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IAC 05-206 – HSR&D Study

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IAC 05-206
AUDIT-C as a Scaled Marker for Health Risks in VA Medical Out-patients
Katharine A. Bradley MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: February 2006 - November 2009

BACKGROUND/RATIONALE:
VA requires that clinicians conduct annual alcohol screening and brief alcohol counseling for patients who screen positive. An important barrier to effective brief alcohol counseling is the time required to assess patients' alcohol misuse severity. For other conditions physiologic "markers" are used to assess severity (e.g. HbA1c for diabetes) but no practical physiologic marker of alcohol misuse is available. The VA uses the Alcohol Use Disorders Identification Test Consumption questionnaire (AUDIT-C) for alcohol screening, and preliminary studies have suggested that the AUDIT-C might be an excellent scaled marker of alcohol-related risks.

OBJECTIVE(S):
This study tested whether AUDIT-C scores were a marker for subsequent adverse health outcomes in VA general internal medicine outpatients.

The specific aims were to evaluate whether AUDIT-C scores were associated with:

1) Medical conditions associated with excessive alcohol use, and

2) Outcomes of three common chronic medical conditions (cardiovascular disease, chronic bronchitis/emphysema, and diabetes), including process, short-term, and longer-term outcomes.

METHODS:
The study used an existing VA data repository, which included: survey data; VA clinical, pharmacy, and laboratory data; VA and Medicare data for diagnoses; health care utilization; and vital status for 35,727 primary care patients from 7 VA sites who completed the AUDIT-C between 1997 and 2000. For Aim 1, we tested whether the AUDIT-C was associated with 4 types of alcohol-related medical conditions using logistic and Cox proportional hazards regression. For Aim 2, we conducted separate analyses among patients with cardiovascular disease, chronic bronchitis/emphysema, and diabetes, evaluating 3 types of outcomes. Adjusted logistic or linear regression was used to test the association of the AUDIT-C with process measures (health behaviors and medication adherence). Adjusted linear regression was used to test the AUDIT-C's association with two short-term outcomes (physiologic or laboratory measures and health status) and adjusted Cox proportional hazards regression was used to test the AUDIT-C as a marker of long-term outcomes (mortality).

FINDINGS/RESULTS:
Compared to patients with low risk drinking (AUDIT-C 1-3), VA outpatients with AUDIT-C scores >= 8 were at increased risk for alcoholic liver disease, fractures, and hospitalizations for trauma or ambulatory care sensitive conditions (primary or secondary diagnosis). AUDIT-C scores >= 8 were also associated with increased mortality in analyses adjusted for demographics. AUDIT-C scores >= 4 were associated with non-adherence to anti-hypertensive medications and AUDIT-C >= 6 with non-adherence to statins, among patients prescribed these medications. Among patients with hypertension and diabetes, adherence to recommended self-care decreased as AUDIT-C scores increased. Blood pressure and HDL cholesterol increased linearly as AUDIT-C scores increased. However, there was no significant association between AUDIT-C scores and mortality in subgroups with chronic diseases, except that nondrinkers had higher mortality.

IMPACT:
This research identified AUDIT-C thresholds at which clinically meaningful health risks associated with alcohol misuse increased. This essential information can be used for patient and provider education and is being incorporated into educational materials for national dissemination. This research also identifies high-risk groups of patients who might benefit from more intensive alcohol-related interventions if they do not respond to brief counseling.

PUBLICATIONS:

