Alcohol 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.
This 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.
VA 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.
Among 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).
A national PM supported by dissemination of an electronic CR for BI was associated with meaningful increases in the prevalence of documented brief alcohol interventions.
"Scores of 3–5 (women) or 4–5 (men), 6–7, 8–9, and 10–12 points represent mild, moderate, severe, and very severe unhealthy alcohol use, respectively (Au et al., 2007; Kinder et al., 2009; Williams et al., 2012, 2010). Because the VA began incentivizing brief intervention during the study period for patients with AUDIT-C scores of 5 or more (Lapham et al., 2012), which may have resulted in greater assessment for and/or documentation of alcohol or substance use disorders in patients with scores of 5 or more, scores for mild unhealthy alcohol use were split into two groups—3–4 (women)/4 (men) and 5. "
[Show abstract][Hide abstract] ABSTRACT: The 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.
VA 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.
Among 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.
One-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.
Drug and alcohol dependence 11/2013; 135(1). DOI:10.1016/j.drugalcdep.2013.11.016 · 3.42 Impact Factor
"Additionally, the care managers may only refer patients who expressed interest in abstinence-oriented treatment. A recent work by Lapham and colleagues (Lapham et al., 2012) demonstrated the importance of systematically documenting whether the referral for treatment was discussed, implemented, and completed in relation to facilitating treatment referral in primary care. Additionally, in this study, we were able to take into account care managers' variations in referral rates which may reflect provider factors and variable access to substance abuse treatment services at different clinics. "
[Show abstract][Hide abstract] ABSTRACT: This study examined the relationship between substance treatment referrals and depression improvement among 2,373 participants with concurrent substance use and depressive disorders enrolled in an integrated behavioral health program. Three groups of substance treatment referral status were identified: accessed treatment (n=780), declined treatment (n=315), and no referral for treatment (n=1278). The primary outcome is improvement in depressive symptoms (PHQ-9<10 or≥50% reduction). Using propensity score adjustments, patients accessing substance treatment were significantly more likely to achieve depression improvement than those who declined receiving treatment services (hazard ratio (HR)=1.82, 95% confidence interval (CI): 1.50-2.20, p<0.001) and those without a referral for treatment (HR=1.13, 95% CI: 1.03-1.25, p=0.014). Each 1week delay in initiating a referral was associated with a decreased likelihood of depression improvement (HR=0.97, 95% CI: 0.96-0.98, p<0.001). Study findings highlight the need of enhancing early treatment contact for co-occurring substance use disorders in primary care.
"An additional barrier is the lack of an unambiguous tool for monitoring the quality of SBIRT, which ideally should include assessment of core brief intervention components rather than non-specific provider or patient report of alcohol counseling [6,95]. Interestingly, implementation of a performance measure and electronic reminders were each associated with an increase in the receipt of brief intervention in outpatient VA settings , and this type of strategy has the potential to enhance SBIRT performance in the hospital . "
[Show abstract][Hide abstract] ABSTRACT: There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.
Addiction science & clinical practice 06/2013; 8(1):11. DOI:10.1186/1940-0640-8-11
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