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

Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening

BACKGROUND/OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Promoting substance use education among generalist physicians: an evaluation of the Chief Resident Immersion Training (CRIT) program

BACKGROUND

Education about substance use (SU) disorders remains inadequate in medical training.

OBJECTIVE

To describe the Chief Resident Immersion Training (CRIT) program in addiction medicine and to evaluate its impact on chief resident (CR) physicians' substance use knowledge, skills, clinical practice, and teaching.

DESIGN

A controlled educational study of CRIT programs (2003, 2004, and 2005) for incoming CRs in generalist disciplines. Intervention CRs were trained to diagnose, manage, and teach about SU. The control CRs sought but did not receive the intervention.

PARTICIPANTS

Eighty-six CR applicants to the CRIT program.

MEASUREMENTS

Baseline and 6-month questionnaires assessing substance use knowledge, skills, clinical practice, and teaching. Outcomes were compared within groups from baseline to follow-up and between groups at follow-up.

RESULTS

The intervention (n = 64) and control (n = 22) CRs were similar demographically. At 6-month follow-up, the intervention CRs reported a significant increase in SU knowledge, confidence, and preparedness to diagnose, manage, and teach and an increase in SU clinical and teaching practices compared to their baseline and control CRs.

CONCLUSIONS

This intensive training for chief residents (CRs) improved knowledge, confidence, and preparedness to diagnose, manage, and teach about substance use (SU), affecting both the CRs' SU clinical and teaching practices. The CRIT program was an effective model for dissemination of SU knowledge and skills to educators in a key position to share this training with a broader audience of medical trainees. This model holds potential to address other high priority medical, yet under-addressed, content areas as well.

Discussions about preventive services: a qualitative study

BACKGROUND

Elderly minority patients are less likely to receive influenza vaccination and colorectal cancer screening than are other patients. Communication between primary care providers (PCPs) and patients may affect service receipt.

METHODS

Encounters between 7 PCPs and 18 elderly patients were observed and audiotaped at 2 community health centers. Three investigators coded transcribed audiotapes and field notes. We used qualitative analysis to identify specific potential barriers to completion of preventive services and to highlight examples of how physicians used patient-centered communication and other facilitation strategies to overcome those barriers.

RESULTS

Sharing of power and responsibility, the use of empathy, and treating the patient like a person were all important communication strategies which seemed to help address barriers to vaccination and colonoscopy. Other potential facilitators of receipt of influenza vaccine included (1) cultural competence, (2) PCP introduction of the discussion, (3) persistence of the PCP (revisiting the topic throughout the visit), (4) rapport and trust between the patient and PCP, and (5) PCP vaccination of the patient. PCP persistence as well as rapport and trust also appeared to facilitate receipt of colorectal cancer screening.

CONCLUSION

Several communications strategies appeared to facilitate PCP communications with older patients to promote acceptance of flu vaccination and colorectal cancer screening. These strategies should be studied with larger samples to determine which are most predictive of compliance with prevention recommendations.

Communicating about alcohol consumption to nonharmful drinkers with Hepatitis C: patient and provider perspectives

BACKGROUND

Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C(HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not bea problem in the absence of their HCV diagnosis.

OBJECTIVE

This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.

DESIGN

We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N=50) and healthcare providers (N=14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.

RESULTS

We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients.Patient respondents who reported hearing “stop completely”were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in“medical language” than were GI providers.

CONCLUSIONS

To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

Substance abuse treatment in human immunodeficiency virus: the role of patient-provider discussions

Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.

Communicating about alcohol consumption to nonharmful drinkers with hepatitis C: patient and provider perspectives

BACKGROUND

Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.

OBJECTIVE

This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.

DESIGN

We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.

RESULTS

We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing "stop completely" were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in "medical language" than were GI providers.

CONCLUSIONS

To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.