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Blalock DV, Berlin SA, Berkowitz T, Smith VA, Wright C, Bachrach RL, Grubber JM. Associations Between a Primary Care-Delivered Alcohol-Related Brief Intervention and Subsequent Opioid-Related Outcomes. Am J Psychiatry 2024; 181:434-444. [PMID: 38706328 PMCID: PMC11076009 DOI: 10.1176/appi.ajp.20230683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
OBJECTIVE The co-occurrence of unhealthy alcohol use and opioid misuse is high and associated with increased rates of overdose, emergency health care utilization, and death. The current study examined whether receipt of an alcohol-related brief intervention is associated with reduced risk of negative downstream opioid-related outcomes. METHODS This retrospective cohort study included all VISN-6 Veterans Affairs (VA) patients with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening results (N=492,748) from 2014 to 2019. Logistic regression was used to examine the association between documentation of an alcohol-related brief intervention and probability of a new 1) opioid prescription, 2) opioid use disorder (OUD) diagnosis, or 3) opioid-related hospitalization in the following year, controlling for demographic and clinical covariates. RESULTS Of the veterans, 13% (N=63,804) had "positive" AUDIT-C screen results. Of those, 72% (N=46,216) had a documented alcohol-related brief intervention. Within 1 year, 8.5% (N=5,430) had a new opioid prescription, 1.1% (N=698) had a new OUD diagnosis, and 0.8% (N=499) had a new opioid-related hospitalization. In adjusted models, veterans with positive AUDIT-C screen results who did not receive an alcohol-related brief intervention had higher odds of new opioid prescriptions (adjusted odds ratio [OR]=1.10, 95% CI=1.03-1.17) and new OUD diagnoses (adjusted OR=1.19, 95% CI=1.02-1.40), while new opioid-related hospitalizations (adjusted OR=1.19, 95% CI=0.99-1.44) were higher although not statistically significant. Removal of medications for OUD (MOUD) did not impact associations. All outcomes were significantly associated with an alcohol-related brief intervention in unadjusted models. CONCLUSIONS The VA's standard alcohol-related brief intervention is associated with subsequent lower odds of a new opioid prescription or a new OUD diagnosis. Results suggest a reduction in a cascade of new opioid-related outcomes from prescriptions through hospitalizations.
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Affiliation(s)
- Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham NC
| | - Sophia A. Berlin
- Institute for Medical Research, Durham NC
- Durham Veterans Affairs Health Care System, Durham NC
| | - Theodore Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | | | - Rachel L. Bachrach
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Janet M. Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC
- Cooperative Studies Program Coordinating Center, Veterans Affairs Boston Health Care System, Boston MA
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Erga AH, Ushakova A, Elstad M, Fodstad EC, Belfrage A. The Relationship Between Self-Reported Childhood Maltreatment and Mental Health in Substance Use Disorders: A 6-Year Retrospective Analysis. J Dual Diagn 2024:1-13. [PMID: 38648609 DOI: 10.1080/15504263.2024.2338799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE This longitudinal cohort study aims to investigate the relationship between self-reported childhood maltreatment (CM) and the retrospective trajectory of substance use, mental health, and satisfaction with life in individuals with substance use disorders. METHODS One hundred eleven treatment-seeking individuals with substance use disorder were recruited from clinical settings and monitored prospectively for 6 years. The participants' substance use, mental health, and satisfaction with life were assessed using standardized measures. Cluster analysis divided the cohort into two groups-low CM and high CM-based on their scores on the Childhood Trauma Questionnaire Short Form at year 6. Mixed-effects linear models were fitted to assess the association between longitudinal scores on drug use, mental health, and satisfaction with life and CM group. RESULTS Most participants (92%) reported at least 1 CM. Out of all participants, 36% were categorized into the high-CM group, while 59% were categorized into the low-CM group. CM group was not associated with the amount of substance or alcohol use. CM group was significantly associated with the longitudinal course of mental health and life satisfaction. CONCLUSIONS This study underscores the association between self-reported CM and mental health and life satisfaction in patients with substance use disorder. Our results may imply an increased risk of adverse outcomes in patients with high levels of CM, while bearing in mind that both current and retrospective mental health and substance use problems can influence the accuracy of recalling CM.
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Affiliation(s)
- Aleksander H Erga
- Center for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
- Department of Social Studies, University of Stavanger, Stavanger, Norway
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, Stavanger, Norway
| | - Anastasia Ushakova
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway
| | - Maria Elstad
- Center for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Elise Constance Fodstad
- Center for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Anna Belfrage
- Center for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
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Jia-Richards M, Williams EC, Rosland AM, Boudreaux-Kelly MY, Luther JF, Mikolic J, Chinman MJ, Daniels K, Bachrach RL. Unhealthy alcohol use and brief intervention rates among high and low complexity veterans seeking primary care services in the Veterans Health Administration. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 152:209117. [PMID: 37355154 PMCID: PMC10527472 DOI: 10.1016/j.josat.2023.209117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/31/2023] [Accepted: 06/21/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Brief intervention (BI) is recommended for all primary care (PC) patients who screen positive for unhealthy alcohol use; however, patients with multiple chronic health conditions who are at high-risk of hospitalization (i.e., "high complexity" patients) may face disparities in receiving BIs in PC. The current study investigated whether high complexity and low complexity patients in the Veterans Health Administration (VHA) differed regarding screening positive for unhealthy alcohol use, alcohol-use severity, and receipt of BI for those with unhealthy alcohol use. METHODS Patients were veterans receiving PC services at the VHA in a mid-Atlantic region of the United States. The study extracted VHA administrative and clinical data for a total of 282,242 patients who had ≥1 PC visits between 1/1/2014 and 12/31/2014, during which they were screened for unhealthy alcohol use by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). The study defined high complexity patients as those within and above the 90th percentile of risk for hospitalization per the VHA's Care Assessment Need Score. Logistic regression models assessed if being a high complexity patient was associated with screening positive for unhealthy alcohol use (AUDIT-C ≥ 5), severity of unhealthy alcohol use in those who screened positive (AUDIT-C score range 5-12), and receipt of BI in those who screened positive. RESULTS Our sample was 94.5% male, 83% White, 13% Black, 4% other race, and 1.7% Hispanic. A total of 10,813 (3.8%) patients screened positive for unhealthy alcohol use from which we identified 569 (5.3%) high complexity and 10,128 (93.6%) low complexity patients (n = 116 removed due to missing complexity data). Relative to low complexity patients, high complexity patients were less likely to screen positive for unhealthy alcohol use (3.3% vs. 4.1%, AOR = 0.59, p < .001); however, in patients who screened positive, high complexity patients had higher AUDIT-C scores (Mean AUDIT-C = 7.75 vs. 6.87, AOR = 1.46, p < .001) and were less likely to receive a BI (78.0% vs. 92.6%, AOR = 0.42, p < .001). CONCLUSIONS Disparities in BI exist for highly complex patients despite having more severe unhealthy alcohol use. Future research should examine the specific patient- and/or clinic-level factors impeding BI delivery for complex patients.
