Identification of and Guidance for Problem Drinking by General Medical Providers

What Should We Do When Participants Report Dangerous Drinking? The Impact of Personalized Letters Versus General Pamphlets as a Function of Sex and Controlled Orientation

Research in which participants report potentially dangerous health-related behaviors raises ethical and professional questions about what to do with that information. Policies and laws regarding reportable behaviors vary across states and Institutional Review Boards (IRB). In alcohol research, IRBs often require researchers to respond to participants who report dangerous drinking practices. Researchers have little guidance regarding how best to respond in such cases. Personalized feedback or general nonpersonalized information may prove differentially effective as a function of gender and/or level of self-determination. This study evaluated response strategies for reducing peak blood alcohol concentration (BAC) among participants reporting dangerous BACs (≥ .35%) in the context of a two-year longitudinal intervention trial with 818 heavy drinking college students. After each assessment, participants who reported drinking to estimated BACs at or greater than .35% were sent either a personalized letter expressing concern and indicating their reported BAC or a nonpersonalized pamphlet that included general information about alcohol and other substances, referral information, and a BAC handout. Hierarchical linear modeling results revealed that both strategies were associated with reduced peak BAC when controlling for previous BAC. The personalized letter was more effective for women and for students who tend to regulate their behavior based on others' expectations and contingencies in the environment. This research provides some guidance for researchers considering appropriate responses to participants who report dangerous health behavior in the context of a research trial.

Gender differences in provider's use of a standardized screening tool for prenatal substance use

OBJECTIVES

Prenatal substance use contributes birth defects, prematurity, and infant mortality in the U.S. As such, it is critical that medical professionals receive appropriate education and actively engage in screening patients; however, a physician's gender may influence differences in screening practices. The purpose of this study is to examine male and female Ob/Gyn physician's beliefs and practices related to perinatal substance use screening and to identify the significant correlates of using a standardized screening tool.

METHODS

Data were collected from 131 Ob/Gyn physician's in Kentucky using a web-based survey. Chi-square and t-tests were used to distinguish differences between male (n=84) and female (n=47) providers. Binary logistic regression was also used to assess the independent correlates of the use of a standardized screening tool.

RESULTS

Female Ob/Gyn physician's were more likely to "believe in" the effectiveness of screening, to discuss sensitive topics with patients, and were motivated to screen as a part of comprehensive care or because screening could produce a behavioral change. Female providers were also more likely to use a screening tool in a multivariate model; however, being female was no longer significant after additional variables were included in the model. Specifically, younger Ob/Gyn physicians who frequently discussed mental health issues with female patients of childbearing age, and were motivated to screen because it is part of comprehensive care were significantly more likely to use a standardized substance use screening tool.

CONCLUSIONS

In summary, less than half of Ob/Gyn physicians were using a standardized screening tool and the majority of physicians were using the CAGE. This suggests additional training is needed to increase their use of substance use screening tools, especially those geared towards pregnant women.

Hospitalizations for alcohol and drug overdoses in young adults ages 18-24 in the United States, 1999-2008: results from the Nationwide Inpatient Sample

OBJECTIVE

Recent reports indicate an increase in rates of hospitalizations for drug overdoses in the United States. The role of alcohol in hospitalizations for drug overdoses remains unclear. Excessive consumption of alcohol and drugs is prevalent in young adults ages 18-24. The present study explores rates and costs of inpatient hospital stays for alcohol overdoses, drug overdoses, and their co-occurrence in young adults ages 18-24 and changes in these rates between 1999 and 2008.

METHOD

Data from the Nationwide Inpatient Sample were used to estimate numbers, rates, and costs of inpatient hospital stays stemming from alcohol overdoses (and their subcategories, alcohol poisonings and excessive consumption of alcohol), drug overdoses (and their subcategories, drug poisonings and nondependent abuse of drugs), and their co-occurrence in 18- to 24-year-olds.

RESULTS

Hospitalization rates for alcohol overdoses alone increased 25% from 1999 to 2008, reaching 29,412 cases in 2008 at a cost of $266 million. Hospitalization rates for drug overdoses alone increased 55%, totaling 113,907 cases in 2008 at a cost of $737 million. Hospitalization rates for combined alcohol and drug overdoses increased 76%, with 29,202 cases in 2008 at a cost of $198 million.

