Quality Concerns with Routine Alcohol Screening in VA Clinical Settings

Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 03/2011; 26(3):299-306. DOI: 10.1007/s11606-010-1509-4
Source: PubMed


Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings.
The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results.
Cross sectional.
A national sample of 6,861 VA outpatients (fiscal years 2007-2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen).
Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens).
Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks.
Use of a validated alcohol screening questionnaire does not-by itself-ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.

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Available from: Emily C Williams, Dec 27, 2013
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    • "Previous research, conducted in primary care settings, across diverse groups of patients has found single alcohol screening questions and the AUDIT-C to have similar sensitivity when both were administered verbally in confidential studies [18,21,24,27,29]. Bradley et al. previously compared verbal administration of the AUDIT-C in the clinical setting with self-administered AUDIT-C questionnaires collected through a mail survey, and found clinical screening to be less effective in identifying unhealthy drinkers [30]. This study is one of the first to compare verbal administration of a single question screen with written administration of the AUDIT-C, and found similar levels of detection of unhealthy drinking. "
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    ABSTRACT: Background Although screening and brief intervention (SBI) are effective in reducing unhealthy alcohol use, major challenges exist in implementing clinician-delivered SBI in primary care settings. This 2006–2007 pilot study describes the impact of systems changes and booster trainings designed to increase SBI rates in a family medicine residency clinic which annually screened adults with a self-administered AUDIT-C questionnaire and used paper prompts to encourage physician interventions for patients with positive screens. Methods Investigators added the Single Alcohol Screening Question (SASQ) to nursing vital signs forms, added a checkbox for documenting brief interventions to the clinicians’ outpatient encounter form, and conducted one-hour nurse and clinician booster trainings. Impact was measured using chart reviews conducted before implementing systems changes, then six weeks and six months post-implementation. Results At all three time points screening rates using AUDIT-C plus SASQ exceeded 90%, however AUDIT-C screening decreased to 85% after 6 months (p=.025). Identification of unhealthy alcohol users increased from 4% to 22.9% at six weeks and 18.8% at six months (p=.002) using both screens. Nursing vital signs screening using the SASQ reached 71.4% six weeks after implementation but decreased to 45.5% at six months. Changes in clinician brief intervention rates did not achieve statistical significance. Conclusions This is the second study reporting sustained primary care alcohol screening rates of more than 90%. Screening patients with SASQ and/or AUDIT-C identified a higher percentage of patients with unhealthy alcohol use. Dissemination of effective strategies for identifying unhealthy alcohol users should continue, while future research should focus on identifying more effective strategies for increasing intervention rates.
    Full-text · Article · Feb 2013 · Substance Abuse Treatment Prevention and Policy
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    • "The AUDIT-C, a brief version of the AUDIT, consists of three items. This version has been shown to have similar sensitivity and specificity to the full questionnaire [41]. The third question of the AUDIT-C alone (which examines the frequency of respondents had 6 or more drinks) predicts alcohol-related morbidity [42]. "
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    ABSTRACT: Background The incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma. Methods and design The study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up. Discussion This project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma. Trial Registration The trial has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) and Trial Registration: ACTRN12611000135910.
    Full-text · Article · Oct 2012 · BMC Health Services Research
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    • "The VA implemented routine clinical alcohol screening [11] and brief intervention (BI) after implementation of a performance measure and electronic decision support [12]. However, false-negative screens [13], receipt of care outside the VA, and stigma-related concerns [8,14] prevent many OEF/OIF veterans from accessing alcohol-related care. Innovative approaches are needed to increase the reach of SBI for OEF/OIF veterans. "
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    ABSTRACT: Veterans 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. Outpatient 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. During 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. Results of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.
    Full-text · Article · Aug 2012 · Addiction science & clinical practice
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