Brief alcohol counseling offered to outpatients with unhealthy alcohol use identified by screening is effective and widely recommended, but has been challenging to implement. Using a strategy of performance measures and electronic clinical reminders that allow for prompting and documenting care, the U.S. Veterans Health Administration (VA) has accomplished high rates of documented alcohol screening and brief alcohol counseling (>90% of all outpatients screened and >75% of all screen-positive patients offered brief intervention). However, it is unknown whether VA patients are reaping the expected benefit of this program, which is decreased drinking. Moreover, previous research has identified variation in the quality of alcohol screening across VA sites, and it is unknown how individual facilities have implemented alcohol screening and brief alcohol counseling.
This study evaluated whether brief alcohol counseling documented with an electronic clinical reminder was associated with resolution of unhealthy drinking at follow-up screening among VA outpatients who initially screened positive (Aim 1). This study also developed and pilot-tested a key-informant interview at a single VA Medical Center to identify strategies used to implement brief alcohol counseling, as well as individual- and system-level needs of frontline adopters (Aim 2).
For Aim 1, we used secondary clinical and administrative VA data to identify a cohort of outpatients from 30 VA medical centers in the north and western U.S. who: 1) screened positive for unhealthy alcohol use (AUDIT-C 5) after the VA's performance measure for brief alcohol counseling was implemented (10/07), and 2) had follow-up AUDIT-C screening documented at least 270 days after the initial screen. Eligible patients were assigned to one of two categories: those with and those without documented brief alcohol counseling. Logistic regression, adjusted for demographics, alcohol use severity, other substance use, and physical and mental comorbid conditions, was used to assess the association between documented brief alcohol counseling and resolution of unhealthy alcohol use (screening negative at follow-up with >2 points reduction in AUDIT-C score). For Aim 2, we developed a 20-30-minute, semi-structured key-informant interview. Snowball sampling was used to recruit key informants (n=29) at 5 VA primary care clinics affiliated with a single VA medical center. Key informants completed the semi-structured interview, each of which was recorded and transcribed. Qualitative data were analyzed using template analysis, and key themes were extracted for presentation.
Aim 1 identified 6,210 eligible patients, 1,751 (28%) of whom had documented brief alcohol counseling and 2,922 (47%) of whom resolved unhealthy alcohol use at follow-up screening. Patients with documented brief alcohol counseling had more severe unhealthy alcohol use than those without. Adjusted prevalences of resolution for patients with and without documented brief alcohol counseling were 48% (45% - 51%) and 47% (45% - 49%), respectively (p=0.51). Aim 2 interviews found that clinical staff and providers believed that addressing unhealthy alcohol use is an important part of care but had not received standard training regarding how to conduct alcohol screening or brief alcohol counseling. Implementation of both practices occurred at these clinics via availability of clinical decision support and peer-to-peer demonstration of its use. Participants perceived the screening questions to be sensitive and reported modifying questions to increase patient comfort. Participants were largely focused on identifying patients with the most severe condition-alcohol dependence, and perceived that specialty addictions treatment is the only option, lacked optimism regarding patients' readiness to change or interest in treatment, and perceived that patients have to be actively seeking help in order for it to be offered.
Among outpatients with unhealthy alcohol use, this study found no difference in resolution at follow-up among those with and without documented brief alcohol counseling. These findings may reflect the early stage of implementation given that only 28% had brief intervention, and those who did had more severe unhealthy alcohol use. However, results from the local qualitative study (Aim 2) suggested that, although staff and providers believed addressing alcohol use was important, they did not yet understand that alcohol screening and brief alcohol counseling are part of VA's preventive agenda. Discomfort discussing alcohol observed in previous studies appeared to be a barrier to screening and brief alcohol counseling. Together findings from the two Aims suggest that the quality of care for unhealthy alcohol use may have room for improvement in VA. Standardized training regarding the reason for alcohol screening and the efficacy of brief alcohol counseling as part of a preventive agenda, as well as efforts to overcome discomfort, may be required. Findings may also provide a foundation for a larger evaluation of the comparative effectiveness of different strategies for implementing alcohol-related care in the VA.
- Williams EC, Rubinsky AD, Chavez LJ, Lapham GT, Rittmueller SE, Achtmeyer CE, Bradley KA. An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration. Addiction (Abingdon, England). 2014 Sep 1; 109(9):1472-81.
- Williams EC, Lapham GT, Rubinsky AD, Chavez LJ, Rittmueller SE, Bradley KA. Early evaluation of VA’s implementation of brief intervention for unhealthy alcohol use. Presented at: Addiction Health Services Research Conference; 2013 Oct 1; Portland, OR.
- Williams EC, Achtmeyer CE, Rittmueller S, Lapham GT, Chavez LJ, Thomas RM, Berger DB, Bradley KA. Factors Underlying Quality Problems with Alcohol Screening in Routine Care. Paper presented at: International Network on Brief Interventions for Alcohol Problems Annual Conference; 2013 Sep 19; Rome, Italy.
- Williams EC, Rubinsky AF, Lapham GT, Achtmeyer CE, Rittmueller S, Bradley KA. No Association between Documented Brief Intervention and Resolution of Alcohol Misuse in 30 VA Medical Centers. Poster session presented at: Addiction Health Services Research Conference; 2012 Oct 18; New York, NY.
- Williams EC, Rubinsky AF, Lapham GT, Achtmeyer CE, Rittmueller S, Bradley KA. No Association between Documented Brief Intervention and Resolution of Alcohol Misuse in 30 VA Medical Centers. Poster session presented at: International Network on Brief Interventions for Alcohol Problems Annual Conference; 2012 Sep 28; Barcelona, Spain.
Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction