Gwen T. Lapham

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

AIMSnThe 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.nnnDESIGNnObservational, retrospective cohort study using secondary clinical and administrative data.nnnSETTINGnThirty VA facilities.nnnPARTICIPANTSnOutpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-Cu2009≥u20095)] in the 6 months after the brief intervention performance measure (nu2009=u200922u2009214) and had follow-up screening 9-15 months later (nu2009=u20096210; 28%).nnnMEASUREMENTSnMulti-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).nnnFINDINGSnAmong 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-valuesu2009<u20090.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI)u2009=u200942-52%] and 48% (95% CIu2009=u200942-54%) for patients with and without documented brief intervention, respectively (Pu2009=u20090.50).nnnCONCLUSIONSnDuring 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.

Prevalence of clinically recognized alcohol and other substance use disorders among VA outpatients with unhealthy alcohol use identified by routine alcohol screening

OBJECTIVEnThe purpose of routine alcohol screening is to identify patients who may benefit from brief intervention, but patients who also have alcohol and other substance use disorders (AUD/SUD) likely require more intensive interventions. This study sought to determine the prevalence of clinically documented AUD/SUD among VA outpatients with unhealthy alcohol use identified by routine screening.nnnMETHODSnVA patients 18-90 years who screened positive for unhealthy alcohol use (AUDIT-C ≥3 women; ≥4 men) and were randomly selected for quality improvement standardized medical record review (6/06-6/10) were included. Gender-stratified prevalences of clinically documented AUD/SUD (diagnosis of AUD, SUD, or alcohol-specific medical conditions, or VA specialty addictions treatment on the date of or 365 days prior to screening) were estimated and compared across AUDIT-C risk groups, and then repeated across groups further stratified by age.nnnRESULTSnAmong 63,397 eligible patients with unhealthy alcohol use, 25% (n=2109) women and 28% (n=15,199) men had documented AUD/SUD (p<0.001). The prevalence of AUD/SUD increased with increasing AUDIT-C risk, ranging from 13% (95% CI 13-14%) to 82% (79-85%) for women and 12% (11-12%) to 69% (68-71%) for men in the lowest and highest AUDIT-C risk groups, respectively. Patterns were similar across age groups.nnnCONCLUSIONSnOne-quarter of all patients with unhealthy alcohol use, and a majority of those with the highest alcohol screening scores, had clinically recognized AUD/SUD. Healthcare systems implementing evidence-based alcohol-related care should be prepared to offer more intensive interventions and/or effective pharmacotherapies for these patients.

Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff.

BACKGROUND AND OBJECTIVEnPopulation-based alcohol screening, followed by brief intervention for patients who screen positive for unhealthy alcohol use, is widely recommended for primary care settings and considered a top prevention priority, but is challenging to implement. However, new policy initiatives in the U.S., including the Affordable Care Act, may help launch widespread implementation. While the nationwide Veterans Health Administration (VA) has achieved high rates of documented alcohol screening and brief intervention, research has identified quality problems with both. We conducted a qualitative key informant study to describe local implementation of alcohol screening and brief intervention from the perspectives of frontline adopters in VA primary care in order to understand the process of implementation and factors underlying quality problems.nnnMETHODSnA purposive snowball sampling method was used to identify and recruit key informants from 5 VA primary care clinics in the northwestern U.S. Key informants completed 20-30 minute semi-structured interviews, which were recorded, transcribed, and qualitatively analyzed using template analysis.nnnRESULTSnKey informants (N=32) included: clinical staff (n=14), providers (n=14), and administrative informants (n=4) with varying participation in implementation of and responsibility for alcohol screening and brief intervention at the medical center. Ten inter-related themes (5 a priori and 5 emergent) were identified and grouped into 3 applicable domains of Greenhalghs conceptual framework for dissemination of innovations, including values of adopters (theme 1), processes of implementation (themes 2 and 3), and post-implementation consequences in care processes (themes 4-10). While key informants believed alcohol use was relevant to health and important to address, the process of implementation (in which no training was provided and electronic clinical reminders just showed up) did not address critical training and infrastructure needs. Key informants lacked understanding of the goals of screening and brief intervention, believed referral to specialty addictions treatment (as opposed to offering brief intervention) was the only option for following up on a positive screen, reported concern regarding limited availability of treatment resources, and lacked optimism regarding patients interest in seeking help.nnnCONCLUSIONSnFindings suggest that the local process of implementing alcohol screening and brief intervention may have inadequately addressed important adopter needs and thus may have ultimately undermined, instead of capitalized on, staff and providers belief in the importance of addressing alcohol use as part of primary care. Additional implementation strategies, such as training or academic detailing, may address some unmet needs and help improve the quality of both screening and brief intervention. However, these strategies may be resource-intensive and insufficient for comprehensively addressing implementation barriers.

Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples

BackgroundThe AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice.MethodsThis study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (Nu2009=u200926,610) and a Veterans Health Administration (VA) outpatient survey (Nu2009=u2009467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C.ResultsAmong men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking.LimitationsThis study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens.ConclusionsUp to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.

Among patients with unhealthy alcohol use, those with HIV are less likely than those without to receive evidence-based alcohol-related care: A national VA study

BACKGROUNDnAlcohol use has important adverse effects on people living with HIV (PLWH). This study of patients with recognized unhealthy alcohol use estimated and compared rates of alcohol-related care received by PLWH and HIV- patients.nnnMETHODSnOutpatients from the Veterans Health Administration who had one or more positive screen(s) for unhealthy alcohol use (AUDIT-C≥5) documented in their medical records 10/2009-5/2013 were eligible. Primary and secondary outcomes were brief intervention documented ≤14days after a positive alcohol screen, and a composite measure of any alcohol-related care (brief intervention, specialty addictions treatment or pharmacotherapy documented ≤365 days), respectively. Unadjusted and adjusted regression analyses compared alcohol-related care outcomes in PLWH and HIV- patients.nnnRESULTSnThe sample included 830,825 outpatients (3,514 PLWH), reflecting 1,172,606 positive screens (1-5 per patient). For PLWH, 57.0% (95% confidence interval 55.4-58.5%) of positive screens were followed by brief intervention, compared to 73.8% (73.7-73.9%) for HIV- patients [relative rate: 0.77 (0.75-0.79), p<0.001]. After adjustment, comparable proportions were 61.0% (59.3-62.6%) for PLWH and 73.7% (73.6-73.8%) for HIV- patients [adjusted RR=0.83 (0.80-0.85); p<0.001]. Secondary outcome results were similar: for PLWH and HIV- patients, 67.1% (65.7-68.6%) and 77.7% (95% CI 77.7-77.8%) of positive screens, respectively, were followed by any alcohol-related care after adjustment [adjusted RR=0.86 (0.85-0.88), p<0.001].nnnCONCLUSIONSnIn this large national sample of VA outpatients with unhealthy alcohol use, PLWH were less likely to receive alcohol-related care than HIV- patients. Special efforts may be needed to ensure alcohol-related care reaches PLWH.

Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population.

AIMSnTo evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2).nnnDESIGNnCohort study.nnnSETTINGnTwenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention.nnnPARTICIPANTSnA total of 486u2009115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥xa012xa0months apart (baseline and follow-up).nnnMEASUREMENTSnIndependent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations (GI hospitalizations) and (3) physical trauma, each in the years after baseline and follow-up.nnnFINDINGSnBaseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI)xa0=xa041.3-41.5] to 53.5 (95% CIxa0=xa051.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CIxa0=xa00.48-0.51%) to 1.8% (95% CIxa0=xa01.3-2.3%) and trauma from 3.0% (95% CIxa0=xa02.95-3.06%) to 6.0% (95% CIxa0=xa05.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all <xa00.05). For example, among those with baseline low-risk use, in those with persistent low-risk use versus severe misuse at follow-up, the probabilities of subsequent trauma were 2.65% (95% CIxa0=xa02.54-2.75%) versus 5.15% (95% CIxa0=xa03.86-6.45%), respectively. However, for patients who decreased to lower AUDIT-C risk groups at follow-up, findings were inconsistent across outcomes, with only mean HDL decreasing in most groups that decreased use (P-values all <xa00.05).nnnCONCLUSIONSnWhen AUDIT-C screening is conducted in clinical settings, baseline AUDIT-C scores and score increases to moderate-severe alcohol misuse at follow-up screening appear to have predictive validity for HDL cholesterol, alcohol-related gastrointestinal hospitalizations and physical trauma. Decreasing AUDIT-C scores collected in clinical settings appear to have predictive validity for only HDL.

