Alcohol Counseling Reflects Higher Quality of Primary Care
Richard Saitz, MD, MPH1,2,3, Nicholas J. Horton, ScD6, Debbie M. Cheng, ScD1,4,
and Jeffrey H. Samet, MD, MA, MPH1,5
1Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center and Boston University
School of Medicine, Boston, MA, USA;2Youth Alcohol Prevention Center, Boston University School of Public Health, Boston, MA, USA;
3Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA;4Department of Biostatistics, Boston University
School of Public Health, Boston, MA, USA;5Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston,
MA, USA;6Department of Mathematics and Statistics, Smith College, Northampton, MA, USA.
BACKGROUND: Some primary care physicians do not
conduct alcohol screening because they assume their
patients do not want to discuss alcohol use.
OBJECTIVES: To assess whether (1) alcohol counseling
can improve patient-perceived quality of primary care,
and (2) higher quality of primary care is associated with
subsequent decreased alcohol consumption.
DESIGN: A prospective cohort study.
SUBJECTS: Two hundred eighty-eight patients in an
academic primary care practice who had unhealthy
MEASUREMENTS: The primary outcome was quality of
care received [measured with the communication,
whole-person knowledge, and trust scales of the Primary
Care Assessment Survey (PCAS)]. The secondary out-
come was drinking risky amounts in the past 30 days
(measured with the Timeline Followback method).
RESULTS: Alcohol counseling was significantly associ-
ated with higher quality of primary care in the areas of
communication (adjusted mean PCAS scale scores: 85
vs. 76) and whole-person knowledge (67 vs. 59). The
quality of primary care was not associated with drink-
ing risky amounts 6 months later.
CONCLUSIONS: Although quality of primary care may
not necessarily affect drinking, brief counseling for
unhealthy alcohol use may enhance the quality of
KEY WORDS: alcohol; counseling; brief intervention; quality of primary
J Gen Intern Med 23(9):1482–6
© Society of General Internal Medicine 2008
Practice guidelines recommend that clinicians screen and offer
brief intervention for unhealthy alcohol use (the spectrum from
drinking at-risk amounts through dependence) in adults1,2.
Despite these guidelines and available efficacious strategies,
unhealthy alcohol use among primary care patients is often
unrecognized3,4and treated ineffectively5,6.
Many barriers to addressing unhealthy alcohol use exist,
including the assumption held by some physicians that
patients do not want to discuss drinking. Physicians who are
concerned about alienating their patients or believe their
patients lack interest in discussing alcohol use will either avoid
raising the subject or may not address it adequately7,8. These
doctors may also worry that alcohol counseling will diminish
patient-perceived quality of care9.
Most patients, however, are not bothered by alcohol discus-
sions and may welcome them10,11. They often find the dis-
cussions useful3and are more likely to be satisfied with their
care than are patients who do not have such discussions12.
Still, whether alcohol counseling is associated with higher
quality of care remains unknown. Therefore, we conducted
this study of patients with unhealthy alcohol use to determine
whether alcohol counseling during a primary care visit influ-
ences patient-perceived quality of primary care. Further, we
studied whether quality of care is associated with drinking of
Subjects were patients in an urban, academic primary care
practice who had participated in a randomized trial testing the
effects of providing physicians with patients’ alcohol screening
results5. In that cluster randomized trial, physicians were
randomly assigned to receive or not receive the results of
alcohol screening that was done in the waiting room prior to
the physician visit. Patients had unhealthy alcohol use and
presented for a visit with the physician and were identified in
the waiting room by screening. The intervention consisted of a
sheet of paper summarizing the results of the CAGE test,
recent drinking amounts, and readiness to change. Eligible
subjects spoke English or Spanish, drank in the past month,
and had either a ≥1 on the CAGE alcohol screening test13or
drank risky amounts (past 30 days; Table 1)14.
Results of this study were presented at the following meetings: the
annual national meeting of the Society of General Internal Medicine,
Chicago, May 2004 and the annual national meeting of the Research
Society on Alcoholism, Vancouver, Canada, June 2004. This study was
funded by a grant from the Robert Wood Johnson Foundation (grant
031489). Dr. Samet received support from the National Institute on
Alcohol Abuse and Alcoholism (K24-AA015674).
Received May 22, 2007
Revised October 29, 2007
Accepted February 25, 2008
Published online July 10, 2008
Enrolled subjects provided written informed consent and
were compensated. The Institutional Review Board at Boston
Medical Center approved this study.
Research associates (RAs) screened patients waiting to see one
of 40 primary care physicians, for eligibility through a self-
administered questionnaire (there was no other basis for
selection). RAs then interviewed enrolled subjects immediately
before and immediately after the physician visits.
