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ImportanceUnhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment.ObjectiveTo test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration.Design, Setting, and ParticipantsThe Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021.InterventionsThe implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice’s intervention period.Main Outcomes and MeasuresCoprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression.ResultsA total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04).Conclusions and RelevanceIn this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation.Trial RegistrationClinicalTrials.gov Identifier: NCT02675777

BACKGROUND: Most people with alcohol use disorder do not receive treatment, and primary care (PC)-based management of alcohol use disorder is a key strategy to close this gap. Understanding PC patients’ perspectives on changing drinking and receiving alcohol-related care is important for this goal, particularly those who decline alcohol-related care. This study examined perspectives on barriers and facilitators to changing drinking and receiving alcohol-related care among Veterans Health Administration (VA) PC patients who indicated interest but did not enroll in the Choosing Healthier drinking Options In primary CarE trial (CHOICE), which tested a PC-based alcohol care management intervention. METHODS: VA PC patients with frequent heavy drinking who indicated interest in CHOICE but did not enroll were invited to participate. Twenty-seven patients completed in-person, semi-structured interviews. Interview transcripts were analyzed using iterative deductive and inductive content analysis. RESULTS: Participants were mostly men (96%) and White (59%), and mean age was 48. Seventy-four percent met criteria for alcohol use disorder, and median number of past-week standard drinks was 41.5. Participants reported fewer alcohol-related problems, lower importance of/readiness to change drinking, and higher confidence in ability to change than patients who enrolled in the CHOICE trial. Barriers fell into 5 domains: drinking fulfills need(s); reducing drinking or treatment is not needed; treatment is not effective/not acceptable; alcohol-related stigma; and practical barriers. Facilitators fell into 4 domains: reasons to change drinking; social support; treatment is acceptable/meets patients’ needs; and practical facilitators. Participants discussed how Veteran identity and military experiences impacted drinking and willingness to receive care, which amplified multiple barriers/facilitators. CONCLUSIONS: This study identified barriers and facilitators to changing drinking and receiving alcohol-related care among VA PC patients who indicated interest but did not enroll in an alcohol care management trial. Findings can inform patient-centered interventions and support clinicians in engaging patients in care.

BACKGROUND: This pilot study evaluated whether use of evidence-based implementation strategies to integrate care for cannabis and other drug use into primary care (PC) as part of Behavioral Health Integration (BHI) increased diagnosis and treatment of substance use disorders (SUDs). METHODS: Patients who visited the three pilot PC sites were eligible. Implementation strategies included practice coaching, electronic health record decision support, and performance feedback (3/2015–4/2016). BHI introduced annual screening for past-year cannabis and other drug use, a Symptom Checklist for DSM-5 SUDs, and shared decision-making about treatment options. Main analyses tested whether the proportions of PC patients diagnosed with, and treated for, new cannabis or other drug use disorders (CUDs and DUDs, respectively), differed significantly pre- and post-implementation. RESULTS: Of 39,599 eligible patients, 57% and 59% were screened for cannabis and other drug use, respectively. Among PC patients reporting daily cannabis use (2%) or any drug use (1%), 51% and 37%, respectively, completed an SUD Symptom Checklist. The proportion of PC patients with newly diagnosed CUD increased significantly post-implementation (5 v 17 per 10,000 patients, p

OBJECTIVE: To describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018). DATA SOURCES/STUDY SETTING: Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN: Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS: Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING: Implementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS: When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.