Journal Articles

  1. Rittmueller SE, Frey MS, Williams EC, Sun H, Bryson CL, Bradley KA. Association between alcohol use and cardiovascular self-care behaviors among male hypertensive Veterans Affairs outpatients: a cross-sectional study. Substance Abuse. 2014 Jun 25; 36(1):6-12.
  2. Harris AH, Lembke A, Henderson P, Gupta S, Moos R, Bradley KA. Risk of future trauma based on alcohol screening scores: a two-year prospective cohort study among US veterans. Addiction science & clinical practice. 2013 Mar 11; 7(1):6.
  3. Thomas RM, Francis Gerstel PA, Williams EC, Sun H, Bryson CL, Au DH, Bradley KA. Association between alcohol screening scores and diabetic self-care behaviors. Family medicine. 2012 Sep 1; 44(8):555-63.
  4. Cecere LM, Williams EC, Sun H, Bryson CL, Clark BJ, Bradley KA, Au DH. Smoking cessation and the risk of hospitalization for pneumonia. Respiratory medicine. 2012 Jul 1; 106(7):1055-62.
  5. Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between alcohol screening results and hospitalizations for trauma in Veterans Affairs outpatients. The American journal of drug and alcohol abuse. 2012 Jan 1; 38(1):73-80.
  6. Harris AH, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. The Journal of Bone and Joint Surgery. 2011 Feb 16; 93(4):321-7.
  7. Bradley KA, Rubinsky AD, Sun H, Bryson CL, Bishop MJ, Blough DK, Henderson WG, Maynard C, Hawn MT, Tønnesen H, Hughes G, Beste LA, Harris AH, Hawkins EJ, Houston TK, Kivlahan DR. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. Journal of general internal medicine. 2011 Feb 1; 26(2):162-9.
  8. Chew RB, Bryson CL, Au DH, Maciejewski ML, Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? The journal of behavioral health services & research. 2011 Jan 1; 38(1):3-15.
  9. Harris AH, Bradley KA, Bowe T, Henderson P, Moos R. Associations between AUDIT-C and mortality vary by age and sex. Population health management. 2010 Oct 1; 13(5):263-8.
  10. Williams EC, Peytremann-Bridevaux I, Fan VS, Bryson CL, Blough DK, Kivlahan DR, Bradley KA. The association between alcohol screening scores and health status in male veterans. Journal of addiction medicine. 2010 Mar 1; 4(1):27-37.
  11. Au DH, Bryson CL, Chien JW, Sun H, Udris EM, Evans LE, Bradley KA. The effects of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations. Journal of general internal medicine. 2009 Apr 1; 24(4):457-63.
  12. Kinder LS, Bryson CL, Sun H, Williams EC, Bradley KA. Alcohol screening scores and all-cause mortality in male Veterans Affairs patients. Journal of studies on alcohol and drugs. 2009 Mar 1; 70(2):253-60.
  13. Harris AH, Bryson CL, Sun H, Blough D, Bradley KA. Alcohol screening scores predict risk of subsequent fractures. Substance use & misuse. 2009 Jan 1; 44(8):1055-69.
  14. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Annals of internal medicine. 2008 Dec 2; 149(11):795-804.
  15. Greene CC, Bradley KA, Bryson CL, Blough DK, Evans LE, Udris EM, Au DH. The association between alcohol consumption and risk of COPD exacerbation in a veteran population. Chest. 2008 Oct 1; 134(4):761-7.
  16. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcoholism, clinical and experimental research. 2007 Mar 1; 31(3):443-51.
Journal Other

  1. Bradley KA, Kivlahan DR, Williams EC. Brief approaches to alcohol screening: practical alternatives for primary care. [Editorial]. Journal of general internal medicine. 2009 Jul 1; 24(7):881-3.
VA Cyberseminars

  1. Bradley KA, Achtmeyer C. Using AUDIT-C Alcohol Screening Data in VA Research, Interpretation, Strengths, Limitations & Sources. [Cyberseminar]. 2011 Mar 15.
Conference Presentations