During the interview before the visit, RAs assessed readi-
ness to change (visual analogue scale from 0 to 10)15and
medical comorbidity16. Immediately after the visit, RAs asked
patients whether they had received alcohol counseling (a
referral and/or advice on safe drinking limits, decreasing
intake, or abstaining) during the visit and about quality of
care based on three (of 11) scales from the Primary Care
Assessment Survey (PCAS)17, a validated tool that measures
the fundamental characteristics of primary care defined by the
Institute of Medicine18. The scales, ranging from 0 to 100
with 100 indicating the highest level of performance, included
communication (e.g., attention to what patients say); whole-
person knowledge (e.g., physician’s knowledge of a patient’s
health concerns, values, and beliefs); and trust (e.g., phy-
sicians’ integrity). Lastly, RAs evaluated subjects’ alcohol
consumption (past 30 days, Timeline Followback method)19
and current alcohol problems [Short Inventory of Problems
(SIP 2R)]20. Six months later, RAs interviewed subjects by
The primary outcome was patient-perceived primary care
quality, measured with the three PCAS scales17immediately
after physician visits. The secondary outcome was drinking
risky amounts at the 6-month follow-up.
We performed all analyses using SAS software, version 8.1.
(SAS Institute, Cary, North Carolina). We used the chi-square
test and t test, as appropriate, for bivariate comparisons.
Reported P values are two-tailed; a P value of <0.05 was
considered statistically significant.
We used linear mixed effects models to test the association
between alcohol counseling and the three PCAS scales and
generalized estimating equations (GEE) logistic regression mod-
els to test the associations between the PCAS scales and
drinking. These correlated data models were used to adjust for
clustering of patients by physician (exchangeable working corre-
lations 0.03 to 0.08 for PCAS scales). The mixed model used an
exchangeable working covariance structure and the GEE model
used an independence working correlation structure.
Of eligible patients, 55% enrolled (Fig. 1). Enrolled and eligible
but not enrolled subjects were similar on age, sex, race, and
CAGE questionnaire responses; however, enrolled subjects
Table 1. Characteristics at Enrollment: 288 Subjects with Unhealthy Alcohol Use
Male, no. (%)
Age, mean (SD)
African American, no. (%)
White, no. (%)
Latino, no. (%)
High school education, no. (%)
Medical comorbidity,bever, no. (%)
Drinks per drinking day,cpast 30 days, mean (SD)
Alcohol problems,dcurrent, mean score (SD)
Drank risky amounts,epast 30 days, no. (%)
Readiness to change,fmean (SD)
Met physician previously, no. (%)
Wanted the physician they were seeing to provide general information
about alcohol use, no. (%)
Wanted the physician they were seeing to give advice about their
drinking habits,gno. (%)
Had a physician who was randomized to the intervention group in the
randomized controlled trial, no. (%)
Had a physician who was faculty, no. (%)
83 (63)82 (53)0.09
72 (55) 80 (51)0.58
106 (80)116 (74)0.23
aBased on patient self-report
bDetermined with the method of Katz et al16
cDetermined by the Timeline Followback method, which assesses the type and number of standard drinks consumed on each of the previous 30 days19
dShort Inventory of Problems (SIP 2R) total score20
e>14 standard drinks per week or >4 drinks per occasion for men; >7 drinks per week or >3 drinks per occasion for women and people ≥66 years14
fBased on a visual analogue scale ranging from 0 to 1015; n=114 for counseled, 149 for not counseled
gn=155 for not counseled
Saitz et al.: Alcohol Counseling and Quality Primary Care
had significantly greater alcohol consumption (drinks/drink-
ing day, 4.5 vs. 3.4) and readiness to change their drinking
(mean score, 5.5 vs. 4.9).
Of the enrolled sample, 301 (96%) answered questions
about alcohol counseling during their primary care visit; 288
(96%) of these completed the PCAS and compose our sample.
At 6 months, 223 of the 288 (77%) were assessed. Compared to
those lost to follow-up, interviewed subjects were significantly
more likely to have a high school education (68% vs. 41%) and
to have met their doctor before (74% vs. 60%).
Mean (SD) PCAS scores were communication 81 (SD 16),
comprehensiveness 66 (SD 21), and trust 80 (SD 12). Almost
half of the sample [132 (46%)] reported receiving alcohol
counseling during their primary care visit. Counseled subjects
were significantly more likely than subjects who had not been
counseled to be older, have no high school education, and have
a higher mean number of drinks/drinking day, alcohol
problem score, and readiness to change (Table 1).