Over the past decade, overdoses involving opioids and benzodiazepines have risen at alarming rates, making reductions in coprescribing of these medications a priority, particularly among patients who may be susceptible to adverse events due to high-risk conditions.This quality improvement project evaluated the effectiveness of a medication alert designed to reduce opioid and benzodiazepine coprescribing among Veterans with known high-risk conditions (substance use, sleep apnea, suicide-risk, age 65 and above) at 1 Veterans Affairs (VA) health care system.Prescribers were exposed to the point-of-prescribing alert for 12 months. For each high-risk cohort we used interrupted time series design to examine population trends in coprescribing 12 months after alert launch adjusting for coprescribing 12 months before launch, demographics and clinical covariates. Trends at the alert site were compared with those of a similar VA health care system without the alert. Secondary analyses examined population trends in opioid and benzodiazepine prescribing separately.Over 12 months, the alert activated for 1332 patients. Proportions of patients with concurrent prescriptions decreased significantly postalert launch among substance use [adjusted odds ratio (AOR)=0.97; 95% confidence interval (CI)=0.96-0.99; 12-month decrease=25.0%], sleep apnea (AOR=0.97, 95% CI=0.95-0.98, 12-month decrease=38.5%), and suicide-risk (AOR=0.94, 95% CI=0.91-0.98, 12-month decrease=61.5%) cohorts at the alert site. Decreases in coprescribing were significantly different from the comparison site among suicide-risk (AOR=0.92, 95% CI=0.86-0.97) and sleep apnea (AOR=0.98, 95% CI=0.96-1.00) cohorts. Significant decreases in benzodiazepine prescribing trends were observed at the alert site only.Medication alerts hold promise as a means of reducing opioid and benzodiazepine coprescribing among certain high-risk groups.

BACKGROUND: Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely. OBJECTIVE: This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including “segmenting the market,” to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications. DESIGN: Qualitative, interview-based study. PARTICIPANTS: Twenty-four providers from five VA PC clinics. APPROACH: Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review. KEY RESULTS: Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective “tool” or “foot in the door” for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have. CONCLUSIONS: We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

Background Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample. Methods The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011–2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs. Results A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22–75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14–24] and a median readiness to change drinking score of 5 (IQR 2.75–6.25) on a 1–10 Likert scale. Conclusion The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

AIMS To evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2). DESIGN Cohort study. SETTING Twenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention. PARTICIPANTS A total of 486 115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥ 12 months apart ('baseline' and 'follow-up'). MEASUREMENTS Independent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations ('GI hospitalizations') and (3) physical trauma, each in the years after baseline and follow-up. FINDINGS Baseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI) = 41.3-41.5] to 53.5 (95% CI = 51.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CI = 0.48-0.51%) to 1.8% (95% CI = 1.3-2.3%) and trauma from 3.0% (95% CI = 2.95-3.06%) to 6.0% (95% CI = 5.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all

Background Experts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care (“SPARC implementation intervention” hereafter). The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics. Methods/Design The SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015–July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies. Discussion The SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care—alcohol screening and brief intervention—as well as diagnosis and treatment of AUDs. Trial registration The trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777. Electronic supplementary material The online version of this article (10.1186/s13012-018-0795-9) contains supplementary material, which is available to authorized users.

BACKGROUND: Clinical performance measures often require documentation of patient counseling by healthcare providers. Little is known about whether such measures encourage delivery of counseling or merely its documentation. OBJECTIVE: To assess changes in provider documentation of alcohol counseling and patient report of receiving alcohol counseling in the Veterans Administration (VA) from 2009 to 2012. DESIGN: Retrospective time-series analysis. PARTICIPANTS: A total of 5413 men who screened positive for unhealthy alcohol use at an outpatient visit and responded to a confidential mailed survey regarding alcohol counseling from a VA provider in the prior year. MAIN MEASURES: Rates of provider documentation of alcohol counseling in the electronic health record and patient report of such counseling on the survey were assessed over 4 fiscal years. Annual rates were calculated overall and with patients categorized into four mutually exclusive groups based on their own reports of alcohol counseling (yes/no) and whether alcohol counseling was documented by a provider (yes/no). KEY RESULTS: Provider documentation of alcohol counseling increased 23.6% (95% CI: 17.0, 30.2), from 59.4% to 83.0%, while patient report of alcohol counseling showed no significant change (4.0%, 95% CI: −2.3, 10.3), increasing from 66.1% to 70.1%. An 18.7% (95% CI: 11.7, 25.7) increase in the proportion of patients who reported counseling that was documented by a provider largely reflected a 14.7% decline (95% CI: 8.5, 20.8) in the proportion of patients who reported alcohol counseling that was not documented by a provider. The proportion of patients who did not report counseling but whose providers documented it did not show a significant change (4.9%, 95%CI: 0.0, 9.9). CONCLUSIONS: If patient report is accurate, increased rates of documented alcohol counseling in the VA from 2009 to 2012 predominantly reflected improved documentation of previously undocumented counseling rather than delivery of additional counseling or increased documentation of counseling that did not meaningfully occur.

Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas.A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis.Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources.Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Background Efforts to identify genetic moderators of pharmacotherapy response have generated interest in clinical applications of pharmacogenetic tests in alcohol use disorder (AUD) treatment. To date, no research on providers' interest in using pharmacogenetic tests in the context of AUD treatment has been reported. We conducted qualitative interviews with primary care providers from 5 clinics in the Veterans Health Administration (VA) to assess their interest in using a hypothetical genetic test to inform treatment of AUD with pharmacotherapy. Methods Key contacts were used to recruit 24 providers from 5 primary care clinics associated with a single large VA medical facility. Participants completed 30-minute in-person semi-structured interviews focused on barriers and facilitators to provision of pharmacotherapy for AUD. Interviews included a hypothetical scenario regarding the availability of a genetic test to inform AUD pharmacotherapy provision and/or selection. Provider responses to the hypothetical scenario were recorded, transcribed and analyzed qualitatively using inductive content analysis. Data were independently coded by three investigators, and themes were identified via consensus. Results Participants were generally interested in a genetic test to aid in AUD treatment planning. Five common themes were identified, including: perceived benefits of a pharmacogenetic test (e.g., aiding with therapeutic choice, positively impacting patient motivation for and engagement with AUD treatment), perceived drawbacks (e.g., limiting potential benefits of pharmacotherapy by reducing the target population for its receipt, adverse impacts of "negative" results), caveats to clinical utility (e.g., utility would depend on prognostic accuracy and/or medication characteristics), uncertainty as to whether such a test would impact clinical decision-making, and pragmatic barriers to use (costs and other resources, such as laboratory facilities). Conclusions Primary care providers in this study generally believed a genetic test to aid in AUD treatment planning would be useful, due to its potential to hone treatment choice as well as to influence patient motivation and adherence to treatment. However, providers acknowledged that a test's utility would depend on the strength of its prognostic characteristics, its other benefits relative to standard care, and lack of pragmatic barriers.

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.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.Cross sectional.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).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).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.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.

Importance Experts recommend that alcohol use disorders (AUDs) be managed in primary care, but effective approaches are unclear. Objective To test whether 12 months of alcohol care management, compared with usual care, improved drinking outcomes among patients with or at high risk for AUDs. Design, Setting, and Participants This randomized clinical trial was conducted at 3 Veterans Affairs (VA) primary care clinics. Between October 11, 2011, and September 30, 2014, the study enrolled 304 outpatients who reported heavy drinking (≥4 drinks per day for women and ≥5 drinks per day for men). Interventions Nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner–prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The comparison was usual primary care. Main Outcomes and Measures Primary outcomes, assessed by blinded telephone interviewers at 12 months, were percentage of heavy drinking days in the prior 28 days measured by timeline follow-back interviews and a binary good drinking outcome, defined as abstinence or drinking below recommended limits in the prior 28 days (according to timeline follow-back interviews) and no alcohol-related symptoms in the past 3 months as measured by the Short Inventory of Problems. Results Of 304 participants, 275 (90%) were male, 206 (68%) were white, and the mean (SD) age was 51.4 (13.8) years. At baseline, both the CHOICE intervention (n = 150) and usual care (n = 154) groups reported heavy drinking on 61% of days (95% CI, 56%-66%). During the 12-month intervention, 137 of 150 patients in the intervention group (91%) had at least 1 nurse visit, and 77 of 150 (51%) had at least 6 nurse visits. A greater proportion of patients in the intervention group than in the usual care group received alcohol-related care: 42% (95% CI, 35%-49%; 63 of 150 patients) vs 26% (95% CI, 19%-35%; 40 of 154 patients). Alcohol-related care included more AUD medication use: 32% (95% CI, 26%-39%; 48 of 150 patients in the intervention group) vs 8% (95% CI, 5%-13%; 13 of 154 patients in the usual care group). No significant differences in primary outcomes were observed at 12 months between patients in both groups. The percentages of heavy drinking days were 39% (95% CI, 32%-47%) and 35% (95% CI, 28%-42%), and the percentages of patients with a good drinking outcome were 15% (95% CI, 9%-22%; 18 of 124 patients) and 20% (95 % CI, 14%-28%; 27 of 134 patients), in the intervention and usual care groups, respectively ( P = .32-.44). Findings at 3 months were similar. Conclusions and Relevance The CHOICE intervention did not decrease heavy drinking or related problems despite increased engagement in alcohol-related care. Trial Registration clinicaltrials.gov Identifier:NCT01400581

