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Background: Despite the United States Preventive Services Task Force recommendation to screen adults for unhealthy alcohol use, the implementation of alcohol screening in primary care remains suboptimal. Methods: A pre and post-implementation study design that used Agile implementation process to increase screening for unhealthy alcohol use in adult patients from October 2021 to June 2022 at a large primary care clinic serving minority and underprivileged adults in Indianapolis. Results: In comparison to a baseline screening rate of 0%, the agile implementation process increased and sustained screening rates above 80% for alcohol use using the Alcohol Use Disorders Identification Test – Consumption tool (AUDIT-C). Conclusions: Using the agile implementation process, we were able to successfully implement evidence-based recommendations to screen for unhealthy alcohol use in primary care. [ABSTRACT FROM AUTHOR]

Researchers and practitioners recognise the importance of context when implementing healthcare interventions, but the influence of wider environment is rarely mapped. This paper identifies the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru. Qualitative data obtained through interviews, logbooks and document analysis are used to explain quantitative data on number of alcohol screenings and screening providers in each of the countries. Existing alcohol screening standards in Mexico, and policy prioritisation of primary care and consideration of alcohol as a public health issue in Colombia and Mexico positively contributed to the outcome, while the COVID-19 pandemic had a negative impact. In Peru, the context was unsupportive due to a combination of: political instability amongst regional health authorities; lack of focus on strengthening primary care due to the expansion of community mental health centres; alcohol considered as an addiction rather than a public health issue; and the impact of COVID-19 on healthcare. We found that wider environment-related factors interacted with the intervention implemented and can help explain country differences in outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics. OBJECTIVE: We aimed to understand factors that might contribute to low sensitivity of alcohol screening. DESIGN: This was an observational, qualitative study. PARTICIPANTS: Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S. APPROACH: Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes. KEY RESULTS: We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort. CONCLUSIONS: This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort. [ABSTRACT FROM AUTHOR]

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 onehour 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. [ABSTRACT FROM AUTHOR]

Researchers and practitioners recognise the importance of context when implementing healthcare interventions, but the influence of wider environment is rarely mapped. This paper identifies the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru. Qualitative data obtained through interviews, logbooks and document analysis are used to explain quantitative data on number of alcohol screenings and screening providers in each of the countries. Existing alcohol screening standards in Mexico, and policy prioritisation of primary care and consideration of alcohol as a public health issue in Colombia and Mexico positively contributed to the outcome, while the COVID-19 pandemic had a negative impact. In Peru, the context was unsupportive due to a combination of: political instability amongst regional health authorities; lack of focus on strengthening primary care due to the expansion of community mental health centres; alcohol considered as an addiction rather than a public health issue; and the impact of COVID-19 on healthcare. We found that wider environment-related factors interacted with the intervention implemented and can help explain country differences in outcomes.

Background: Although alcohol use disorder can complicate depression management, there is no standard process for assessing AUD symptoms (i.e., AUD diagnostic criteria) in primary care for patients who screen positive for depression. This study characterizes the association between depressive symptoms and high-risk drinking reported by primary care patients on screening measures in routine care. Then, using data from a novel clinical program, this study characterizes the association between depressive symptoms and AUD symptoms reported by primary care patients with high-risk drinking via an Alcohol Symptom Checklist.Methods: In this cross-sectional study, electronic health record data were obtained from patients who visited 33 Kaiser Permanente Washington primary care clinics between 03/2018 and 02/2020 and completed depression (PHQ-2) and alcohol consumption (AUDIT-C) screening measures as part of routine care (N = 369,943). Patients who reported high-risk drinking (AUDIT-C scores 7-12) also completed an Alcohol Symptom Checklist where they reported the presence or absence of 11 AUD criteria as defined by the DSM-5 (N = 8,184). Generalized linear models estimated and compared the prevalence of high-risk drinking (AUDIT-C scores 7-12) and probable AUD (2-11 AUD symptoms on Alcohol Symptom Checklists) for patients with and without positive depression screens.Results: Patients who screened positive for depression had a 131% higher prevalence of high-risk drinking than those who screened negative (5.2% vs. 2.2%; p < 0.001). Among patients with high-risk drinking, positive depression screens were associated with a significantly higher prevalence of probable AUD (69.8% vs. 48.0%; p < 0.001), with large differences in the prevalence of probable AUD observed with increasing PHQ-2 scores (e.g., probable AUD prevalence of 37.6%, 55.3% and 65.2%, for PHQ-2 scores of 0, 1, and 2, respectively). Although the overall prevalence of high-risk drinking was higher for male patients, similar patterns of association between depression screens, high-risk drinking, and AUD symptoms were observed for male and female patients.Conclusions: Patients with positive depression screens are more likely to have high-risk drinking. Large percentages of patients with positive depression screens and high-risk drinking report symptoms consistent with AUD to healthcare providers when given the opportunity to do so using an Alcohol Symptom Checklist. [ABSTRACT FROM AUTHOR]