Comparison of provider-documented and patient-reported brief intervention for unhealthy alcohol use in VA outpatients

BACKGROUNDnPerformance measures for brief alcohol interventions (BIs) are currently based on provider documentation of BI. However, provider documentation may not be a reliable measure of whether or not patients are offered clinically meaningful BIs. In particular, BI documented with clinical decision support in an electronic medical record (EMR) could appear identical irrespective of the quality of BI provided. We hypothesized that differences in how BI was implemented across health systems could lead to differences in the proportion of documented BI recalled and reported by patients across health systems.nnnMETHODSnMale outpatients with unhealthy alcohol use identified by confidential satisfaction surveys (2009-2012) were assessed for whether they reported receiving BI in the past year (patient-reported BI) and whether they had BI documented in the EMR during the same period (documented BI). We evaluated and compared the prevalence of documented BI to patient-reported BI across 21 VA networks to determine whether documented BI had a variable association with patient-reported BI across the networks.nnnRESULTSnOf 9896 eligible male outpatients with unhealthy alcohol use, 59.0% (95% CI 57.4-60.5%) reported BI (50.4-64.9% across networks) and 37.4% (95% CI 36.0-38.9%) had BI documented in the EMR (28.0-44.2% across networks). Overall, 72.9% (95% CI 70.8-75.5%) of patients with documented BI also reported BI. The association between documented BI and patient-reported BI did not vary across VA networks in adjusted logistic regression models.nnnCONCLUSIONSnPerformance measures of BI that rely on provider documentation in EMRs appear comparable to patient report for comparing care across VA networks.

Annual rescreening for alcohol misuse: diminishing returns for some patient subgroups.

Background:Routine alcohol screening is widely recommended, and Medicare now reimburses for annual alcohol screening. Although up to 18% of patients will screen positive for alcohol misuse, the value of annual rescreening for patients who repeatedly screen negative is unknown. Objective:To evaluate the probability of converting to a positive alcohol screen at annual rescreening among VA outpatients who previously screened negative 2–4 times. Research Design:Retrospective cohort study. Subjects:A total of 179,035 VA outpatients (10,588 women) who previously screened negative on 2 and up to 4 consecutive annual alcohol screens and were rescreened the next year. Measures:AUDIT-C alcohol screening scores (range, 0–12) were obtained from electronic medical record data. The probability of converting to a positive screen (scores: men ≥4; women, ≥3) at rescreening after 2–4 prior negative screens was evaluated overall and across subgroups based on age, sex, and prior negative screen scores (scores: men, 0–3; women, 0–2). Results:The overall probability of converting to a positive subsequent screen decreased modestly from 3.5% to 1.9% as the number of prior consecutive negative screens increased from 2 to 4, yet varied widely across subgroups based on age, sex, and prior negative screen scores (0.6%–38.7%). Conclusions:The likelihood of converting to a positive screen at annual rescreening is strongly influenced by age, sex, and scaled screening scores on prior negative alcohol screens. Algorithms for the frequency of repeat alcohol screening for patients who repeatedly screen negative should be based on these factors. These results may have implications for other routine behavioral health screenings.

Binge drinking and perceived ethnic discrimination among Hispanics/Latinos: Results from the Hispanic community health study/study of Latinos sociocultural ancillary study

ABSTRACT The study assessed whether overall perceived ethnic discrimination and four unique discrimination types were associated with binge drinking in participants from the Hispanic Community Health Study/Study of Latinos who also completed the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study (n = 5,313). In unadjusted analyses that were weighted for sampling strategy and design, each unit increase in discrimination type was associated with a 12–63% increase in odds of binge drinking; however, after adjusting for important demographic variables including age, sex, heritage group, language, and duration of U.S. residence, there was no longer an association between discrimination and binge drinking. Further research still needs to identify the salient factors that contribute to increased risk for binge drinking among Hispanics/Latinos.