CONCLUSIONS

Rates of hospitalizations for alcohol overdoses, drug overdoses, and their combination all increased from 1999 to 2008 among 18- to 24-year-olds. The cost of such hospitalizations now exceeds $1.2 billion annually. The steepest increase occurred among cases of combined alcohol and drug overdoses. Stronger efforts are needed to educate medical practitioners and the public about the risk of overdoses, particularly when alcohol is combined with other drugs.

Differential effects of daily-moderate versus weekend-binge alcohol consumption on atherosclerotic plaque development in mice

OBJECTIVES

We examined the effect of daily-moderate (2 drinks/day, 7 days/week) and weekend-binge (7 drinks/day, 2 days/week) patterns of alcohol consumption on plasma lipid levels and physiological parameters of atherosclerotic plaque development.

METHODS

ApoE k/o mouse were fed (1) 'daily-moderate' (blood alcohol content: 0.07%) or (2) 'weekend-binge' (blood alcohol content: 0.23%), or (3) an isocaloric cornstarch mix. Then, to induce atherosclerotic plaque formation, all groups underwent partial carotid artery ligation, started on an atherogenic diet and continued on the alcohol feeding regimen. After 2 weeks plasma lipid levels and atherosclerotic plaque formation were assessed.

RESULTS

While there was an increase in HDL-C levels in both binge and moderate groups, LDL-C levels were significantly decreased in the daily-moderate drinking mice and significantly elevated in the weekend-binge drinking mice. In the daily-moderate alcohol group there was a decrease in atherosclerotic plaque volume, concomitant with an increase in lumen volume and decreased macrophage accumulation, when compared to no alcohol mice. In contrast, after 4 weeks of weekend-binge alcohol there was an increase in plaque volume, concomitant with a decrease in lumen volume and increased deposition of macrophages.

CONCLUSION

These findings demonstrate for the first time a differential effect of daily-moderate vs. weekend-binge alcohol consumption on atherosclerotic plaque development and highlight the importance of patterns of alcohol consumption, as opposed to total amount consumed, in relation to the cardiovascular effects of alcohol.

Alcohol-related discussions in health care--a population view

AIMS

The present study aimed to evaluate the frequency and the target group of alcohol screening and brief interventions in health-care settings and how well this level of activity reflects public opinion.

DESIGN

A general population survey.

SETTING AND PARTICIPANTS

A random sample of Finns aged 15-69 years with a 74% response rate (n = 2725).

MEASUREMENTS

Frequency counts were used to evaluate the level of activity. Logistic regression models were used to examine which groups were asked and advised about alcohol use and which groups considered it useful.

FINDINGS

More than 90% had positive attitudes towards being asked about their alcohol use. Of those who had been in contact with health care (n = 2062) in the 12 months before the survey, 33.3% had been asked about their alcohol use, being most often men, young, heavy drinkers and those of high socio-economic status. Thirty-seven per cent of those who had been asked were given advice, being most often heavy drinkers and those with a normal body mass index. However, 50% of heavy drinkers who had been asked about their alcohol use had not been advised about it. Of those who had been advised, 71.9% considered it useful, especially older subjects, and also including heavy episodic drinkers, although less than others.

CONCLUSIONS

In Finland, the frequency of health-care professionals asking and giving advice on alcohol is relatively low. However, public opinion towards these discussions is positive. Our results encourage the support and uptake of systematic screenings and brief interventions in health-care settings.