• INTRODUCTION This paper provides a comprehensive view of the implementation of alcohol, screening, brief intervention, and referral to treatment (SBIRT) in the primary health care system of the region of Ribeirão Preto, in the State of São Paulo, Brazil, mostly concerning the evaluation of SBIRT training. • METHODS The data were obtained from a community-based study of 776, public primary health care professionals enrolled in an SBIRT training and implementation program in the region of Ribeirão Preto, SP, Brazil from 2003 to 2008. The majority of health professionals who attended the trainings were community health agents (59%) working in the Family Health Program. Physicians, psychologists and nurses also contributed. Data collection was performed using self-report questionnaires, direct interviews, observational, methods and focus groups. • RESULTS There was a statistically significant decrease in health professionals' positive beliefs about alcohol consumption in the post-training period and a significant increase in SBIRT knowledge. Among professional groups, physicians and nurses showed most improvement in their perceived feeling of being "prepared to counsel" patients about risky alcohol use. Qualitative analysis showed an improvement in the level, of awareness of alcohol problems, adoption of a disease model, and an increase in referrals for alcohol treatment. The program was disseminated to a large enough proportion of the health professionals in small, cities to have a significant reach into the general, population of heavy drinkers. • CONCLUSION The training model combined with concurrent supervision and support seem to be effective in the implementation of SBIRT in the routine of health professionals in primary hearth care. This model shows promise as a way to implement alcohol screening and brief intervention as a standard practice in primary health care in large population areas of Brazil. It has been extended to other parts of Brazil and could serve as a model for other Latin-American countries. [ABSTRACT FROM AUTHOR]

Background: Foetal alcohol spectrum disorders (FASDs) are one of the most common preventable forms of developmental disability and congenital abnormalities globally, particularly in countries where alcohol is considered socially acceptable. Screening for alcohol use early in pregnancy can facilitate the detection of alcohol-exposed pregnancies and identify women who require further assessment. However, only a small percentage of children with FASD are identified in the United Kingdom. This may be partly attributed to a lack of awareness of the condition by National Health Service (NHS) health professionals. Methods: We developed an online survey to determine health care professionals' (midwives, health visitors, obstetricians, paediatricians, and general practitioners) perceived knowledge, attitudes, and clinical practices relating to alcohol in pregnancy and FASD. Results: There were a total of 250 responses to the surveys (78 midwives, 60 health visitors, 55 obstetricians, 31 paediatricians, and 26 general practitioners). About 58.1% of paediatricians had diagnosed a patient with foetal alcohol syndrome (FAS) or FASD and 36.7% worried about stigmatisation with diagnosis. Paediatricians reported the highest levels of FASD training (54.8%), with much lower levels in midwives (21.3%). This was reflected in perceived knowledge levels; overall, only 19.8% of respondents knew the estimated UK prevalence of FASD for example. Conclusions: We identified a need for training in alcohol screening in pregnancy and FASD to improve awareness and recognition by UK professionals. This could improve patient care from the antenatal period and throughout childhood. [ABSTRACT FROM AUTHOR]

Background: Risky drinking is associated with risky sexual experiences, however the relationship between alcohol and sex is complex. The aim of the study was to assess the feasibility of delivering alcohol screening and brief interventions in genitourinary medicine (GUM) clinics. The objectives were to; understand the levels of alcohol use amongst patients; report on the number of alcohol interventions delivered; and to analyse the relationship between alcohol use with demographic data as well as diagnosed sexually transmitted infections (STIs) to see if there were any associations.Methods: All new patients attending GUM between April 2012 and March 2013 self-completed the Alcohol Use Disorder Identification Test (AUDIT) prior to their clinical consultation. Where appropriate (scoring 8+ on AUDIT) the clinician would deliver up to 2-3 min of alcohol brief intervention. Descriptive statistics, t-tests, ANOVA and logistic regression were carried out as appropriate.Results: AUDIT scores were available for 90% of all new patients (3058/3390) with an average mean score of 7.75. Of those who drank alcohol, 44% were categorised as being AUDIT positive, including 2% who had a score indicative of probable alcohol dependence (20+). 55 % (n = 638) of patients who screened positive on the AUDIT received a brief intervention whilst 24% (n = 674) of drinkers were diagnosed with a STI. Logistic regression modelling revealed that males, younger age groups and those of 'white' ethnicity were more likely to score positive on AUDIT. Patients classified as non-students, living in deprivation quintiles one to four and categorised as probable alcohol dependence on the AUDIT were more likely to be diagnosed with an STI.Conclusion: It is possible to embed alcohol screening into routine practice within sexual health services however further work is required to embed brief interventions particularly amongst increasing risk drinkers. If resources are limited, services may consider more targeted rather than universal alcohol screening to specific population groups. The study was undertaken in one GUM service in the North East of England and therefore findings may not be generalizable. The study did not assess efficacy of alcohol brief intervention in this setting. [ABSTRACT FROM AUTHOR]

