Increased Documented Brief Alcohol Interventions With a Performance Measure and Electronic Decision Support

Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98101, USA.
Medical care (Impact Factor: 3.23). 09/2010; 50(2):179-87. DOI: 10.1097/MLR.0b013e3181e35743
Source: PubMed


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.

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    • "Fig. 1 offers a graphic representation of the a priori and emergent identified themes organized by the most applicable domains of Greenhalgh's implementation framework (Greenhalgh et al., 2004). In addition, Fig. 1 depicts how identified themes may have resulted in previously identified implementation outcomes [i.e., high rates of documented alcohol screening (Bradley et al., 2006) and brief intervention (Bradley, Johnson, & Williams, 2011; Lapham et al., 2012), and quality problems with each (Bradley, Lapham, et al., 2011; Williams, Rubinsky, Chavez, et al., 2014 "
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    ABSTRACT: Population-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. A 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. Key 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 Greenhalgh's 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. Findings 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. Published by Elsevier Inc.
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    • "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. "
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    • "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. "
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