A meta-analysis of the efficacy of nonphysician brief interventions for unhealthy alcohol use: implications for the patient-centered medical home

Brief physician interventions can reduce alcohol consumption. Physicians may not have the time to provide brief interventions, and it is unclear whether nonphysicians can do so effectively. We conducted a systematic review and meta-analysis to examine the efficacy of brief interventions by nonphysician clinicians for unhealthy alcohol use. We searched the English-language literature in MEDLINE and other databases covering the domains of alcohol problems, primary care, nonphysician, and brief interventions. Studies of brief interventions delivered at least in part by nonphysicians in primary care and examining drinking outcomes were included. Sensitivity analyses examined the effect of excluding studies that contributed disproportionately to the heterogeneity of results. Thirteen studies, conducted 1996-2008, met our criteria. Seven studies with a total of 2,633 patients were included in the meta-analysis. Nonphysician interventions were associated with 1.7 (95% confidence interval [CI]=-.03 to -3.5) fewer standard drinks per week than control conditions (p = .054). Excluding the one study that increased heterogeneity, the effect was smaller but reached statistical significance; nonphysician counseling was associated with 1.4 (95% CI = .3- 2.4) fewer standard drinks per week compared to control (p = .012). Nonphysician brief interventions are modestly effective at reducing drinking in primary care patients with unhealthy alcohol use.

Severity of alcohol problems and readiness to change alcohol use in primary care

Screening measures for hazardous alcohol use that are efficient and can provide clinically relevant information are essential for primary care providers (PCPs). This study examined the clinical utility of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-Consumption (AUDIT-C) as predictors of readiness to change alcohol use in a primary care setting. In total, 114 veterans completed the AUDIT, readiness to change ruler, and an alcohol use disorders diagnostic interview. Two AUDIT-C scores were obtained; one administered during a primary care visit and one derived from the AUDIT. The AUDIT, both AUDIT-C scores, and number of dependence symptoms significantly predicted readiness to change independent of demographic variables. The AUDIT accounted for the greatest percentage of variance in readiness to change (19%). The AUDIT provides information about alcohol severity and readiness to change, which could be clinically useful for providers identifying patients for brief alcohol interventions.

Self-injury in adolescents with eating disorders: correlates and provider bias

INTRODUCTION

Self-injurious behavior (SIB) is common among adolescents, and has been shown to be associated with eating disorders (ED). This study examines the prevalence of SIB and SIB screening in adolescents with ED, and associations with binge eating, purging, and diagnosis.

METHODS

Charts of 1,432 adolescents diagnosed with ED, aged 10-21 years, at an academic center between January 1997 and April 2008, were reviewed.

RESULTS

Of patients screened, 40.8% were reported to be engaging in SIB. Patients with a record of SIB were more likely to be female, have bulimia nervosa, or have a history of binge eating, purging, co-morbid mood disorder, substance use, or abuse. Patients who engaged in both binge eating and purging were more likely to report SIB than those engaged in restrictive behavior or either behavior alone. Providers documented screening for SIB in fewer than half of the patients. They were more likely to screen patients who fit a profile of a self-injurer: older patients who binge, purge, or had a history of substance use.

CONCLUSIONS

SIB was common in this population, and supports extant literature on associations with bulimia nervosa, mood disorders, binge eating, purging, abuse, and substance use. Providers may selectively screen patients.

Inside the physician's black bag: critical ingredients of brief alcohol interventions

Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians' collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.

Correlates of alcohol-related discussions between older adults and their physicians

OBJECTIVES

To identify predictors of alcohol-related patient-physician discussions.

DESIGN

Cross-sectional study using baseline data from a randomized controlled trial.

SETTING

Community-based group practice.

PARTICIPANTS

Thirty-one physicians in Project Senior Health and Alcohol Risk Education and 3,305 of their patients aged 60 and older who use alcohol and completed a survey that included the Comorbidity Alcohol Risk Evaluation Tool (CARET).

MEASUREMENTS

At study baseline, older adults were asked whether alcohol-related discussions with a physician had occurred in the prior year. This outcome was modeled using logistic regression models with physician random effects. Predictor variables included patient-level variables such as demographics and seven CARET-defined risk factors, specifically a medical or psychiatric comorbidity that alcohol might worsen, a potentially alcohol-related symptom, use of a medication that may interact negatively with alcohol, excessive quantity or frequency of alcohol use, binge drinking, concern from others about drinking, and drinking and driving. Physician-level predictors (age, sex, years since graduation, specialty) were also included.

RESULTS

The probability of reporting alcohol-related discussions declined with patient age (e.g., odds ratio (OR)=0.40 for patients aged ≥80) and was significantly lower for Latinos (OR=0.38). Drinking and driving (OR=1.69) or concern from others (OR=6.04) were significantly associated with alcohol-related discussions; having comorbidities or using medications that may interact with alcohol were not.