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Affiliation(s)
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington, School of Public Health, Seattle, WA, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Ann-Marie Rosland
- Center for Health Equity and Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - James F Luther
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA; Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joseph Mikolic
- StatCore, Veterans Affairs Pittsburgh Healthcare System Research Office, Pittsburgh, PA, USA
| | - Matthew J Chinman
- Center for Health Equity and Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; The RAND Corporation, Pittsburgh, PA, USA
| | - Karin Daniels
- Center for Health Equity and Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Rachel L Bachrach
- Center for Health Equity and Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
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Hoggatt KJ, Chawla N, Washington DL, Yano EM. Trends in substance use disorder diagnoses among Veterans, 2009-2019. Am J Addict 2023; 32:393-401. [PMID: 36883297 DOI: 10.1111/ajad.13413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/11/2023] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data. METHODS We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD. RESULTS Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances. DISCUSSION AND CONCLUSIONS Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults. SCIENTIFIC SIGNIFICANCE These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.
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Affiliation(s)
- Katherine J Hoggatt
- San Francisco VA Health Care System, Research Division, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Neetu Chawla
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Blonigen DM, Hawkins EJ, Kuhn E, Timko C, Dulin PL, Boothroyd D, Possemato K. Stand Down-Think Before You Drink: protocol for an effectiveness-implementation trial of a mobile application for unhealthy alcohol use with and without peer support. BMJ Open 2023; 13:e072892. [PMID: 37055201 PMCID: PMC10106019 DOI: 10.1136/bmjopen-2023-072892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Mobile apps can increase access to alcohol-related care but only if patients actively engage with them. Peers have shown promise for facilitating patients' engagement with mobile apps. However, the effectiveness of peer-based mobile health interventions for unhealthy alcohol use has yet to be evaluated in a randomised controlled trial. The goal of this hybrid I effectiveness-implementation study is to test a mobile app ('Stand Down-Think Before You Drink'), with and without peer support, to improve drinking outcomes among primary care patients. METHODS AND ANALYSIS In two US Veterans Health Administration (VA) medical centres, 274 primary care patients who screen positive for unhealthy alcohol use and are not currently in alcohol treatment will be randomised to receive usual care (UC), UC plus access to Stand Down (App), or UC plus Peer-Supported Stand Down (PSSD-four peer-led phone sessions over the initial 8 weeks to enhance app engagement). Assessments will occur at baseline and 8-, 20- and 32-weeks postbaseline. The primary outcome is total standard drinks; secondary outcomes include drinks per drinking day, heavy drinking days and negative consequences from drinking. Hypotheses for study outcomes, as well as treatment mediators and moderators, will be tested using mixed effects models. Semi-structured interviews with patients and primary care staff will be analysed using thematic analysis to identify potential barriers and facilitators to implementation of PSSD in primary care. ETHICS AND DISSEMINATION This protocol is a minimal risk study and has received approval from the VA Central Institutional Review Board. The results have the potential to transform the delivery of alcohol-related services for primary care patients who engage in unhealthy levels of drinking but rarely seek treatment. Study findings will be disseminated through collaborations with healthcare system policymakers as well as publications to scholarly journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER NCT05473598.
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Affiliation(s)
- Daniel M Blonigen
- HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Eric J Hawkins
- Center of Excellence in Substance Addiction Treatment and Education, US Department of Veterans Affairs, Seattle, Washington, USA
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Eric Kuhn
- HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
- National Center for PTSD, Dissemination & Training Division, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Christine Timko
- HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Patrick L Dulin
- Department of Psychology, University of Alaska Anchorage, Anchorage, Alaska, USA
| | - Derek Boothroyd
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
| | - Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse, New York, USA
- Syracuse University, Syracuse, NY, USA
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Chi FW, Parthasarathy S, Palzes VA, Kline-Simon AH, Weisner CM, Satre DD, Grant RW, Elson J, Ross TB, Awsare S, Lu Y, Metz VE, Sterling SA. Associations between alcohol brief intervention in primary care and drinking and health outcomes in adults with hypertension and type 2 diabetes: a population-based observational study. BMJ Open 2023; 13:e064088. [PMID: 36657762 PMCID: PMC9853251 DOI: 10.1136/bmjopen-2022-064088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D). DESIGN A population-based observational study using electronic health records data. SETTING An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care. PARTICIPANTS Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017. MAIN OUTCOME MEASURES We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and 'controlled HbA1c' (HbA1c<8%) at 18-month follow-up. RESULTS For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined. CONCLUSIONS Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact.
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Affiliation(s)
- Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Constance M Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joseph Elson
- Permanente Medical Group, San Francisco, California, USA
| | - Thekla B Ross
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Matson TE, Harris AHS, Chen JA, Edmonds AT, Frost MC, Rubinsky AD, Blosnich JR, Williams EC. Influence of a national transgender health care directive on receipt of alcohol-related care among transgender Veteran Health Administration patients with unhealthy alcohol use. J Subst Abuse Treat 2022; 143:108808. [PMID: 35715286 DOI: 10.1016/j.jsat.2022.108808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use. METHODS The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications. RESULTS The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients. CONCLUSIONS Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.
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Affiliation(s)
- Theresa E Matson
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation, Veterans Affairs (VA) Palo Alto Healthcare System, Menlo Park, CA 94304, USA; Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA.
| | - Amy T Edmonds
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
| | - Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34(th) St., Los Angeles, CA 90089, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA 15219, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
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Papini S, Chi FW, Schuler A, Satre DD, Liu VX, Sterling SA. Comparing the effectiveness of a brief intervention to reduce unhealthy alcohol use among adult primary care patients with and without depression: A machine learning approach with augmented inverse probability weighting. Drug Alcohol Depend 2022; 239:109607. [PMID: 36084444 PMCID: PMC9969525 DOI: 10.1016/j.drugalcdep.2022.109607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND The combination of unhealthy alcohol use and depression is associated with adverse outcomes including higher rates of alcohol use disorder and poorer depression course. Therefore, addressing alcohol use among individuals with depression may have a substantial public health impact. We compared the effectiveness of a brief intervention (BI) for unhealthy alcohol use among patients with and without depression. METHOD This observational study included 312,056 adult primary care patients at Kaiser Permanente Northern California who screened positive for unhealthy drinking between 2014 and 2017. Approximately half (48%) received a BI for alcohol use and 9% had depression. We examined 12-month changes in heavy drinking days in the previous three months, drinking days per week, drinks per drinking day, and drinks per week. Machine learning was used to estimate BI propensity, follow-up participation, and alcohol outcomes for an augmented inverse probability weighting (AIPW) estimator of the average treatment (BI) effect. This approach does not depend on the strong parametric assumptions of traditional logistic regression, making it more robust to model misspecification. RESULTS BI had a significant effect on each alcohol use outcome in the non-depressed subgroup (-0.41 to -0.05, all ps < .003), but not in the depressed subgroup (-0.33 to -0.01, all ps > .28). However, differences between subgroups were nonsignificant (0.00 to 0.11, all ps > .44). CONCLUSION On average, BI is an effective approach to reducing unhealthy drinking, but more research is necessary to understand its impact on patients with depression. AIPW with machine learning provides a robust method for comparing intervention effectiveness across subgroups.