Brief alcohol counseling is a foremost US prevention priority, but no health-care system has implemented it into routine care. This study evaluated the effectiveness of an electronic clinical reminder for brief alcohol counseling ("reminder"). The specific aims were to (1) determine the prevalence of use of the reminder and (2) evaluate whether use of the reminder was associated with resolution of unhealthy alcohol use at follow-up screening.The reminder was implemented in February 2004 in eight VA clinics where providers routinely used clinical reminders. Patients eligible for this retrospective cohort study screened positive on the AUDIT-C alcohol screening questionnaire (February 2004-April 2006) and had a repeat AUDIT-C during the 1-36 months of follow-up (mean 14.5). Use of the alcohol counseling clinical reminder was measured from secondary electronic data. Resolution of unhealthy alcohol use was defined as screening negative at follow-up with a/=2-point reduction in AUDIT-C scores. Logistic regression was used to identify adjusted proportions of patients who resolved unhealthy alcohol use among those with and without reminder use.Among 4,198 participants who screened positive for unhealthy alcohol use, 71% had use of the alcohol counseling clinical reminder documented in their medical records. Adjusted proportions of patients who resolved unhealthy alcohol use were 31% (95% CI 30-33%) and 28% (95% CI 25-30%), respectively, for patients with and without reminder use (p-value = 0.031).The brief alcohol counseling clinical reminder was used for a majority of patients with unhealthy alcohol use and associated with a moderate decrease in drinking at follow-up.

Background Routine primary care screening for depression and alcohol use is widely recommended. Benefits of screening for marijuana and drug use are less clear, but might identify patients whose drug use complicates their health. As a result, leaders of a large integrated healthcare system in a U.S. state, where recreational marijuana use was recently legalized, implemented screening for marijuana and drug use as part of a pilot of behavioral health integration in primary care. The objective is to describe the prevalence of screening and further assessment of marijuana and drug use compared to depression and alcohol misuse during early implementation.

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.

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.

SummaryIntroduction Objectives: Despite evidence documenting their ineffectiveness, sliding scale insulin is a commonly used regimen for glucose management for hospitalized patients with diabetes mellitus. At the Veterans Affairs Puget Sound Medical Center, where computer order entry has been mandated, we tested the hypothesis that an evidence-based minimal intervention order (supplemental insulin only when fasting serum glucoses exceeded 400 mg/dl) would decrease the use of sliding scale insulin orders. Methods: Using a computerized order entry system, providers were initially offered a traditional sliding scale order or their own ad hoc orders for glycemic control of inpatients. After 34 weeks providers were offered a third option; a “minimal intervention order” with supplemental insulin only for glucose >400 mg/dl. We extracted all regular insulin orders and performed a retrospective review of insulin sliding scale orders written between December 1, 1998 and November 16, 1999. We compared the frequency of traditional insulin sliding scale orders before and after the introduction of the minimal intervention order. Results: Nearly all orders in the first 34 weeks were traditional insulin sliding scales. We found a significant decrease in the number of traditional insulin sliding scale orders in the 16 weeks after the introduction of a computerized quick-order for minimal intervention, from 978/1007 (97.1%) to 254/398 (63.8%) (P Conclusions: A simple, evidenced-based quick-order in a computer order entry system rapidly and significantly reduced use of sliding scale insulin regimens for glycemic control of inpatients.

