelines are available, the routine screening of young women for harmful behaviours varies widely among primary care doctors.
The MHI assessment begins with a common screening toolset administered by the family doctor, who determines, together with the patient and family, the severity of the mental health concerns. It includes comprehensive, self reported measures of family history and relational support, environmental stressors, use of substances, depression, anxiety, and bipolar and attention deficit disorders.
The results determine whether the doctor continues routine treatment or triages the patient to the MHI psychologist, psychiatrist, or psychiatric nurse practitioner for prompt consultation. The team includes a nurse care manager, who provides support and feedback to the doctor, the patient, and the family. The care manager also provides education and information and links the patient to community resources, if this will benefit the patient. The team members use harm reduction strategies to improve education and to provide treatment for alcohol misuse. They also facilitate the involvement of families and community resources in social support and reinforcement of abstinence.11 Strategies that are tailored to the preferences of patients and communities are more likely to result in positive behaviour change.12
Intermountain’s MHI database identified 123 263 patients across all age groups, 45% of whom were women (55 568). The data show that 25 945 girls and women aged <39 were being treated for substance misuse and that 9107 had comorbidity of depression and substance misuse. Of those with a diagnosis of substance misuse, 420 (1.6%) were 18 years old or younger.
Adopting a harm reduction approach to help young female drinkers and their families will require quality improvement interventions that provide institutional support for the primary care doctor to deliver care that is matched to the family’s and community’s social, financial, and cultural healthcare preferences for wellness. Higher levels of social capital exert strong protective effects against alcohol misuse and harm.13 Intermountain’s MHI programme is one example of a quality improvement intervention that tackles social capital needs and such barriers as failed access and limited, fragmented treatment choices, which many families face when trying to find help.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally reviewed.