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Affiliation(s)
- Santiago Papini
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
| | - Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Alejandro Schuler
- Division of Biostatistics, UC Berkeley School of Public Health, 2121 Berkeley Way, Berkeley, CA 94704, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 675 18th Street, San Francisco, CA 94143, USA
| | - Vincent X Liu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 675 18th Street, San Francisco, CA 94143, USA
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Chi FW, Parthasarathy S, Palzes VA, Kline-Simon AH, Metz VE, Weisner C, Satre DD, Campbell CI, Elson J, Ross TB, Lu Y, Sterling SA. Alcohol brief intervention, specialty treatment and drinking outcomes at 12 months: Results from a systematic alcohol screening and brief intervention initiative in adult primary care. Drug Alcohol Depend 2022; 235:109458. [PMID: 35453082 PMCID: PMC10122418 DOI: 10.1016/j.drugalcdep.2022.109458] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Alcohol screening, brief intervention and referral to treatment (SBIRT) in adult primary care is an evidence-based, public health strategy to address unhealthy alcohol use, but evidence of effectiveness of alcohol brief intervention (ABI) in real-world implementation is lacking. METHODS We fit marginal structural models with inverse probability weighting to estimate the causal effects of ABI on 12-month drinking outcomes using longitudinal electronic health records data for 312,056 adults with a positive screening result for unhealthy drinking between 2014 and 2017 in a large healthcare system that implemented systematic primary care-based SBIRT. We examined effects of ABI with and without adjusting for receipt of specialty alcohol use disorder (AUD) treatment, and whether effects varied by patient demographic characteristics and alcohol use patterns. RESULTS Receiving ABI resulted in significantly greater reductions in heavy drinking days (mean difference [95% CI] = -0.26 [-0.45, -0.08]), drinking days per week (-0.04 [-0.07, -0.01]), drinks per drinking day (-0.05 [-0.08, -0.02]) and drinks per week (-0.16 [-0.27, -0.04]). Effects of ABI on 12-month drinking outcomes varied by baseline consumption level, age group and whether patients already had an AUD, with better improvement in those who were drinking at levels exceeding only daily limits, younger, and without an AUD. CONCLUSIONS Systematic ABI in adult primary care has the potential to reduce drinking among people with unhealthy drinking considerably on both an individual and population level. More research is needed to help optimize ABI, in particular tailoring it to diverse sub-populations, and studying its long-term public health impact.
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Affiliation(s)
- Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry, Weill Institute of Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Joseph Elson
- The Permanente Medical Group, 1600 Owens Street, San Francisco, CA 94158, USA
| | - Thekla B Ross
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
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Bachrach RL, Chinman M, Rodriguez KL, Mor MK, Kraemer KL, Garfunkel CE, Williams EC. Using practice facilitation to improve alcohol-related care in primary care: a mixed-methods pilot study protocol. Addict Sci Clin Pract 2022; 17:19. [PMID: 35287714 PMCID: PMC8919159 DOI: 10.1186/s13722-022-00300-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background Alcohol use is a significant risk factor for disability and death in U.S. adults, and approximately one out of every six Veterans seen in primary care (PC) report unhealthy alcohol use. Unhealthy alcohol use is associated with increased risk for poor medical outcomes, substantial societal costs, and death, including suicide. Based on substantial evidence from randomized controlled trials and the U.S. Preventive Services Task Force, VA/DoD clinical guidelines stipulate that all Veterans screening positive for unhealthy alcohol use should receive evidence-based alcohol care in PC, including brief counseling interventions (BI) and additional treatment (e.g., pharmacotherapy) for those with alcohol use disorders (AUD). The VA pioneered implementing alcohol screening and BI in PC, yet substantial implementation gaps remain. To improve alcohol-related care, this study will conduct a pilot study to assess whether a multi-faceted evidence-based implementation strategy—practice facilitation—has the potential to improve PC-based alcohol-related care at a single VA clinic. Methods We will first recruit and conduct qualitative interviews with Veterans with unhealthy alcohol use (n = 20–25) and PC stakeholders (N = 10–15) to understand barriers and facilitators to high-quality alcohol care and use results to refine and hone the multifaceted practice facilitation intervention. Qualitative interviews, analysis, and refinement of the intervention will be guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups with a small sample of PC providers and staff (n = 5–7) will be used to further refine the practice facilitation intervention and assess its acceptability and feasibility. The refined practice facilitation intervention will then be offered in the PC clinic to assess implementation (e.g., reach) and effectiveness (reduced drinking) outcomes based on the RE-AIM framework. Discussion This research directly addresses one of the largest public health crises of our time, as alcohol kills more people than opioids and is associated with increased risk of suicide. If successful, this pilot may generate an intervention with far-reaching effects on adverse outcomes experienced by Veterans with unhealthy alcohol use, including increased access to care and suicide prevention. Trial registration Clinicaltrials.gov identifier: NCT04565899; Date of registration: 9/25/2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00300-x.
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Affiliation(s)
- Rachel L Bachrach
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA. .,Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA. .,Department of Psychology, University of Pittsburgh, Pittsburgh, PA, 15260, USA.