Alcohol use is a major cause of disability and death worldwide. To improve prevention and treatment addressing unhealthy alcohol use, experts recommend that alcohol-related care be integrated into primary care (PC). However, few healthcare systems do so. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington partnered to design a high-quality Program of Sustained Patient-centered Alcohol-related Care (SPARC). Here, we describe the SPARC pilot implementation, evaluate its effectiveness within three large pilot sites, and describe the qualitative findings on barriers and facilitators. Across the three sites (N = 74,225 PC patients), alcohol screening increased from 8.9% of patients pre-implementation to 62% post-implementation (p < 0.0001), with a corresponding increase in assessment for alcohol use disorders (AUD) from 1.2 to 75 patients per 10,000 seen (p < 0.0001). Increases were sustained over a year later, with screening at 84.5% and an assessment rate of 81 patients per 10,000 seen across all sites. In addition, there was a 50% increase in the number of new AUD diagnoses (p = 0.0002), and a non-statistically significant 54% increase in treatment within 14 days of new diagnoses (p = 0.083). The pilot informed an ongoing stepped-wedge trial in the remaining 22 PC sites.

Valid quality indicators are needed to monitor and encourage identification and management of mental health and substance use conditions (behavioral conditions). Because behavioral conditions are frequently underidentified, quality indicators often evaluate the proportion of patients who screen positive for a condition who also have appropriate follow-up care documented. However, these "positive-screen-based" quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality ("denominator bias") and could reward identification of fewer patients with the behavioral conditions of interest. This study evaluated denominator bias in the performance of Veterans Health Administration (VHA) networks on a quality indicator of follow-up for alcohol misuse that used the number of patients with positive alcohol screens as the denominator.Two quality indicators of follow-up for alcohol misuse--a positive-screen-based quality indicator and a population-based quality indicator-were compared among 21 VHA networks by review of 219,119 medical records.Results for the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7% and 65.4% follow-up) even though one network identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% versus 7.4%, respectively).A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.

This study integrates two lines of research on the AUDIT-C: a study which estimated average alcohol consumption at each AUDIT-C score using national U.S. population data, and a set of studies which evaluated the association of AUDIT-C scores with alcohol-related health outcomes. This presentation synthesizes results from these studies to depict the association between 1) AUDIT-C scores, and 2) mean daily alcohol consumption as well as adverse alcohol-related health outcomes.

Since 2004 >90% of outpatients in the US Veterans Health Administration (VA) have been screened for unhealthy alcohol use with the AUDIT-C. However, research suggests variability in the quality of screening. To understand factors underlying variable quality, we conducted two qualitative studies: 1) an ethnographic study where we observed clinical staff performing screening, and 2) a key-informant study where we conducted 1:1 interviews with clinical staff. For Study 1, four researchers observed alcohol screening at 9 primary care clinics and took handwritten notes, which were transcribed. For Study 2, snowball sampling was used to recruit key informants (n=29) at 5 additional clinics who completed 20-30 minute semi-structured interviews, which were recorded and transcribed. Both qualitative datasets were analyzed using an a priori coding template. In Study 1, we observed 58 clinical staff caring for 166 patients. Alcohol screening was observed 74 times. Clinical staff appeared uncomfortable conducting verbal alcohol screening, and most screening was not verbatim. Study 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 or why to conduct alcohol screening. Information on alcohol screening was provided to clinicians via email announcement of the availability of electronic clinical decision support and ad-hoc 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—for which brief intervention does not have confirmed efficacy. Lack of training and discomfort are barriers contributing to variability in screening quality. Addressing the spectrum of unhealthy alcohol use is not yet viewed as part of a preventive agenda. Additional strategies are likely needed to improve screening quality.