CONCLUSION

Although patient demographics, including age and ethnicity, are associated with the occurrence of alcohol-related discussions, clinical factors that may negatively interact with alcohol to increase risk are not. This suggests that physicians may not be attuned to the entire spectrum of alcohol-related risks for older adults.

Identification of substance use and dependence among patients with viral hepatitis

BACKGROUND

As drug abuse and addiction have been shown to decrease adherence to treatment of hepatitis C virus (HCV) or HIV, screening for substance use should be standard clinical practice in those undergoing an evaluation for these diseases.

AIMS

To assess the effectiveness of the Kreek-McHugh-Schluger-Kellogg (KMSK) scale to quantify substance use and dependence among patients with viral hepatitis.

METHODS

The KMSK scale, a validated instrument that quantifies lifetime use of alcohol, cocaine, heroin, and tobacco, was distributed to 161 consecutive patients referred to a hepatology clinic at an academic, tertiary-care center over a 1-year period.

RESULTS

Of the 159 patients who returned the KMSK scale, 62% reported illicit drug use and 30% met defined criteria for lifetime dependence on cocaine or heroin. We found that 15% of our population at some time had been co-dependent on cocaine and heroin. The KMSK scale identified significantly more cocaine, heroin, and alcohol use than that detected through the medical record (chi(2)=7.61, p<0.01, chi(2)=9.66, p<0.002, respectively). Cocaine dependence was significantly higher among HCV/HIV co-infected than among mono-infected patients (chi(2)=5.46, p<0.02).

CONCLUSIONS

The KMSK scale may be useful to diagnose drug and alcohol use and dependence among patients undergoing evaluation for treatment of viral hepatitis.

Prevalence and correlates of at-risk drinking among older adults: the project SHARE study

BACKGROUND

At-risk drinking, excessive or potentially harmful alcohol use in combination with select comorbidities or medication use, affects about 10% of elderly adults and is associated with higher mortality. Yet, our knowledge is incomplete regarding the prevalence of different categories of at-risk drinking and their associations with patient demographics.

OBJECTIVE

To examine the prevalence and correlates of different categories of at-risk drinking among older adults.

DESIGN

Cross-sectional analysis of survey data.

SUBJECTS

Current drinkers ages 60 and older accessing primary care clinics around Santa Barbara, California (n = 3,308).

MEASUREMENTS

At-risk drinkers were identified using the Comorbidity Alcohol Risk Evaluation Tool (CARET). At-risk alcohol use was categorized as alcohol use in the setting of 1) high-risk comorbidities or 2) high-risk medication use, and 3) excessive alcohol use alone. Adjusted associations of participant characteristics with at-risk drinking in each of the three at-risk categories and with at-risk drinking of any kind were estimated using logistic regression.

RESULTS

Over one-third of our sample (34.7%) was at risk. Among at-risk individuals, 61.9% had alcohol use in the context of high-risk comorbidities, 61.0% had high-risk medication use, and 64.3% had high-risk alcohol behaviors. The adjusted odds of at-risk drinking of any kind were decreased and significant for women (odds ratio, OR = 0.41; 95% confidence interval: 0.35-0.48; p-value < 0.001), adults over age 80 (OR = 0.55; CI: 0.43-0.72; p < 0.001 vs. ages 60-64), Asians (OR = 0.40; CI: 0.20-0.80; p = 0.01 vs. Caucasians) and individuals with higher education levels. Similar associations were observed in all three categories of at-risk drinking.

CONCLUSIONS

High-risk alcohol use was common among older adults in this large sample of primary care patients, and male Caucasians, those ages 60-64, and those with lower levels of education were most likely to have high-risk alcohol use of any type. Our findings could help physicians identify older patients at increased risk for problems from alcohol consumption.

The quality of preventive health care delivered to adults: results from a cross-sectional study in Southern Italy

BACKGROUND

It is assumed that providing clinical preventive services to patients can identify or detect early important causes of adult mortality. The aim of this study was to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients.