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,The RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Deparatment of Biostistic, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Kevin L Kraemer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Cécile E Garfunkel
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, 98195, USA.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, 98108, USA
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11
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Edmonds AT, Rhew IC, Jones-Smith J, Chan KC, Nelson K, Williams EC. Patient-centered primary care and receipt of evidence-based alcohol-related care in the national Veterans Health Administration. J Subst Abuse Treat 2022; 138:108709. [DOI: 10.1016/j.jsat.2021.108709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/31/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022]
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12
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Rubin A, Livingston NA, Brady J, Hocking E, Bickmore T, Sawdy M, Kressin N, Saitz R, Simon S. Computerized Relational Agent to Deliver Alcohol Brief Intervention and Referral to Treatment in Primary Care: a Randomized Clinical Trial. J Gen Intern Med 2022; 37:70-77. [PMID: 34145518 PMCID: PMC8212899 DOI: 10.1007/s11606-021-06945-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 05/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Alcohol screening and brief intervention have demonstrated efficacy but limited effectiveness and implementation in real-world primary care settings. OBJECTIVE To evaluate the effectiveness of a computerized Relational Agent programmed to provide alcohol screening, brief intervention, and referral to treatment. We hypothesized that participants in the experimental condition would report greater reductions in their drinking and higher rates of brief intervention and referrals to specialty care compared to those in treatment as usual (TAU). DESIGN This was a Hybrid I implementation design and stratified RCT. Participants were randomized to TAU or Relational Agent + TAU and assessed at baseline and 3-month follow-up. PARTICIPANTS A total of 178 veteran participants were recruited by referral from primary care staff after a positive alcohol screen, or via letter sent do patients screening positive during recent visit. INTERVENTION(S) TAU involved yearly reminders to screen alcohol use and provide brief intervention and treatment referrals, as needed. The Relational Agent added an automated brief intervention, a 1-month follow-up Relational Agent visit, and referral to treatment if needed. MAIN MEASURES We measured average drinks per day, drinking days per week, number of brief interventions, and number of referrals over 3 months. KEY RESULTS Participants decreased their drinking in both study conditions, with no significant between-group differences on primary alcohol measures. However, Relational Agent + TAU participants evidenced greater improvements regarding negative alcohol-related consequences over 3 months, and were significantly more likely to receive a brief intervention and referral to specialty care. CONCLUSIONS The Relational Agent successfully provided brief intervention and referred many more patients to specialty care and was able to intervene with patients with less severe drinking without increasing primary care burden. TRIAL REGISTRATION clinicaltrials.gov , NCT02030288, https://clinicaltrials.gov/ct2/home.
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Affiliation(s)
- Amy Rubin
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Nicholas A Livingston
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
- Behavioral Sciences Division, National Center for PTSD, Boston, MA, USA.
| | - Julianne Brady
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
| | - Elise Hocking
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | | | - Molly Sawdy
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
| | - Nancy Kressin
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Richard Saitz
- School of Public Health, Boston University, Boston, MA, USA
| | - Steven Simon
- U.S. Department of Veterans Affairs, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Harvard Medical School, Boston, MA, USA
- David Geffen UCLA School of Medicine, Los Angeles, CA, USA
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13
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Williams EC, Chen JA, Frost MC, Rubinsky AD, Edmonds AT, Glass JE, Lehavot K, Matson TE, Wheat CL, Coggeshall S, Blosnich JR. Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients. J Subst Abuse Treat 2021; 131:108565. [PMID: 34274175 DOI: 10.1016/j.jsat.2021.108565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/OBJECTIVE Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. METHODS We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients. RESULTS Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002). CONCLUSIONS Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA.
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Joseph E Glass
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA
| | - Keren Lehavot
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA
| | - Theresa E Matson
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA
| | - Chelle L Wheat
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, WA 98108, USA
| | - Scott Coggeshall
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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14
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Rates and predictors of brief intervention for women veterans returning from recent wars: Examining gaps in service delivery for unhealthy alcohol use. J Subst Abuse Treat 2021; 123:108257. [PMID: 33612192 DOI: 10.1016/j.jsat.2020.108257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 11/01/2020] [Accepted: 12/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3-4; =5-7; =8-12), and the role of alcohol risk level and other factors in predicting receipt of BI. METHODS From administrative data (2010-2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not. RESULTS While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems. CONCLUSIONS Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.
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15
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Leibowitz A, Satre DD, Lu W, Weisner C, Corriveau C, Gizzi E, Sterling S. A Telemedicine Approach to Increase Treatment of Alcohol Use Disorder in Primary Care: A Pilot Feasibility Study. J Addict Med 2021; 15:27-33. [PMID: 32467415 PMCID: PMC7704783 DOI: 10.1097/adm.0000000000000666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Unhealthy drinking is a leading threat to health, yet few people with alcohol use disorder (AUD) receive treatment. This pilot tested the feasibility of addiction medicine video consultations in primary care for improving AUD medication adoption and specialty treatment initiation. METHODS Primary care providers (PCPs) received training and access to on-call addiction medicine consultations. Feasibility measures were training attendance, intention to use the service and/or AUD pharmacotherapy, and user feedback. Secondary outcomes were utilization, prescription and treatment initiation rates, and case reports. χ2 tests were used to compare prescription and treatment initiation rates for consult recipients and non-recipients. RESULTS Ninety-one PCPs (71.1%) attended a training, and 60 (65.9%) provided feedback. Of those, 37 (64.9%) mentioned pharmacotherapy and 41 (71.9%) intended to use the video consult service. Of 27 users, 19 provided feedback; 12 (63.1%) rated its value at 8 or above, on a scale of 1 to 10 (average 6.9). The most useful aspect was immediacy, and users wanted an easier workflow and increased consultant availability. Of 32 patients who received a consult, 11 (34.4%) were prescribed naltrexone, versus 43 (6.4%) of non-recipients (P < 0.0001); 11 (34.4%) initiated specialty treatment, versus 105 (19.7%) of non-recipients (P < 0.05). CONCLUSIONS PCP training attendance and feedback suggest that an addiction telemedicine consult service would be valuable to PCPs and might increase AUD medication uptake and specialty addiction treatment initiation. However, future research should include significant modifications to the piloted telemedicine model: robust staffing and simpler, more flexible methods for PCPs to obtain consults.
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Affiliation(s)
- Amy Leibowitz
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143
| | - Wendy Lu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403
| | - Caroline Corriveau
- The Permanente Medical Group, Addiction Medicine and Recovery Services, 380 W MacArthur Blvd, Oakland, CA 94609
| | - Elio Gizzi
- The Permanente Medical Group, East Bay Technology, 901 Nevin Avenue, Richmond, CA 94801
| | - Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612-2403
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16
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Poikolainen K. Paternalism and alcohol policy. DRUGS AND ALCOHOL TODAY 2020. [DOI: 10.1108/dat-07-2020-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to investigate to what degree scientific evidence supports contemporary paternalistic alcohol policy practices targeting fully competent adults.
Design/methodology/approach
Paternalism may be acceptable if it is effective, fair and protects the safety of the citizen or a third party from the harms caused by the citizen’s autonomic actions. To be justifiable, paternalistic actions should bring about clearly more benefits than harms. Otherwise, autonomy should prevail. The evidence related to alcohol control policies is assessed against these principles.
