Carol E. Achtmeyer

Increased documented brief alcohol interventions with a performance measure and electronic decision support.

BackgroundAlcohol screening and brief interventions (BIs) are ranked the third highest US prevention priority, but effective methods of implementing BI into routine care have not been described. ObjectivesThis study evaluated the prevalence of documented BI among Veterans Affairs (VA) outpatients with alcohol misuse before, during, and after implementation of a national performance measure (PM) linked to incentives and dissemination of an electronic clinical reminder (CR) for BI. MethodsVA outpatients were included in this study if they were randomly sampled for national medical record reviews and screened positive for alcohol misuse (Alcohol Use Disorders Identification Test-Consumption score ≥5) between July 2006 and September 2008 (N=6788). Consistent with the PM, BI was defined as documented advice to reduce or abstain from drinking plus feedback linking drinking to health. The prevalence of BI was evaluated among outpatients who screened positive for alcohol misuse during 4 successive phases of BI implementation: baseline year (n=3504), after announcement (n=753) and implementation (n=697) of the PM, and after CR dissemination (n=1834), unadjusted and adjusted for patient characteristics. ResultsAmong patients with alcohol misuse, the adjusted prevalence of BI increased significantly over successive phases of BI implementation, from 5.5% (95% CI 4.1%-7.5%), 7.6% (5.6%-10.3%), 19.1% (15.4%-23.7%), to 29.0% (25.0%-33.4%) during the baseline year, after PM announcement, PM implementation, and CR dissemination, respectively (test for trend P<0.001). ConclusionsA national PM supported by dissemination of an electronic CR for BI was associated with meaningful increases in the prevalence of documented brief alcohol interventions.

Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol Misuse

PURPOSE Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse. METHODS This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire ≥1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with χ2 statistics. RESULTS Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P <.001 for all measures). CONCLUSIONS Most primary care patients who screen positive for alcohol misuse indicate some readiness to change. Contrary to stereotypes of denial, those with greater alcohol misuse severity are more likely to report readiness to change.

Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study

ABSTRACTBACKGROUNDPopulation-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics.OBJECTIVEWe aimed to understand factors that might contribute to low sensitivity of alcohol screening.DESIGNThis was an observational, qualitative study.PARTICIPANTSParticipants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S.APPROACHFour researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes.KEY RESULTSWe observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort.CONCLUSIONSThis qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.

An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration

AIMS The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation. DESIGN Observational, retrospective cohort study using secondary clinical and administrative data. SETTING Thirty VA facilities. PARTICIPANTS Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%). MEASUREMENTS Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking). FINDINGS Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50). CONCLUSIONS During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

Measuring Performance of Brief Alcohol Counseling in Medical Settings: A Review of the Options and Lessons from the Veterans Affairs (VA) Health Care System.

SUMMARY Brief alcohol counseling is a top US prevention priority but has not been widely implemented. The lack of an easy performance measure for brief alcohol counseling is one important barrier to implementation. The purpose of this report is to outline important issues related to measuring performance of brief alcohol counseling in health care settings. We review the strengths and limitations of several options for measuring performance of brief alcohol counseling and describe three measures of brief alcohol counseling tested in the Veterans Affairs (VA) Health Care System. We conclude that administrative data are not well-suited to measuring performance of brief alcohol counseling. Patient surveys appear to offer the optimal approach currently available for comparing performance of brief alcohol counseling across health care systems, while more options are available for measuring performance within health care systems. Further research is needed in this important area of quality improvement.

Feedback from recently returned veterans on an anonymous web-based brief alcohol intervention

BackgroundVeterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are at increased risk for alcohol misuse, and innovative methods are needed to improve their access to alcohol screening and brief interventions (SBI). This study adapted an electronic SBI (e-SBI) website shown to be efficacious in college students for OEF/OIF veterans and reported findings from interviews with OEF/OIF veterans about their impressions of the e-SBI.MethodsOutpatient veterans of OEF/OIF who drank ≥3 days in the past week were recruited from a US Department of Veterans Affairs (VA) Deployment Health Clinic waiting room. Veterans privately pretested the anonymous e-SBI then completed individual semistructured audio-recorded interviews. Their responses were analyzed using template analysis to explore domains identified a priori as well as emergent domains.ResultsDuring interviews, all nine OEF/OIF veterans (1 woman and 8 men) indicated they had received feedback for risky alcohol consumption. Participants generally liked the standard-drinks image, alcohol-related caloric and monetary feedback, and the website’s brevity and anonymity (a priori domains). They also experienced challenges with portions of the e-SBI assessment and viewed feedback regarding alcohol risk and normative drinking as problematic, but described potential benefits derived from the e-SBI (emergent domains). The most appealing e-SBIs would ensure anonymity and provide personalized transparent feedback about alcohol-related risk, consideration of the context for drinking, strategies to reduce drinking, and additional resources for veterans with more severe alcohol misuse.ConclusionsResults of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.

Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics

BackgroundThree medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely.Objective This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including “segmenting the market,” to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications.DesignQualitative, interview-based study.ParticipantsTwenty-four providers from five VA PC clinics.ApproachProviders completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review.Key ResultsBarriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective “tool” or “foot in the door” for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have.ConclusionsWe identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

Probability and Predictors of Patients Converting from Negative to Positive Screens for Alcohol Misuse

BACKGROUND Medicare reimburses providers for annual alcohol screening. However, the benefit of rescreening patients a year after a negative screen for alcohol misuse is unknown. We hypothesized that some subgroups of patients who screen negative would have a very low probability of converting to a positive subsequent screen (e.g., <0.1%), calling into question the value of annual alcohol screening for some patient subgroups. METHODS This retrospective cohort study estimated the probability of converting to a positive screen for alcohol misuse a year after a negative screen among outpatients from 30 Veterans Health Administration (VA) medical centers. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screening scores (range 0 to 12 points) from 2004 to 2008 were obtained from electronic health record data. Eligible patients screened negative on their initial screen (AUDIT-C scores 0 to 3 for men; 0 to 2 for women). The main outcome was a positive subsequent screen (AUDIT-C scores ≥4 men; ≥3 women). RESULTS Among 21,081 women and 323,913 men who screened negative on an initial screen, 5.4% and 6.0%, respectively, screened positive a year later. The adjusted probability of converting to a positive subsequent screen varied from 2.1 to 38.9% depending on age, gender, and initial negative screen score. Women, older patients, and those with initial AUDIT-C scores of 0 were least likely to a convert to a positive subsequent screen, while younger men with AUDIT-C scores of 3 were most likely to a convert to a positive subsequent screen. CONCLUSIONS The probability of a positive subsequent screen varied depending on age, gender, and initial negative screen score but exceeded 2% in all patient subgroups. Annual rescreening appears reasonable for all VA patients who had a negative screen the year prior.

Factors underlying quality problems with alcohol screening in routine care

Since 2004 >90% of outpatients in the US Veterans Health Administration (VA) have been screened for unhealthy alcohol use with the AUDIT-C. However, research suggests variability in the quality of screening. To understand factors underlying variable quality, we conducted two qualitative studies: 1) an ethnographic study where we observed clinical staff performing screening, and 2) a key-informant study where we conducted 1:1 interviews with clinical staff. For Study 1, four researchers observed alcohol screening at 9 primary care clinics and took handwritten notes, which were transcribed. For Study 2, snowball sampling was used to recruit key informants (n=29) at 5 additional clinics who completed 20-30 minute semi-structured interviews, which were recorded and transcribed. Both qualitative datasets were analyzed using an a priori coding template. In Study 1, we observed 58 clinical staff caring for 166 patients. Alcohol screening was observed 74 times. Clinical staff appeared uncomfortable conducting verbal alcohol screening, and most screening was not verbatim. Study 2 interviews found that clinical staff and providers believed that addressing unhealthy alcohol use is an important part of care but had not received standard training regarding how or why to conduct alcohol screening. Information on alcohol screening was provided to clinicians via email announcement of the availability of electronic clinical decision support and ad-hoc peer-to-peer demonstration of its use. Participants perceived the screening questions to be sensitive and reported modifying questions to increase patient comfort. Participants were largely focused on identifying patients with the most severe condition—alcohol dependence—for which brief intervention does not have confirmed efficacy. Lack of training and discomfort are barriers contributing to variability in screening quality. Addressing the spectrum of unhealthy alcohol use is not yet viewed as part of a preventive agenda. Additional strategies are likely needed to improve screening quality.

Electronic Medical Record Alert Associated With Reduced Opioid and Benzodiazepine Coprescribing in High-risk Veteran Patients

Background: Over the past decade, overdoses involving opioids and benzodiazepines have risen at alarming rates, making reductions in coprescribing of these medications a priority, particularly among patients who may be susceptible to adverse events due to high-risk conditions. Objectives: This quality improvement project evaluated the effectiveness of a medication alert designed to reduce opioid and benzodiazepine coprescribing among Veterans with known high-risk conditions (substance use, sleep apnea, suicide-risk, age 65 and above) at 1 Veterans Affairs (VA) health care system. Methods: Prescribers were exposed to the point-of-prescribing alert for 12 months. For each high-risk cohort we used interrupted time series design to examine population trends in coprescribing 12 months after alert launch adjusting for coprescribing 12 months before launch, demographics and clinical covariates. Trends at the alert site were compared with those of a similar VA health care system without the alert. Secondary analyses examined population trends in opioid and benzodiazepine prescribing separately. Results: Over 12 months, the alert activated for 1332 patients. Proportions of patients with concurrent prescriptions decreased significantly postalert launch among substance use [adjusted odds ratio (AOR)=0.97; 95% confidence interval (CI)=0.96–0.99; 12-month decrease=25.0%], sleep apnea (AOR=0.97, 95% CI=0.95–0.98, 12-month decrease=38.5%), and suicide-risk (AOR=0.94, 95% CI=0.91–0.98, 12-month decrease=61.5%) cohorts at the alert site. Decreases in coprescribing were significantly different from the comparison site among suicide-risk (AOR=0.92, 95% CI=0.86–0.97) and sleep apnea (AOR=0.98, 95% CI=0.96–1.00) cohorts. Significant decreases in benzodiazepine prescribing trends were observed at the alert site only. Conclusions: Medication alerts hold promise as a means of reducing opioid and benzodiazepine coprescribing among certain high-risk groups.