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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    • "Veterans with a positive AUDIT-C screen are required to receive, at minimum, counseling consisting of education about gender-specific safe drinking limits and the potential health effects of alcohol misuse. Although these efforts improved rates (34%–53%) of documented brief alcohol counseling among veterans with alcohol misuse (Lapham et al., 2012), comparisons of the rates of counseling received among men and women have not been conducted. Thus, concerns remain that women veterans may also be less likely to receive brief alcohol counseling. "
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    ABSTRACT: One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP. Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP. Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an "alcoholic," health concerns about drinking, non-health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors. Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans. Published by Elsevier Inc.
    Full-text · Article · Sep 2015 · Women s Health Issues
    • "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: Background and objective: 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. Methods: 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. Results: 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. Conclusions: 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.
    No preview · Article · Jul 2015 · Journal of substance abuse treatment
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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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    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.
    Full-text · Article · Nov 2013 · Drug and alcohol dependence
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