Findings
In peaceful civilized societies, alcohol control policies (high prices, restrictions on supply and marketing) have no or only insignificant effectiveness. Some policies are unfair and may bring about more harms than benefits. There is strong evidence showing that brief interventions aiming to reduce alcohol intake are inefficient. Wide-scale screening for such interventions is likely to waste health service resources. There is sufficient evidence to refute the claim that the previously mentioned policies are effective measures to reduce alcohol-related harms. Heavy alcohol use during pregnancy and driving motor vehicles while intoxicated may bring about harm to others than the user. Behavioural interventions to reduce heavy use in pregnancy have been shown to be inefficient. Light alcohol use may have no harmful effect on the developing embryo, whereas heavy use is likely to cause harm. There is moderate evidence for enforcing legal blood alcohol concentration limits to reduce traffic accidents and fatalities.
Originality/value
This is the first review on the acceptability of paternalism in currently recommended alcohol policies. It shows that in only a few cases, paternalism is effective and compatible with freedom and fairness.
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17
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Chen JA, Glass JE, Bensley KMK, Goldberg SB, Lehavot K, Williams EC. Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration. J Subst Abuse Treat 2020; 119:108078. [PMID: 32736926 DOI: 10.1016/j.jsat.2020.108078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/18/2020] [Accepted: 07/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use. METHODS Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender. RESULTS Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results. CONCLUSIONS Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA.
| | - Joseph E Glass
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Kara M K Bensley
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St, Suite 450, Emeryville, CA 94608, USA; Department of Public Health, Bastyr University, 14500 Juanita Dr NE, Kenmore, WA 98028, USA.
| | - Simon B Goldberg
- Department of Counseling Psychology, University of Wisconsin - Madison, 335 Education Building, 1000 Bascom Mall, Madison, WI, 53706, USA.
| | - Keren Lehavot
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
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Blonigen DM, Harris-Olenak B, Kuhn E, Timko C, Humphreys K, Smith JS, Dulin P. Using peers to increase veterans' engagement in a smartphone application for unhealthy alcohol use: A pilot study of acceptability and utility. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2020; 35:829-839. [PMID: 32597665 DOI: 10.1037/adb0000598] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Mobile apps can only increase access to alcohol treatment if patients actively engage with them. Peers may be able to facilitate such engagement by providing supportive accountability and instruction and encouragement for app use. We developed a protocol for peers to support engagement in the Stand Down app for unhealthy alcohol use in veterans and tested the acceptability and utility of the protocol. Thirty-one veteran primary care patients who screened positive for unhealthy alcohol use and were not currently in addiction treatment were given access to Stand Down for four weeks and concurrently received weekly phone support from a Department of Veterans Affairs peer specialist to facilitate engagement with the app. App usage was extracted daily, and pre/post treatment assessments measured changes in drinking patterns, via the Timeline Followback interview, and satisfaction with care, via quantitative and qualitative approaches. A priori benchmarks for acceptability were surpassed: time spent in the app (M = 93.89 min, SD = 92.1), days of app use (M = 14.05, SD = 8.0), and number of daily interviews completed for tracking progress toward a drinking goal (M = 12.64, SD = 9.7). Global satisfaction, per the Client Satisfaction Questionnaire, was high (M = 26.4 out of 32, SD = 4.5). Pre to post, total standard drinks in the prior 30 days (MPre = 142.7, MPost = 85.6), Drinks Per Drinking Day (MPre = 5.4, MPost = 4.0), and Percent Heavy Drinking Days (MPre = 35.3%, MPost = 20.1%) decreased significantly (ps < .05). Findings indicate that Peer-Supported Stand Down is highly acceptable to veteran primary care patients and may help reduce drinking in this population. A larger controlled trial of this intervention is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Daniel M Blonigen
- Center for Innovation to Implementation, VA Palo Alto Health Care System
| | | | - Eric Kuhn
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Keith Humphreys
- Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Jennifer S Smith
- Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Patrick Dulin
- Department of Clinical and Community Psychology, University of Alaska Anchorage
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19
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Frost MC, Glass JE, Bradley KA, Williams EC. Documented brief intervention associated with reduced linkage to specialty addictions treatment in a national sample of VA patients with unhealthy alcohol use with and without alcohol use disorders. Addiction 2020; 115:668-678. [PMID: 31642124 PMCID: PMC7725424 DOI: 10.1111/add.14836] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/28/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Alcohol screening, brief intervention (BI) and referral to treatment is often considered stepped care, such that BI with referral links patients to treatment. A meta-analysis of randomized trials found no evidence that BI increases treatment for alcohol use disorder (AUD). This study aimed to determine whether BI is associated with receipt of treatment for AUD among patients receiving BI as part of routine care. DESIGN Regression analysis. SETTING US Veterans Health Administration (VA), in which BI is supported by performance measurement and electronic clinical reminders. PARTICIPANTS VA outpatients with positive Alcohol Use Disorders Identification Test Consumption screens (≥ 5) (n = 830,825) documented nationally from 1 October 2009 to 30 May 2013. MEASUREMENTS Regression models estimated the prevalence of receiving VA specialty addictions treatment within 0-365 days for patients with documented BI (advice to reduce/abstain within 0-14 days) compared to those without. Models clustered on patient and adjusted for demographics and mental health and substance use conditions were fit among all patients and stratified across documented past-year AUD diagnosis. Multiple secondary analyses assessed robustness of findings, including assessing repeated BI as a predictor. FINDINGS Among 830,825 VA outpatients with unhealthy alcohol use (1,172,606 positive screens), documented BI was associated with lower likelihood of receiving VA specialty addictions treatment [adjusted incidence rate ratio (aIRR) = 0.84, 95% confidence interval (CI) = 0.83-0.84]. Associations were similar for those with and without AUD (aIRR = 0.83, 95% CI = 0.82-0.84 and aIRR = 0.86, 95% CI = 0.83-0.88, respectively) and in most secondary analyses. However, among patients without AUD, documentation of more than one BI was associated with greater likelihood of treatment relative to no BI (aIRR = 1.75, 95% CI = 1.68-1.83). CONCLUSIONS In a national sample of US Veterans Health Administration patients with unhealthy alcohol use, documented brief intervention for alcohol use was associated with lower likelihood of receiving specialty addictions treatment regardless of alcohol use disorder diagnosis.
