Study Identifies Factors Contributing to Insensitive Clinical Alcohol Screening in VA Primary Care
Routine population-based alcohol screening is recommended in primary care settings. VA has achieved high rates of documented alcohol screening using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) questionnaire and an associated clinical reminder in the electronic medical record. However, while the AUDIT-C has high sensitivity for identifying unhealthy alcohol use based on validation studies, the sensitivity of alcohol screening performed in VA clinics appears to be lower than expected. For example, one study found that 61% of patients who screened positive for unhealthy alcohol use on mailed surveys screened negative when screened clinically. This observational study sought to understand factors that might contribute to low sensitivity of alcohol screening. Between July 2010 and January 2011, study investigators observed VA clinical staff who conducted alcohol screening facilitated by a clinical reminder at nine VA primary care clinics within one VA healthcare system in the Northwestern U.S. Researchers observed 49 clinical staff conducting alcohol screening with 72 Veteran patients.
Most observed screening was done verbally; lesser used methods included paper-based or laminate-based screening.
During verbal screening, questions were often not asked verbatim and were otherwise adapted.
Other verbal screening practices that might contribute to low sensitivity of clinical screening included making inferences, assumptions, and/or suggestions to input responses.
Clinical staff introduced and adapted screening questions to enhance the comfort of Veterans. For example, using introductory statements such as, "I have several questions to ask you that we ask of all Veterans every year – so we are not just singling you out."
Research staff did not audio-record or video-record clinical screening, and were not blinded to the study purpose, which may have influenced their notes.
Staff were aware that they were being observed, which may have altered their practices.
This study did not specifically test whether and how staff delivery of questions impacts patient responses or screening validity.
Non-verbal approaches to screening – or patient self-administration – might enhance validity and standardization of screening, while also addressing limitations of the clinical reminder and issues related to perceived discomfort.
This study was funded through VA HSR&D's Quality Enhancement Research Initiative (RRP 09-178), and Dr. Williams is supported by an HSR&D Career Development Award (CDA 12-276). Drs. Williams, Achtmeyer, and Thomas are part of HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA.
Williams E, Achtmeyer C, Thomas R, et al. Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study. Journal of General Internal Medicine. August 2015;30(8):1125-1132.