In unadjusted analyses, counseled subjects reported higher
quality of primary care in the areas of communication, whole-
person knowledge, and trust, though the latter was not
statistically significant (Table 2). These findings persisted in
At 6 months, 121 of 223 subjects (54%) were drinking risky
amounts. Quality of primary care did not significantly affect
the odds of drinking risky amounts [adjusted odds ratios, 1.0
Table 2. Alcohol Counseling and Quality of Primary Care
Primary care quality domainUnadjusted mean scoresa(95% CI) Adjusted mean scoresb(95% CI)
Counseled n=132 Not counseled n=156
P valueCounseled n=132 Not counseled n=156
aUnadjusted analyses account for clustering of patients by physician.
bAdjusted for sex, race, education, comorbidity, randomization, level of physician training, having met the physician previously, mean drinks per drinking
day, alcohol problem score, and clustering of patients by physician
4,143 patients approached
182 did not complete screener
Received Alcohol Counseling
Did Not Receive Alcohol Counseling
565 eligible (14% of approached patients)
312 enrolled (55% of eligible patients; 21 interviewed in Spanish)
253 did not enroll: 235 declined participation; 18
provided informed consent but had no time before
288 analyzed (92% of enrolled subjects)
11 did not answer questions about drinking; another
13 did not complete PCAS
Fig. 1. Subject Enrollment and Follow-up.
Saitz et al.: Alcohol Counseling and Quality Primary Care
(95% CI, 0.98–1.02) for communication; 1.00 (95% CI, 0.98–
1.01) for whole-person knowledge; and 1.00 (95% CI, 0.98–
1.03) for trust].
Alcohol counseling by primary care physicians was associated
with higher patient-perceived quality of care, specifically better
communication, and whole-person knowledge. Higher quality
of care, however, was not associated with decreased drinking of
risky amounts at 6 months.
This study is novel as it assesses the relationships between
(1) alcohol counseling and quality of primary care with a
validated measure and (2) quality of primary care and drinking
outcomes. Our study supports results from previous research
indicating that patients are not bothered by, and often
appreciate, being asked during primary care visits about their
alcohol use3,10–12. The magnitude of differences in quality
we observed was similar to, though generally smaller than,
those known to impact clinical outcomes17,21. For example,
Kim et al reported that single standard deviation increases in
primary care quality were associated with a lower risk of
subsequent substance use21. While various studies have
reported a link between primary care quality and health
outcomes9,21, ours did not. High-quality primary care may be
necessary, but not sufficient, to help patients reduce their
drinking. The lack of association between quality of primary
care and decreased consumption is most likely because
specific elements of brief interventions that are essential to
change drinking (e.g., targeted advice) were not offered in this
Our study has several strengths. We used a standard
measure of drinking in a sample with a range of unhealthy
alcohol use and a well-validated measure of primary care
quality that has been linked to clinical outcomes. The PCAS
and its individual subscales have high internal consistency
and reliability; each subscale has been validated17. Lastly, we
used a prospective design and assessed counseling and quality
immediately after a primary care visit.
Several limitations should be considered. First, we could not
determine whether alcohol counseling affects quality beyond
the self-report measures assessed. However, the measures we
chose are among the best ways to assess primary care quality
and are particularly relevant to alcohol counseling17. Second,
we assessed the drinking outcome at only one timepoint. This
method is similar to that used in studies supporting brief
intervention for unhealthy alcohol use2. Third, because this
was an observational study, our ability to determine causality
is limited; however, we did adjust analyses for potential
confounding factors. Fourth, the initial research assessment
may have sensitized subjects and influenced their responses to
questions about perceived quality. Fifth, most subjects had
visited their physicians and discussed alcohol previously.
Therefore, the observed associations between counseling and
quality of care may be biased towards the null; nonetheless, we
observed some effects. Sixth, intervening influences (e.g.,
participation in Alcoholics Anonymous) could have affected
drinking outcomes. Brief counseling, however, is known to
reduce consumption beyond such influences. Lastly, the
differences between the enrolled and nonenrolled patients
limited generalizability and, along with the differences in those
followed and lost to follow-up, may have biased analyses (the
latter limited to the drinking analyses). However, the direction
of bias resulting from these differences is difficult to predict.
Physicians should conduct alcohol counseling for unhealthy
alcohol use for many reasons. Alcohol counseling has proven
efficacy in outpatient settings and is recommended in practice
guidelines. Furthermore, most patients want to receive advice
about their drinking, and as indicated by this study, such a
discussion does not diminish quality of care. These findings
provide evidence that screening and intervention for unhealthy
alcohol use may improve quality of care from the patient’s
ACKNOWLEDGEMENT: The authors are indebted to Rosanne T.
Guerriero, MPH, for herefforts in manuscript writing and editing. This
study was funded by a grant from the Robert Wood Johnson
Foundation (grant 031489). Dr. Samet received support from the
National Institute on Alcohol Abuse and Alcoholism (K24-AA015674).
Conflict of Interest: None disclosed.
Corresponding Author: Richard Saitz, MD, MPH; Clinical Addic-
tion Research and Education (CARE) Unit, Section of General
Internal Medicine, Boston Medical Center and Boston University
School of Medicine, 801 Massachusetts Avenue, 2nd floor, Boston,
MA 02118, USA (e-mail: email@example.com).
1. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med.
2. US Preventive Services Task Force. Screening and behavioral counseling
interventions in primary care to reduce alcohol misuse: recommendation
statement. Ann Intern Med. 2004;140(7):554–6.
3. Aalto M, Seppa K. Usefulness, length and content of alcohol-related
discussions in primary health care: the exit poll survey. Alcohol Alcohol.
4. Bradley KA, Curry SJ, Koepsell TD, Larson EB. Primary and secondary
prevention of alcohol problems: US internist attitudes and practices. J
Gen Intern Med. 1995;10(2):67–72.
5. SaitzR, HortonNJ, Sullivan LM,MoskowitzMA, SametJH. Addressing
alcohol problems in primary care: a cluster randomized, controlled trial
of a systems intervention. The screening and intervention in primary
care (SIP) study. Ann Intern Med. 2003;138(5):372–82.
6. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered
to adults in the United States. N Engl J Med. 2003;348(26):2635–45.
7. Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and
intervention for alcohol problems: a national survey of primary care
physicians and psychiatrists. J Gen Intern Med. 2000;15(2):84–91.
8. Beich A, Gannik D, Malterud K. Screening and brief intervention for
excessive alcohol use: qualitative interview study of the experiences of
general practitioners. BMJ. 2002;325(7369):870–4.
9. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR.
Linking primary care performance to outcomes of care. J Fam Pract.
10. Aalto M, Pekuri P, Seppa K. Primary health care professionals’ activity
in intervening in patients’ alcohol drinking: a patient perspective. Drug
Alcohol Depend. 2002;66(1):39–43.
11. Zimmerman M, Farber NJ, Hartung J, Lush DT, Kuzma MA.
Screening for psychiatric disorders in medical patients: a feasibility
and patient acceptance study. Med Care. 1994;32(6):603–8.
12. Steven ID, Thomas SA, Eckerman E, Browning C, Dickens E. The
provision of preventive care by general practitioners measured by patient
completed questionnaires. J Qual Clin Pract. 1999;19(4):195–201.
13. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a
new alcoholism screening instrument. Am J Psychiatry. 1974;131
Saitz et al.: Alcohol Counseling and Quality Primary Care
14. Saunders JB, Lee NK. Hazardous alcohol use: its delineation as a Download full-text
subthreshold disorder, and approaches to its diagnosis and manage-
ment. Compr Psychiatry. 2000;41(2 Suppl 1):95–103.
15. Rollnick S, Heather N, Gold , Hall W. Development of a short ‘readiness
to change’ questionnaire for use in brief, opportunistic interventions
among excessive drinkers. Br J Addict. 1992;87(5):743–54.
16. Katz JN, Chang LC, Sangha O, Fossel AH, Bates DW. Can comorbidity
be measured by questionnaire rather than medical record review? Med
17. Safran DG, Kosinski M, Tarlov A, et al. The Primary Care Assessment
Survey: tests of data quality and measurement performance. Med Care.
18. Institute of Medicine. Primary care: America's health in a new era.
Washington, D.C.: National Academy Press; 1996.
19. Sobell LC, Brown J, Leo GI, Sobell MB. The reliability of the Alcohol
Timeline Followback when administered by telephone and by computer.
Drug Alcohol Depend. 1996;42(1):49–54.
20. Miller W, Tonigan J, Longabaugh R. The Drinker Inventory of Con-
sequences (DrInC). An Instrument for Assessing Adverse Consequences
of Alcohol Abuse. Test Manual. Bethesda, MD: National Institute on
Alcohol Abuse and Alcoholism; 1995.
21. Kim TW, Samet JH, Cheng DM, Winter M, Safran DG, Saitz R. Primary
care quality and addiction severity: a prospective cohort study. Health
Serv Res. 2007;42(2):755–72.
Saitz et al.: Alcohol Counseling and Quality Primary Care