METHODS

In a cross-sectional study adults aged 18 years and over attending primary care physician (PCP) offices located in Southern Italy were interviewed from June through December 2007. Quality indicators of preventive health care developed from RAND's Quality Assessment Tools and Behavioral Risk Factor Surveillance System (BRFSS) were used. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on delivery of clinical preventive services.

RESULTS

A total of 1467 subjects participated in the study. Excepting blood pressure preventive check (delivered to 64.4% of eligible subjects) and influenza vaccination (recommended to 90.2% of elderly), the rates of delivery of clinical preventive services were low across all measures, particularly for screening and counseling on health habits. Rates for providing cancer screening tests at recommended times were 21.3% for colonoscopy, 51.5% for mammography and 52.4% for Pap smear. Statistical analysis showed clear disparities in the provision of clinical preventive services associated with age, gender, education level, perceived health status, current health conditions and primary care access measures.

CONCLUSIONS

There is overwhelming need to develop and implement effective interventions to improve delivery of routine clinical preventive services.

Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum

BACKGROUND

This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education (December, 2008), presents a model curriculum for Family Medicine residency training in substance abuse.

METHODS

The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U.S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models.

RESULTS

This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice.

CONCLUSIONS

Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training.

Screening and brief intervention for underage drinkers

In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible in general health care practice.

Perceived need for treatment for alcohol use disorders: results from two national surveys

OBJECTIVES

Most individuals with alcohol use disorders receive no treatment for their disorder. Past research suggests that a major reason for this is that individuals with alcohol use disorders do not perceive a need for treatment. The research presented here had two objectives. First, to provide updated estimates of the percentage of individuals with alcohol use disorders who perceive a need for treatment, and among those, the percentage who receive any treatment for alcohol use disorders. And second, to investigate the determinants of perceived need for and utilization of treatment for alcohol use disorders.

METHODS

Secondary data analyses were performed for two national surveys, the National Epidemiologic Survey on Alcohol and Related Conditions (3,305 individuals with alcohol use disorders) and the National Survey on Drug Use and Health (7,009 individuals with alcohol use disorders).

RESULTS

In both surveys fewer than one in nine individuals with an alcohol use disorder perceived a need for treatment. In predicting perceived need, the explanatory power of diagnostic variables was much greater than that of demographic variables. Among those with perceived need, two out of every three persons reported receiving treatment in the past year.

CONCLUSIONS

Our results suggest that failure to perceive need continues to be the major reason that individuals with alcohol use disorders do not receive treatment. On the other hand, among those who perceived a need, a majority received treatment. It is likely that high levels of unmet need for treatment services for alcohol use disorders will persist as long as perceived need is low. Efforts are needed to increase levels of perceived need among those with alcohol use disorders.

Alcoholic liver disease

These recommendations provide a data-supported approach. They are based on the following: (i) a formal review and analysis of the recently published world literature on the topic (Medline search); (ii) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines (1); (iii) guideline policies, including the American Association for the Study of Liver Diseases (AASLD) Policy on the development and use of practice guidelines and the AGA Policy Statement on Guidelines (2); and (iv) the experience of the authors in the specified topic. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to the standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting the recommendations, the Practice Guideline Committee of the AASLD requires a Class (reflecting the benefit vs. risk) and Level (assessing the strength or certainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Association Practice Guidelines) (3,4).

Alcohol misuse and multiple sclerosis

OBJECTIVE

To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS).

DESIGN

Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006.

SETTING

Veterans Health Administration (VHA).

PARTICIPANTS

Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcohol-related advice from a medical professional.

RESULTS

Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5-15.2), with 11.9% (CI, 10.6-13.2) and 2.0% (CI, 1.4-2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (<50y; adjusted odds ratio [AOR]=1.66; CI, 1.17-2.37, and 50-59; AOR=1.64; CI, 1.19-2.27), employment (AOR=1.54; CI, 1.06-2.24) and better physical health (AOR=1.02; CI, 1.01-1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5-30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR=3.65; CI, 1.85-7.17) and less likely among those with better mental health (AOR=0.97; CI, 0.94-1.00).

CONCLUSIONS

Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care.