Background: Unhealthy alcohol use is a major contributor to the global burden of disease and injury. The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical settings since 2004. Yet less than one in six US adults report health care professionals discussing alcohol with them. Little is known about methods for increasing implementation; different staffing models may be related to implementation effectiveness. This implementation trial compared delivery of alcohol screening, brief intervention and referral to specialty treatment (SBIRT) by physicians versus non-physician providers receiving training, technical assistance, and feedback reports. Methods: The study was a cluster randomized implementation trial (ADVISe [Alcohol Drinking as a Vital Sign]). Within a private, integrated health care system, 54 adult primary care clinics were stratified by medical center and randomly assigned in blocked groups of three to SBIRT by physicians (PCP arm) versus non-physician providers and medical assistants (NPP and MA arm), versus usual care (Control arm). NIH-recommended screening questions were added to the electronic health record (EHR) to facilitate SBIRT. We examined screening and brief intervention and referral rates by arm. We also examined patient-, physician-, and system-level factors affecting screening rates and, among those who screened positive, rates of brief intervention and referral to treatment. Results: Screening rates were highest in the NPP and MA arm (51 %); followed by the PCP arm (9 %) and the Control arm (3.5 %). Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm. The PCP arm had higher brief intervention and referral rates (44 %) among patients screening positive than either the NPP and MA arm (3.4 %) or the Control arm (2.7 %). Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm. Conclusion: Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation. Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models. Trial registration: Clinical Trials NCT01135654 [ABSTRACT FROM AUTHOR]

Background The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ⩾4 points for men and ⩾3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to "gold standard" measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening-positive or negative based on AUDIT-C scores-can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice. Methods This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results-positive or negative screens based on the AUDIT-C score-that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C. Results Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking. Limitations This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens. Conclusions Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C. [ABSTRACT FROM AUTHOR]

Background: 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.Objective: 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.Design: Cross sectional.Participants: 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).Main Measures: 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).Key Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