  1. Clark BJ, Ho PM, Au DH, Bradley KA, Burnham EL, Moss M. Brief Versus Full Alcohol Use Disorders Identification Test For The Identification Of Alcohol Misuse In Critical Illness. Poster session presented at: American Thoracic Society Annual International Conference; 2014 Jun 16; San Diego, CA.
  2. Clark BJ, Rubinsky AD, Ho PM, Au DH, Moss M, Bradley KA. Alcohol Screening Scores And Risk Of Intensive Care Unit Admission In The Veterans Affairs Health System. Poster session presented at: American Thoracic Society Annual International Conference; 2014 May 16; San Diego, CA.
  3. Bradley KA, Rubinsky AF, Lapham GT, Williams EC, Au DH, Blough DK, Berger D, Johnson-Chavez M, Hawkins EJ. Changes in AUDIT-C Scores Reflect Changes in Drinking - Results of a Biomarker Study. Presented at: Research Society on Alcoholism Annual Scientific Meeting; 2012 Jun 25; San Francisco, CA.
  4. Johnson ML, Lapham GT, Williams EC, Bradley KA. Prevalence of Patient-Reported Alcohol-Related Advice Following Performance Measure Implementation. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2011 Jun 27; Atlanta, GA.
  5. Rubinsky AF, Williams EC, Bradley KA. Utility of AUDIT-C Alcohol Screening Scores as a Scaled Marker of meran Daily Drinking. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2011 Jun 27; Atlanta, GA.
  6. Johnson ML, Lapham GT, Williams EC, Bradley KA. Evaluating the Prevalence of Patient-Reported Alcohol-Related Advice Following Implementation of a National Performance Measure and Electronic Clinical Reminder. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 15; Seattle, WA.
  7. Rubinsky AF, Sun H, Blough DK, Maynard CC, Bryson CL, Harris AH, Hawkins EJ, Beste LA, Henderson WG, Hawn MT, Hughes G, Bishop MJ, Etzioni R, Tennesen H, Kivlahan DR, Bradley KA. AUDIT-C Alcohol Misuse Screening Results and Postoperative Inpatient Health Care Utilization. Poster session presented at: University of Washington Department of Health Services Annual Research Meeting; 2011 Jun 15; Seattle, WA.
  8. Rubinsky AF, Sun H, Blough DK, Maynard CC, Bryson CL, Harris AH, Hawkins EJ, Beste LA, Henderson WG, Hawn MT, Hughes G, Bishop MJ, Etzioni R, Tennesen H, Kivlahan DR, Bradley KA. AUDIT-C Alcohol Misuse Screening Results and Postoperative Inpatient Health Care Utilization. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 14; Seattle, WA.
  9. Greene CC, Williams EC, Bradley KA, Au DH. The Association between Alcohol Misuse and Health Status among Veterans with COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO.
  10. Bradley KA, Lapham GT, Williams EC, Achtmeyer CE, Hawkins EJ, Saitz R, Kivlahan DR. Effects of the Proportion Screening Positive on a Performance Measure for Brief Alcohol Intervention. Paper presented at: International Society for Biomedical Research on Alcoholism Annual Meeting; 2010 Sep 16; Paris, France.
  11. Williams EC, Bradley KA, Harris AS. Association between Alcohol Screening Scores and Mortality among Black, Hispanic, and White Male Veterans. Presented at: International Society for Biomedical Research on Alcoholism Annual Meeting; 2010 Sep 16; Paris, France.
  12. Williams EC, Lapham GT, Johnson M, Bradley KA. Strategies to Implement Alcohol Screening and Brief Intervention: A Structured Literature Review. Presented at: International Society for Biomedical Research on Alcoholism Annual Meeting; 2010 Sep 15; Paris, France.
  13. Berger D, Williams E, Bryson CL, Bradley KA. Alcohol Questionnaires and HDL: Screening Scores as Scaled Markers. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  14. Bradley KA, Kivlahan DR, Lapham GT, Williams EC, Achtmeyer C, Hawkins EJ. Implementation of alcohol screening and brief intervention (SBI) in VA Health Care System: Successes and challenges. Paper presented at: American Society of Addiction Medicine Annual Meeting; 2010 Apr 16; San Francisco, CA.
  15. Bradley KA, Lapham GT, Kivlahan DR. Implications of Varying Alcohol Screening Instruments and Thresholds for a Performance Measure of Brief Alcohol Counseling. Presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA.
  16. Delaney KE, Lapham GT, Kivlahan DR, Bradley KA. Limitations of using AUDIT-C or AUDIT scores alone in developing feedback for web-based SBI. Poster session presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA.
  17. Lapham GT, Achtmeyer CA, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased brief intervention for alcohol misuse after national implementation of a performance measure and dissemination of an electronic clinical reminder. Poster session presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA.
  18. Thomas RM, Francis GP, Williams E, Sun H, Bryson CL, Au DH, Bradley KA. Alcohol Screening Scores are Associated with Decreased Adherence to Self Care Behaviors in Diabetic Primary Care Patients. Presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA.
  19. Williams E, Lapham GT, Hawkins EJ, Kivlahan DR, Rubinsky AD, Bradley KA. Referral and Treatment Initiation Practices in the Veterans Affairs Health Care System Prior to a Performance Measure for Brief Alcohol Counseling. Poster session presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA.
  20. Williams E, Bryson CL, Sun H, Frey MS, Bradley KA. Association between Anginal Symptoms and Alcohol Screening Scores in VA Outpatients. Presented at: Research Society on Alcoholism Annual Scientific Meeting; 2008 Jun 29; Washington, DC.
  21. Bryson CL, Au DH, Sun H, Williams E, Kivlahan DR, Bradley KA. Medication Adherence Decreases with Increasing AUDIT-C Alcohol Screening Scores. Presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.
  22. Frey MS, Sun H, Williams E, Bryson CL, Au DH, Blough DK, Kivlahan DR, Harris AH, Bradley KA. The Association of Alcohol Misuse and Self-Reported Health Behaviors among Male Outpatients. Presented at: Association for Medical Education and Research in Substance Abuse Annual Meeting; 2007 Nov 15; Washington, DC.


DRA: Substance Abuse and Addiction
DRE: Treatment - Observational
Keywords: Alcohol
MeSH Terms: none

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