At-risk drinking among diabetic patients

Diabetes Mellitus is a serious chronic disease, affecting an increasing number of individuals worldwide. Adherence to diabetes self-care behaviors is key to the successful management of the disease. At-risk drinking is common among diabetic patients and is associated with inferior diabetes treatment adherence and outcomes, resulting in increased mortality and morbidity. Furthermore, individuals with diabetes who engage in at-risk drinking are also in danger of incurring the negative consequences of at-risk drinking found in the general population. Research suggests that alcohol use screening and intervention do not commonly occur during the course of primary care treatment for diabetes. While methods for reducing alcohol use in this population have been largely unexplored to date, brief interventions to reduce at-risk drinking have been well-validated in other patient populations and offer the promise to reduce at-risk drinking among diabetic patients, resulting in improved diabetes treatment adherence and outcomes.

Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study

OBJECTIVE

To determine which factors affect alcohol counselling practices among medical students.

DESIGN

Cohort study.

SETTING

Nationally representative medical schools (n=16) in the United States.

PARTICIPANTS

Medical students who graduated in 2003.

INTERVENTIONS

Questionnaires were completed (response rate 83%) at the start of students' first year (n=1846/2080), entrance to wards (typically during the third year of training) (n=1630/1982), and their final (fourth) year (n=1469/1901).

MAIN OUTCOME MEASURES

Previously validated questions on alcohol consumption and counselling.

RESULTS

78% (3777/4847) of medical students reported drinking in the past month, and a third (1668/ 4847) drank excessively; these proportions changed little over time. The proportion of those who believed alcohol counselling was highly relevant to care of patients was higher at entrance to wards (61%; 919/1516) than in final year students (46%; 606/1329). Although students intending to enter primary care were more likely to believe alcohol counselling was highly relevant, only 28% of final year students (391/1393) reported usually or always talking to their general medical patients about their alcohol consumption. Excessive drinkers were somewhat less likely than others to counsel patients or to think it relevant to do so. In multivariate models, extensive training in alcohol counselling doubled the frequency of reporting that alcohol counselling would be clinically relevant (odds ratio 2.3, 95% confidence interval 1.6 to 3.3) and of reporting doing counselling (2.2, 1.5 to 3.3).

CONCLUSIONS

Excessive drinking and binge drinking among US medical students is common, though somewhat less prevalent than among comparably aged adults in the US general population. Few students usually discussed alcohol use with patients, but greater training and confidence about alcohol counselling predicted both practising and believing in the relevance of alcohol counselling. Medical schools should consider routinely training students to screen and counsel patients for alcohol misuse and consider discouraging excessive drinking.

Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention

AIMS

To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care.

DESIGN

Two-year randomized, controlled trial.

SETTING/PARTICIPANTS

Twenty-one primary care practices across the United States with a common electronic medical record.

INTERVENTION

To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies.

MEASUREMENTS

Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses.

FINDINGS

Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7-38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3-23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling.

CONCLUSIONS

Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures.

Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness

BACKGROUND

The U.S. Preventive Services Task Force (USPSTF) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardized rating for the clinically preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services.

METHODS

A systematic review of the literature from 1992 through 2004 to identify relevant randomized controlled trials and cost-effectiveness studies was completed in 2005. Clinically preventable burden (CPB) was calculated as the product of effectiveness times the alcohol-attributable fraction of both mortality and morbidity (measured in quality-adjusted life years or QALYs), for all relevant conditions. Cost effectiveness from both the societal perspective and the health-system perspective was estimated. These analyses were completed in 2006.

RESULTS

The calculated CPB was 176,000 QALYs saved over the lifetime of a birth cohort of 4,000,000, with a range in sensitivity analysis from -43% to +94% (primarily due to variation in estimates of effectiveness). Screening and brief counseling was cost-saving from the societal perspective and had a cost-effectiveness ratio of $1755/QALY saved from the health-system perspective. Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving.

CONCLUSIONS

These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.

Identification and treatment of mental and substance use conditions: health plans strategies

BACKGROUND

Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment.

OBJECTIVES

The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies.

METHODS

In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total).

MEASURES

We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population.