Alcohol Drinking Patterns and Health Care Utilization in a Managed Care Organization Gary A. Zarkin, Jeremy W. Bray, Thomas F. Babor, and John C. Higgins-Biddle Objective. To estimate the relationship between current drinking patterns and health care utilization over the previous two years in a managed care organization (MCO) among individuals who were screened for their alcohol use. Study Design. Three primary care clinics at a large western MCO administered a short health and lifestyle questionnaire to all adult patients on their first visit to the clinic from March 1998 through December 1998. Patients who exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for moderate drinking were given a more comprehensive alcohol screening using a modified version of the Alcohol Use Disorders Identification Test (AUDIT). Health care encounter data for two years preceding the screening visit were linked to the remaining individuals who responded to one or both instruments. Using both quantity­frequency and AUDIT- based drinking pattern variables, we estimated negative binomial models of the relationship between drinking patterns and days of health care use, controlling for demographic characteristics and other variables. Principal Findings. For both the quantity­frequency and AUDIT-based drinking pattern variables, current alcohol useisgenerally associatedwithless healthcare utilization relative to abstainers. This relationship holds even for heavier drinkers, although the differences are not always statistically significant. With some exceptions, the overall trend is that more extensive drinking patterns are associated with lower health care use. Conclusions. Basedonoursample,wefindlittleevidencethatalcoholuseisassociated with increased health care utilization. On the contrary, we find that alcohol use is generally associated with decreased health care utilization regardless of drinking pattern. Key Words. Alcohol, health care utilization, alcohol screening Alcoholism and alcohol abuse impose significant costs on society. One consequence that has received much attention is the possibility that alcohol abuse leads to increased health care utilization. Although the alcohol treatment cost offset literature (e.g., Holder and Blose 1991, 1992; Holder and Cunningham 1992; Holder, Lennox, and Blose 1992) has demonstrated that untreated alcoholics have greater health care utilization than nonalco- holics, it does not shed light on the relationship between the level and intensity of alcohol use (as opposed to abuse or dependence) and health care utilization. 553 Because the number of alcohol users is much greater than the number of dependent or abusive drinkers,1 understanding the relationship between alcohol use patterns and health care utilization is important to policymakers. Once this relationship is understood, policymakers need to understand the underlying reasons for the relationship and whether a screening intervention is warranted to detect and change these patterns. Our article contributes to the first part of this research by examining the relationship between alcohol drinking patterns and health care utilization. Several recent studies have examined the relationship between alcohol consumption and health care utilization. In general, the results appear counterintuitive in light of the cost offset literature. For example, Armstrong, Midanik, and Klatsky (1998) found in a survey of health maintenance organization (HMO) users that the heaviest drinkers (as measured by weekly consumption), after adjusting for age and race, had fewer hospital days, fewer hospitalizations, and fewer outpatient visits than abstainers. Rice et al. (2000) examined the relationship between health care use (outpatient visits and odds of hospital use) and alcohol use collected from a member survey at an HMO. Results indicate that current drinkers had lower rates of health care utilization than nondrinkers and that nondrinkers with a drinking history had substantially greater utilization than nondrinkers without a history. Polen et al. (2001) examined the relationship between alcohol consumption (based on a user survey at an HMO) and health care utilization (health care costs, outpatient visits, inpatient days, and emergency room visits). Several patterns of alcohol consumption were created from the AUDIT, including drinks per month. No strong, consistent relationship was found between the multiple drinking patterns and health care utilization cost and use. However, they found that nondrinkers had greater health care costs and utilization than drinkers. Cryer et al. (1999) examined the relationship between alcohol consumption and acute and preventive health care use for a random sample of adults in South East England. They found that although heavy drinkers used more acute care, they also used less preventative care. Interestingly, they This study was funded by a contract to RTI from the University of Connecticut Health Center as part of the Cutting Back s research study funded by the Robert Wood Johnson Foundation. Additional funding was provided by NIAAA (R01­AA 12788). Address correspondence to Gary A. Zarkin, Ph.D., RTI International, 3040 Cornwallis Rd., P.O. Box 12194, Research Triangle Park, NC 27709. Jeremy W. Bray, Ph.D., is also with RTI International. Thomas F. Babor, Ph.D., and John C. Higgins-Biddle, Ph.D., are with the University of Connecticut. 554 HSR: Health Services Research 39:3 (June 2004) found that abstainers were also overusers of acute care but underusers of preventative services. These findings of a negative relationship between alcohol use and health care utilization (with the exception of Cryer et al. 1999) are consistent with the possibility that moderate alcohol consumption may provide beneficial health effects, which in turn may lead to lower health care utilization. Numerous studies have found that moderate alcohol use is associated with reduced risk of coronary heart disease and with reduced overall mortality within certain populations (Doll 1998; Chick 1998; Klatsky 1999; Ashley et al. 1994). Indeed, Doll (1998) concluded that alcohol consumption in the range of one to four drinks per day is associated with reductions in the risk of premature death. Unfortunately, much of the previous literature on alcohol use and health care utilization has focused on measures of weekly or monthly alcohol consumption, and so we cannot determine if the beneficial health effect of regular, moderate drinking explains the results of this literature (an exception is Rice et al. 2000, which used drinks per day). Nor has previous health services research taken into account the quantity­frequency pattern of drinking as we do here. There is evidence, for example, that frequent binge drinking----which is a typical pattern in Russia, Poland, and the Baltic states----is associated with increased mortality and morbidity (Chenet et al. 1998). Further complicating the putative association between drinkers and abstainers is the issue that abstainers include never drinkers and former drinkers, and these two groups are very different. For example, Fillmore et al. (1998) found that former drinkers are more likely to have health risk factors such as cigarette smoking, depression, and obesity. Polen et al. (2001) found that former drinkers have higher health care costs than never drinkers and light drinkers. This study expands the previous literature on the relationship between alcohol use and health care utilization in an MCO by examining two different drinking pattern measures: quantity-frequency and alcohol problem severity measures. In addition, we have included covariates for two important health behaviors----smoking and exercising. Controls for exercise have not been available in the previous literature. We have also included more traditional demographic factors, such as age and gender. DATA AND METHODS Data Data for this analysis were collected as part of Cutting Back s , a six-year, five- site national research project evaluating the application of alcohol screening Drinking Patterns and Health Care Utilization 555 [ABSTRACT FROM AUTHOR]