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Affiliation(s)
- Madeline C. Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108,Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
| | - Joseph E. Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101
| | - Katharine A. Bradley
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108,Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195,Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101,Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
| | - Emily C. Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108,Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
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20
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Rubinsky AD, Chavez LJ, Berger D, Lapham GT, Hawkins EJ, Williams EC, Bradley KA. Utility of routine alcohol screening for monitoring changes in alcohol consumption. Drug Alcohol Depend 2019; 201:155-160. [PMID: 31229703 PMCID: PMC7001877 DOI: 10.1016/j.drugalcdep.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/11/2019] [Accepted: 03/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Routine alcohol screening scores are increasingly available in electronic health records (EHRs). Changes in such scores could be useful for monitoring response to brief intervention or treatment of alcohol use disorder. However, it is unclear whether changes in clinically-documented AUDIT-C alcohol screening scores reflect true changes in drinking. This study evaluated associations between changes in EHR AUDIT-C scores and changes in high density lipoprotein cholesterol (HDL), a laboratory test that reflects average alcohol consumption. METHODS National U.S. Veterans Affairs EHR data (2004-2007) were used to identify patients screened with the AUDIT-C (0-12 points), on two occasions at least a year apart, who had HDL measured in the year after each screen. First differencing linear regression estimated associations between changes in AUDIT-C score (-12 to 12 points; modeled categorically to allow for non-linear associations) and subsequent changes in HDL (mg/dL), adjusting for baseline HDL. Additional analyses evaluated whether associations between changes in AUDIT-C and changes in HDL were modified by baseline AUDIT-C. RESULTS Among 316,712 patients, increases-but not decreases-in AUDIT-C scores were associated with commensurate changes in HDL. However, a significant interaction was observed with baseline AUDIT-C score (p < 0.00001), which revealed that decreases in AUDIT-C scores were also associated with commensurate decreases in HDL (p-values<0.05) except among the 1.5% of patients with the highest baseline AUDIT-C scores (10-12). CONCLUSIONS Findings suggest that changes in EHR AUDIT-C scores reflect changes in drinking. These results support the use of clinically-documented alcohol screening scores for monitoring patients' alcohol use over time.
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Affiliation(s)
- Anna D. Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA.,Kidney Health Research Collaborative, University of California, San Francisco, and Department of Veterans Affairs San Francisco Health Care System, 4150 Clement Street (111A1), San Francisco, CA 94121, USA
| | - Laura J. Chavez
- Division of Health Services Management and Policy, The Ohio State University, College of Public Health, 1841 Neil Ave, Columbus, Ohio 43210, USA
| | - Douglas Berger
- General Medicine Service, Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way (S-152), Seattle, WA, 98108, USA; Department of Medicine, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, USA.
| | - Gwen T. Lapham
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA.,Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue Ste. 1600, Seattle, WA 98101, USA
| | - Eric J. Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA.,Center of Excellence in Substance Addiction Treatment and Education (CESATE), Seattle, WA 98108, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, USA
| | - Emily C. Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA.,Department of Health Services, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, USA
| | - Katharine A. Bradley
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA.,Center of Excellence in Substance Addiction Treatment and Education (CESATE), Seattle, WA 98108, USA.,Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue Ste. 1600, Seattle, WA 98101, USA.,Department of Health Services, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, USA.,Department of Medicine, University of Washington, 1410 NE Campus Parkway, Seattle, WA, 98195, USA
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21
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Wakeman SE, Herman G, Wilens TE, Regan S. The prevalence of unhealthy alcohol and drug use among inpatients in a general hospital. Subst Abus 2019; 41:331-339. [PMID: 31368860 DOI: 10.1080/08897077.2019.1635961] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Unhealthy substance use is a growing public health issue. Intersections with the health care system offer an opportunity for intervention; however, recent estimates of prevalence for unhealthy substance use among all types of hospital inpatients are unknown. Methods: Universal screening for unhealthy alcohol or drug use was implemented across a 999-bed general hospital between January 1 and December 31, 2015. Nurses completed alcohol screening using the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) with a cutoff of ≥5 for moderate risk and ≥8 for high risk and drug screening using the single-item screening question with ≥1 episode of use considered positive. Results: Out of 35,288 unique inpatients, screens were completed on 21,519. There were 3,451 positive screens (16% of all completed screens), including 1,291 (6%) moderate risk and 1,111 (5%) high risk screens for alcohol and 1,657 (8%) positive screens for drug use. Among screens that were positive for moderate- or high-risk alcohol use, 221 (17%) and 297 (27%), respectively, were concurrently positive for drug use. The majority (61%) of patients with unhealthy alcohol use was on the medical services. Men, those who were white or Hispanic, middle-aged, single, unemployed, or screened positive for drug use were more likely to screen positive for high-risk alcohol use. Those who were younger, single, worked less than full time, or screened high risk for alcohol were more likely to screen positive for drug use. Discordance between diagnosis coding and screening results was noted: 29% of high-risk alcohol use screens had no alcohol diagnosis coding associated with that admission, and 51% of patients with a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnosis code of alcohol dependence had AUDIT-C scores of <8. Conclusions: Across a general hospital, 16% of patients screened positive for unhealthy substance use, with the highest volume on medical floors. Nursing-led screening may offer an opportunity to identify and engage patients with unhealthy substance use during hospitalization.
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Affiliation(s)
- Sarah E Wakeman
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Herman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Timothy E Wilens
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Regan
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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22
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Bensley KM, Fortney J, Chan G, Dombrowski JC, Ornelas I, Rubinsky AD, Lapham GT, Glass JE, Williams EC. Differences in Receipt of Alcohol-Related Care Across Rurality Among VA Patients Living With HIV With Unhealthy Alcohol Use. J Rural Health 2019; 35:341-353. [PMID: 30703856 PMCID: PMC6639081 DOI: 10.1111/jrh.12345] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE It is unknown whether receipt of evidence-based alcohol-related care varies by rurality among people living with HIV (PLWH) with unhealthy alcohol use-a population for whom such care is particularly important. METHODS All positive screens for unhealthy alcohol use (AUDIT-C ≥ 5) among PLWH were identified using Veterans Health Administration electronic health record data (10/1/09-5/30/13). Three domains of alcohol-related care were assessed: brief intervention (BI) within 14 days, and specialty addictions treatment or alcohol use disorder (AUD) medications (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 1 year of positive screen. Adjusted Poisson models and recycled predictions were used to estimate predicted prevalence of outcomes across rurality (urban, large rural, small rural), clustered on facility. Secondary analyses assessed outcomes in the subsample with documented AUD. FINDINGS 4,581 positive screens representing 3,458 PLWH (3,112 urban, 130 large rural, and 216 small rural) were included; 49.1% had diagnosed AUD. PLWH in large rural areas had highest receipt of BI (urban 56.6%, 95% CI: 55.0-58.2; large rural 66.0%, CI: 58.6-73.5; small rural 60.7%, CI: 54.6-67.0). PLWH in urban areas had highest receipt of specialty addictions treatment (urban 28.2%, CI: 26.7-29.8; large rural 19.7%, CI: 13.1-26.2; small rural 19.6%, CI: 14.1-25.0). There was no difference in receipt of AUD medications, although overall receipt was low (3%-4%). Results were similar in the subsample with AUD. CONCLUSION Among PLWH with unhealthy alcohol use, those in rural areas may be vulnerable to under-receipt of specialty addictions treatment. Targeted interventions may help ensure PLWH receive recommended care regardless of rurality.