RESULTS

Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies.

CONCLUSIONS

Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.

Patient gender and physician practice style

BACKGROUND

Patient and physician gender may impact the process of medical care and its outcomes. Our objective was to investigate the influence of patient gender on what takes place during initial primary care visits while controlling for other variables previously demonstrated to affect the physician-patient interaction, such as physician gender and specialty, patient health status, pain, depression, obesity, age, education, and income.

METHODS

New patients (315 women, 194 men) were randomized for care by 105 primary care physicians. Sociodemographic information, self-reported health status and pain measures, a depression evaluation, screening for alcoholism, history of tobacco use, and measured body mass index (BMI) were collected during a previsit interview. The entire medical visit was videotaped, and then analyzed using the Davis Observation Code (DOC) system.

RESULTS

There was no significant difference in the visit length or work intensity (number of behavioral codes) for female patients compared with male patients; however, women's visits had more discussions regarding the results of the therapeutic interventions, more preventive services, less physical examination, and fewer discussions about tobacco, alcohol, and other substance abuse.

CONCLUSIONS

There are significant differences in the process of care between female and male patients. Physicians may be making medical decisions based on gender-related considerations. Strategies for implementing knowledge about these gender differences are crucial for the delivery of gender-sensitive care.

Health plan requirements for mental health and substance use screening in primary care

BACKGROUND

Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it.

OBJECTIVES

We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners.

DESIGN

In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements.

PARTICIPANTS

Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region.

MEASUREMENTS

We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems.

RESULTS

By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening.

CONCLUSIONS

Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment.

Simplifying alcohol assessment: two questions to identify alcohol use disorders

BACKGROUND

Previous work has validated a single question to screen for hazardous or harmful drinking, but identifying those patients who have an alcohol use disorder (AUD) among those who screen positive is still time consuming. We therefore sought to develop and validate a brief assessment instrument using DSM-IV criteria for use in primary care medical practice.

METHODS

Four cross-sectional surveys of past-year drinkers. The developmental sample included patients presenting to emergency departments with an acute injury. The second sample, from the same study, was recruited by random-digit dialing. The third sample was recruited in 5 family medicine practices in Georgia. The fourth sample was the National Epidemiologic Survey on Alcohol and Related Conditions. Interviews with the first 3 samples used the Diagnostic Interview Schedule. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) used the Alcohol Use Disorder and Associated Disabilities Interview Schedule.

RESULTS

Two constructs with promising test characteristics were identified: recurrent drinking in hazardous situations and drinking more than intended. Among those who screened positive with the single question in the developmental sample (N=959), if either of the 2 items was positive, the sensitivity for current AUD was 95% and the specificity was 77%. In the second (N=494) and third (N=280) samples, the sensitivity was 94 and 95% and the specificity was 62 and 66%, respectively, among those with a positive screen. In the NESARC sample, including those with at least 1 occasion in the past year of drinking 5 or more drinks (N=7,890), the sensitivity and specificity were 77 and 86%, respectively.

CONCLUSIONS

The sensitivity and specificity of these 2 items across 4 samples suggest that they could be formulated into 2 questions, potentially providing busy primary care clinicians with an efficient, reasonably accurate assessment instrument to identify AUD among those patients who screen positive with the single screening question.

Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men

BACKGROUND

Alcohol misuse is a common cause of liver disease, upper gastrointestinal (GI) bleeding, and pancreatitis, but it is not known whether alcohol screening questionnaires can identify patients at increased risk for hospitalizations due to these conditions.

OBJECTIVE

To evaluate the association of alcohol screening scores with the risk of subsequent hospitalization for alcohol-related GI conditions.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Male general medicine outpatients from 7 Veterans Affairs (VA) medical centers who returned mailed questionnaires.

MEASUREMENTS

The CAGE questionnaire (0-4 points) and the Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C; 0-12 points) were included on mailed surveys. The main outcome, "GI hospitalization," was a primary VA or Medicare discharge diagnosis indicating liver disease, upper GI bleeding, or pancreatitis.