The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.Observational, retrospective cohort study using secondary clinical and administrative data.Thirty VA facilities.Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%).Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50).During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

Background Medicare reimburses providers for annual alcohol screening. However, the benefit of rescreening patients a year after a negative screen for alcohol misuse is unknown. We hypothesized that some subgroups of patients who screen negative would have a very low probability of converting to a positive subsequent screen (e.g.

Implementation of alcohol screening and brief intervention (SBI) is a prevention priority. The Veterans Affairs (VA) Healthcare System uses a clinical reminder (CR) in the electronic medical record to prompt and document results of screening and trigger a subsequent CR for BI when screening is positive. Although screening rates are over 90%, marked variability in screening quality has been documented. Four researchers observed clinician interactions with CRs during alcohol screening at nine primary care clinics in the northwest US to identify barriers and facilitators to using CRs to implement quality screening. Observers took handwritten notes, which were transcribed and analyzed qualitatively using an a priori coding template adapted during analyses. We observed 58 support staff (25 registered nurses, 26 licensed practical nurses, and seven health technicians) caring for 166 patients. Alcohol screening prompted by the CR was often uncomfortable and of low quality. Clinicians often offered disclaimers prior to screening or made adjustments to how questions were presented, with some citing the sensitive nature of the questions. Verbal screening typically did not include asking questions verbatim. There was substantial variability in methods of conducting screening across clinics, with some using the CR to facilitate in-person screening by interview and others entering patient responses into the CR after completion of a paper-based screen. Although the CR was designed to trigger a subsequent CR for BI when positive, some clinics used paper encounter forms for this. Findings suggest that VA CRs have important limitations as a method of facilitating effective, high-quality alcohol screening. Barriers observed reflect a combination of limitations of CR technology (and the alcohol screening CR specifically), ways the CR was implemented, clinical workflow, complexity of patient needs, and alcohol-related stigma. Future research should address these barriers to effectively implement recommended care.

Background 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. Objectives 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. Methods 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. Results 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 Conclusions 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.

Brief intervention for patients with unhealthy alcohol use is a prevention priority in the United States, but most eligible patients do not receive it. This study evaluated an electronic alcohol-counseling clinical reminder at a single Veterans Affairs general medicine clinic.The systems-level intervention evaluated in this study consisted of making the clinical reminder, which facilitated medical record documentation of brief intervention among patients who screened positive for unhealthy alcohol use, available to providers on one (of two) randomly selected hallways. Secondary electronic data were extracted for all patients who visited the clinic (October 1, 2002, to September 30, 2005). The proportion of patients with clinical-reminder use was evaluated among patients who screened positive for unhealthy drinking and were assigned to intervention hallway providers ("descriptive cohort"). Adjusted logistic regression evaluated the association between the intervention and resolution of unhealthy drinking at follow-up among all screen-positive patients who completed a second Alcohol Use Disorders Identification Test Consumption questionnaire 18 months or longer after the first ("outcomes cohort").Eligible patients (N= 22,863) included 10,392 controls and 12,471 in the intervention group. Fifteen percent (398 of 2,640) of descriptive cohort patients with unhealthy drinking had clinical-reminder use, which varied by severity (14% [n = 302 of 2,165] with mild/moderate and 20% [n = 96 of 475] with severe unhealthy drinking,p = .001). Only 39% (156 of 398) of patients with clinical-reminder use had documented brief intervention; advice to abstain was most common. Access to the clinical reminder was not significantly associated with resolution of unhealthy drinking in 1,358 patients in the outcomes cohort.Availability of a clinical reminder to facilitate brief intervention did not, alone, result in substantial use of the clinical reminder. More active implementation efforts may be needed to get brief interventions onto the agenda of busy primary care providers.