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Affiliation(s)
- Kara M Bensley
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Alcohol Research Group, Public Health Institute, Emeryville, California
| | - John Fortney
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Gary Chan
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Julia C Dombrowski
- Department of Medicine and Allergy & Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - India Ornelas
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Anna D Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco, and VA San Francisco Healthcare System, San Francisco, California
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Emily C Williams
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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23
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Alcohol Withdrawal Syndrome: Improving Recognition and Treatment in the Emergency Department. Adv Emerg Nurs J 2019; 41:65-75. [PMID: 30702536 DOI: 10.1097/tme.0000000000000226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Alcoholism continues to be a persistent health problem in the United States, accounting for up to 62% of emergency department (ED) visits. This quality improvement (QI) project examined whether identifying the benefit for early use of Alcohol Use Disorders Identification Test (AUDIT C) and Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIW-ar) in the ED would avoid escalation of care and offset poor outcomes of alcohol withdrawal syndrome (AWS). A preimplementation chart review (N = 99) showed an average of 12%-15% of patients requiring escalation of care at the project site. The QI project utilized a single-group, pre-/posttest design. The setting was a Southwest Veterans Affair tertiary care referral center. Thirty-five ED staff members were surveyed for baseline knowledge and attended education sessions, led by an advanced practice nurse, on the use of AUDIT-C and CIWA-ar. Posteducation, patients admitted to the hospital were screened with AUDIT-C and treated with CIWA-ar. Postimplementation, charts were reviewed for admitted patients (N = 42) on the use of AUDIT-C, CIWA-ar, length of stay (LOS), and area patient treated. Although the test scores after didactic education were statistically significant (p ≤ 0.050), there was no significant difference in the use of AUDIT-C or CIWA-ar in the ED, nor a significant decrease in LOS for those patients with CIWA-ar ordered. However, the potential for clinical benefit could not be disavowed. Barriers to implementation included survey fatigue, inability to embed AUDIT-C in the electronic medical record, inconsistency in completing AUDIT-C, interrater reliability, and patient fear of stigmatization. Advanced practice nurses provide an integral role to augment early identification and treatment of AWS in the ED.
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24
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Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use. J Gen Intern Med 2019; 34:256-263. [PMID: 30484101 PMCID: PMC6374244 DOI: 10.1007/s11606-018-4749-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/21/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.
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25
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Frost MC, Matson TE, Tsui JI, Williams EC. Influence of comorbid drug use disorder on receipt of evidence-based treatment for alcohol use disorder among VA patients with alcohol use disorder and Hepatitis C and/or HIV. Drug Alcohol Depend 2019; 194:288-295. [PMID: 30469100 PMCID: PMC6312483 DOI: 10.1016/j.drugalcdep.2018.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/08/2018] [Accepted: 10/16/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alcohol use is risky for patients with hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV) infection, but alcohol use disorder (AUD) treatment is underutilized in these populations. Comorbid drug use disorders (DUD) are common, but their influence on AUD treatment receipt is understudied. We evaluated the association between DUD and AUD treatment receipt in two national samples of patients with AUD, those with HIV and those with HCV, in the U.S. Veterans Health Administration. METHODS Samples included patients with AUD and HCV and/or HIV among positive alcohol screens (AUDIT-C≥5) documented 10/01/09-5/30/13 in the national electronic health record. Poisson regression models estimated incidence rate ratios for receiving specialty treatment (stop codes) and pharmacotherapy (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 365 days of positive alcohol screening for patients with DUD versus those without. Models were clustered on patient and adjusted for potential confounders. RESULTS Among 22,039 patients with HCV/AUD, 45.2% (N = 9,964) had DUD, which was associated with receiving specialty treatment [adjusted incidence rate ratio: 1.89 (95% confidence interval 1.82-1.96)] and pharmacotherapy [aIRR: 1.50 (1.37-1.65)]. Among 1,834 patients with HIV/AUD, 56.9% (N = 1,043) had DUD, which was associated with receiving specialty treatment [aIRR: 1.94 (1.68-2.24)], but not pharmacotherapy. CONCLUSIONS Rates of AUD treatment receipt among patients with AUD and HCV and/or HIV were low overall, but likelihood of treatment receipt was generally higher among those with comorbid DUD. Future research should investigate mechanisms underlying these associations, such as enhanced readiness for treatment or differential provider prescribing or referral practices.
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Affiliation(s)
- Madeline C Frost
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States.
| | - Theresa E Matson
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA, 98101, United States.
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States.
| | - Emily C Williams
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States; Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States.
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26
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Bensley KM, McGinnis KA, Fortney J, Chan KCG, Dombrowski JC, Ornelas I, Edelman EJ, Goulet JL, Satre DD, Justice AC, Fiellin DA, Williams EC. Patterns of Alcohol Use Among Patients Living With HIV in Urban, Large Rural, and Small Rural Areas. J Rural Health 2018; 35:330-340. [PMID: 30339740 DOI: 10.1111/jrh.12326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND For people living with HIV (PLWH), alcohol use is harmful and may be influenced by unique challenges faced by PLWH living in rural areas. We describe patterns of alcohol use across rurality among PLWH. METHODS Veterans Aging Cohort Study electronic health record data were used to identify patients with HIV (ICD-9 codes for HIV or AIDS) who completed AUDIT-C alcohol screening between February 1, 2008, and September 30, 2014. Regression models estimated and compared 4 alcohol use outcomes (any use [AUDIT-C > 0] and alcohol use disorder [AUD; ICD-9 codes for abuse or dependence] diagnoses among all PLWH, and AUDIT-C risk categories: lower- [1-3 men/1-2 women], moderate- [4-5 men/3-5 women], higher- 6-7]), and severe-risk [8-12], and heavy episodic drinking (HED; ≥1 past-year occasion) among PLWH reporting use) across rurality (urban, large rural, small rural) and census-defined region. FINDINGS Among 32,699 PLWH (29,540 urban, 1,301 large rural, and 1,828 small rural), both any alcohol use and AUD were highest in urban areas, although this varied across region. Predicted prevalence of any alcohol use was 54.1% (53.5%-54.7%) in urban, 49.6% (46.9%-52.3%) in large rural, and 50.6% (48.3%-52.9%) in small rural areas (P < .01). Predicted prevalence of AUD was 14.4% (14.0%-14.8%) in urban, 11.8% (10.0%-13.5%) in large rural, and 12.3% (10.8%-13.8%) in small rural areas (P < .01). Approximately 12% and 25% had higher- or severe-risk drinking and HED, respectively, but neither differed across rurality. CONCLUSION Though some variation across rurality and region was observed, alcohol-related interventions are needed for PLWH across all geographic locations.