RESULTS

Among 31,311 patients followed, a median of 3.75 years, patients with CAGE scores >or=2 points or AUDIT-C scores >or=6 points were at a significantly increased risk for GI hospitalizations. Adjusted hazard ratios (HR(adj)) ranged from 1.6 (95% CI 1.2-2.0) for CAGE score 2, to 1.7 (1.4-2.2) for CAGE 4, and from 1.4 (1.01-2.0) for AUDIT-C scores from 6 to 7, to 2.7 (1.9-3.8) for AUDIT-C scores from 10 to 12. Secondary analyses demonstrated that the association was the strongest among patients less than 50 years of age who reported drinking in the past year.

CONCLUSIONS

Brief alcohol screening questionnaires predict subsequent hospitalizations for alcohol-related GI conditions.

How primary care providers talk to patients about alcohol: a qualitative study

BACKGROUND

Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse.

OBJECTIVE

To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse.

DESIGN

An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use.

PARTICIPANTS

Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial.

MEASUREMENTS

Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques.

RESULTS

Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions.

LIMITATIONS

Generalizability of findings from this single-site VA study is unknown.

CONCLUSION

Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

PTSD and Substance Use: Unrecognized Sequelae of Bioterrorism in Primary Care Providers

BACKGROUND

Psychological casualties following public health emergencies are likely to significantly outnumber physical casualties. However, postevent psychological disorders may be underrecognized by primary care providers (PCPs).

METHODS

Rural PCPs in northern and central Florida were interviewed using a series of open-ended questions to assess knowledge of likely mental disorders, their risk factors, and preferred treatment options following such events (n=21).

RESULTS

PTSD was identified by 14% and substance abuse by 10% of the sample. Physicians were significantly more likely to identify posttraumatic stress disorder (PTSD) as an expected postevent psychological disorder than nonphysician providers. PCPs were significantly more likely to endorse counseling (86%) than medications (43%) as a preferred treatment option.

CONCLUSIONS

Our findings support the need for increased education and training regarding the mental health consequences of bioterrorism in rural PCPs, particularly for nursing-level and other nonphysician providers. Improvements in knowledge may enhance preparedness for such emergencies.

Alcohol dependence and depression: Advance practice nurse interventions

PURPOSE

To identify alcohol dependence, depression, and their comorbidity as common health problems in the United States. To emphasize advance practice nurse (APN) interventions including screening, treatment, and outcome evaluations for individuals and their families suffering with alcohol dependence and depression.

DATA SOURCES

Scientific literature on alcohol dependence, depression, and their comorbidity as well as general systems theory.

CONCLUSIONS

APNs have the opportunity to successfully intervene with individuals and their family with alcohol dependence, depression, and their comorbidity. These complex health conditions need to be screened for, treated, and evaluated to ensure positive outcomes for the individual and their family system.

IMPLICATIONS FOR PRACTICE

APNs are in an excellent position to intervene at every contact with the individual and family with alcohol dependence and depression. Interventions aimed at the individual and family system are detailed in order to assist the individual and family to optimal health.

Alcohol use disorders in primary care patients in Cagliari, Italy

AIMS

To evaluate the number of subjects with possible alcohol use disorders (SPAUD) among primary care patients in Cagliari, Sardinia, Italy, by means of the self-administration of Alcohol use disorder identification test (AUDIT) and CAGE questionnaires.

METHODS

939 patients waiting in 10 surgeries of primary care physicians were asked to take part in the study. A sample of 309 women and 197 men (total 506), aged between 18 and 65 years, agreed to participate and completed both questionnaires. SPAUD were defined as those achieving cut-off scores of 5 for AUDIT and/or 1 for CAGE.

RESULTS

Seventy-nine (15.61%) patients were SPAUD, achieving a positive score in at least one questionnaire. Fifty-six (11.07%) and forty-six (9.09%) patients yielded positive results with AUDIT and CAGE, respectively. Twenty-three (4.55%) patients were positive at both AUDIT and CAGE. Significantly higher proportions of men than women were recorded among SPAUD.

CONCLUSIONS

The results of the present survey indicate a high number of SPAUD in a sample of primary care settings in Cagliari, closely similar to the occurrence of alcohol use disorders estimated in several other community-based primary care clinics in Western Countries.