Brief alcohol counseling is a top US prevention priority but has not been widely implemented. The lack of an easy performance measure for brief alcohol counseling is one important barrier to implementation. The purpose of this report is to outline important issues related to measuring performance of brief alcohol counseling in health care settings. We review the strengths and limitations of several options for measuring performance of brief alcohol counseling and describe three measures of brief alcohol counseling tested in the Veterans Affairs (VA) Health Care System. We conclude that administrative data are not well-suited to measuring performance of brief alcohol counseling. Patient surveys appear to offer the optimal approach currently available for comparing performance of brief alcohol counseling across health care systems, while more options are available for measuring performance within health care systems. Further research is needed in this important area of quality improvement.

Despite evidence-based guidelines, brief alcohol screening and counseling have not been routinely integrated into most primary care practices in the United States.To describe the results of the implementation of evidence-based alcohol screening by the Veterans Health Administration (VA) in 2004, as the first step toward implementation of brief alcohol counseling.This observational study of outpatients from all 21 VA networks relied on the following 2 data sources from the VA Office of Quality and Performance: (1) Medical record reviews, designed to compare VA networks quarterly, evaluated whether established VA patients had documented screening for alcohol misuse and documented follow-up assessment for alcohol use disorders among those who screened positive for alcohol misuse (January-March 2005); and (2) Mailed patient satisfaction surveys from 2004, which oversampled patients new to the VA (response rate,70%), included the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questions and asked about past-year advice "to drink less or not to drink alcohol" from a VA provider.Based on 10 115 medical record reviews, 93% (range, 89%-96% across networks) of outpatients were screened for alcohol misuse, and 25% (range, 11%-36%) screened positive. Among screen-positive patients, 42% (range, 5%-84%) had documented follow-up assessment, but absolute numbers of screen-positive patients evaluated were small (27-80 patients per network). Based on 235 481 patient surveys, the prevalence of alcohol misuse was 22% (range, 15%-27% across networks), and 28% (range, 20%- 36%) of screen-positive patients reported receiving alcohol-related advice. Alcohol-related advice increased as AUDIT-C scores increased.The VA successfully implemented evidence-based alcohol screening, but the rate of follow-up among screen-positive patients remained low.

PURPOSE Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse. METHODS This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire ≥1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with χ2 statistics. RESULTS Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P

Background In the context of routine population-based alcohol screening to identify primary care (PC) patients who might benefit from brief intervention, many patients identified will have alcohol use disorders (AUD) [1] and will likely require more intensive treatments. FDA approved medications are recommended to treat AUD [2] and could be offered in PC. Currently, use of AUD medications is extremely rare. [3] This qualitative study sought to understand barriers and facilitators to prescribing AUD medications in PC.

Background Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are at increased risk for alcohol misuse, and innovative methods are needed to improve their access to alcohol screening and brief interventions (SBI). This study adapted an electronic SBI (e-SBI) website shown to be efficacious in college students for OEF/OIF veterans and reported findings from interviews with OEF/OIF veterans about their impressions of the e-SBI. Methods Outpatient veterans of OEF/OIF who drank ≥3 days in the past week were recruited from a US Department of Veterans Affairs (VA) Deployment Health Clinic waiting room. Veterans privately pretested the anonymous e-SBI then completed individual semistructured audio-recorded interviews. Their responses were analyzed using template analysis to explore domains identified a priori as well as emergent domains. Results During interviews, all nine OEF/OIF veterans (1 woman and 8 men) indicated they had received feedback for risky alcohol consumption. Participants generally liked the standard-drinks image, alcohol-related caloric and monetary feedback, and the website’s brevity and anonymity (a priori domains). They also experienced challenges with portions of the e-SBI assessment and viewed feedback regarding alcohol risk and normative drinking as problematic, but described potential benefits derived from the e-SBI (emergent domains). The most appealing e-SBIs would ensure anonymity and provide personalized transparent feedback about alcohol-related risk, consideration of the context for drinking, strategies to reduce drinking, and additional resources for veterans with more severe alcohol misuse. Conclusions Results of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.