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Affiliation(s)
- Kara M Bensley
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,Alcohol Research Group, Public Health Institute, Emeryville, California
| | | | - John Fortney
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Seattle, Washington
| | - K C Gary Chan
- University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,University of Washington School of Public Health, Department of Biostatistics, Seattle, Washington
| | - Julia C Dombrowski
- University of Washington School of Medicine, Department of Medicine and Allergy & Infectious Diseases, Seattle, Washington
| | - India Ornelas
- University of Washington School of Public Health, Department of Health Services, Seattle, Washington
| | - E Jennifer Edelman
- Yale University School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Joseph L Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Derek D Satre
- University of California, Department of Psychiatry, San Francisco, California.,Kaiser Permanente Northern California, Division of Research, Oakland, California
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - David A Fiellin
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Emily C Williams
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington
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Bachrach RL, Blosnich JR, Williams EC. Alcohol screening and brief intervention in a representative sample of veterans receiving primary care services. J Subst Abuse Treat 2018; 95:18-25. [PMID: 30352666 DOI: 10.1016/j.jsat.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 11/30/2022]
Abstract
AIMS Unhealthy alcohol use is common among adults, and in particular, Veterans. Routine alcohol screening followed by brief intervention is recommended and considered a prevention priority in primary care settings. While previous studies have found that Veterans enrolled in the Veteran's Health Administration (VA) receive high rates of screening and brief intervention, less than 50% of Veterans receive VA health care. No study has evaluated receipt of these services in a general sample of Veterans. Therefore, in a nationally-representative sample, we examine whether Veteran status was associated with receiving alcohol screening and brief intervention in primary care. METHODS Using the Centers for Disease Control and Prevention's 2014 Behavioral Risk Factor Surveillance System data, we identified adults who endorsed visiting a doctor for routine checkup at least once in the past two years and responded to an optional module assessing alcohol-related care (N = 92,206; 14.1% Veterans). Multivariable logistic regression was used to assess the association between Veteran status and screening and brief intervention outcomes. We also evaluate differences in alcohol-related care across Veteran status stratified by gender. Models were adjusted for sociodemographic and clinical characteristics likely to confound the association. RESULTS Overall, Veterans were more likely than non-Veterans to be screened for alcohol quantity and heavy episodic drinking (ps < 0.05), and more likely to endorse receiving brief intervention advice about alcohol's harmful effects (p < .001). Veteran status predicted an increased likelihood of being screened and receipt of advice about alcohol's harmful effects, but did not predict the likelihood of receiving advice to reduce or abstain from drinking (AOR = 1.00, 95% C.I. [0.80-1.26]). Analyses stratified by gender indicated a similar pattern of results for males as the overall sample. Results among females indicated Veteran status predicted the likelihood of being asked about heavy episodic drinking (AOR = 1.47, 95% C.I. [1.09-1.99]) and being offered advice about the harmful effects of alcohol (AOR = 1.62, 95% C.I. [1.06-2.48]). Female Veterans were not more likely than female non-Veterans to be advised to reduce and/or abstain from drinking. CONCLUSIONS Screening about any alcohol use was common while report of screening for quantity and heavy episodic drinking occurrence and report of brief intervention were less common. Veterans were more likely than non-Veterans to report receiving recommended care, though rates of advice to reduce or abstain from drinking did not differ across groups. Persistent gaps in delivery of recommended alcohol-related care, especially for particularly vulnerable subpopulations such as women Veterans, suggest a need for quality improvement.
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Affiliation(s)
- Rachel L Bachrach
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C, Building 30, Pittsburgh, PA 15240, USA; Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, University Drive C, Building 30, Pittsburgh, PA 15240, USA.
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C, Building 30, Pittsburgh, PA 15240, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore, 3459 Fifth Avenue, Suite W933, Pittsburgh, PA 15213, USA.
| | - Emily C Williams
- Denver-Seattle Center of Innovation for Veteran-Centered Value-Driven Care, Health Services Research & Development, VA Puget Sound Healthcare System, 1660 Columbian Way S. (S-152), Seattle, WA 98108, USA; Department of Health Services, University of Washington, Seattle, WA, USA.
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Hoggatt KJ, Hepner KA. Assessing Brief Intervention for Unhealthy Alcohol Use: A Comparison of Electronic Health Record Documentation and Patient Self-Report. J Stud Alcohol Drugs 2018; 79:697-701. [PMID: 30422782 PMCID: PMC6240012 DOI: 10.15288/jsad.2018.79.697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 04/02/2018] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE Alcohol screening and brief intervention (BI) are recommended preventive health practices. Veterans Health Administration (VA) uses a performance measure to incentivize BI delivery. Concerns have been raised about the validity of the BI performance measure, which relies on electronic health record (EHR) documentation. Our objective was to assess concordance between EHR-based documentation and patient-reported receipt of BI, and to examine correlates of concordance. METHOD Patients with a documented positive screen for unhealthy alcohol use at VA Greater Los Angeles primary care clinics were surveyed (within 15 days on average) in 2013-2014. Documented BI was indicated by an EHR note that the patient was advised to drink within recommended limits or reduce or abstain from drinking. Patient-reported receipt of BI corresponded to an affirmative response to questions on whether a VA provider advised the patient to drink less or abstain. Patient report and documentation were assessed over the same period. RESULTS Documented and patient-reported receipt of BI had low concordance. Almost all patients who reported receiving BI had documentation of BI (93%; 95% CI [90%, 95%]), but only 63% [59%, 67%] of patients with documented BI reported receiving it. BI concordance was associated with more severe unhealthy alcohol use and drinking-related consequences, mental health comorbidity, and greater readiness-to-change alcohol use. CONCLUSIONS Discrepancies between EHR documentation and patient-reported BI raise concerns about performance measure validity. Patient-reported receipt of BI could be an alternative or complementary measure of BI.
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Affiliation(s)
- Katherine J. Hoggatt
- Veterans Health Administration Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
- Department of Epidemiology, University of California, Los Angeles, Fielding School of Public Health, University of California, Los Angeles
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Hepner KA, Hoggatt KJ, Bogart A, Paddock S. Does Documented Brief Intervention Predict Decreases in Alcohol Use in Primary Care? Subst Use Misuse 2018; 53:1633-1637. [PMID: 29364766 PMCID: PMC6143139 DOI: 10.1080/10826084.2017.1421225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brief intervention (BI) is recommended for patients with unhealthy alcohol use, but the effectiveness of BI in usual care settings remains unclear. OBJECTIVE We evaluated whether BI predicts decreases in drinking 6 months after a positive screen for unhealthy alcohol use. METHOD We enrolled patients who recently screened positive for unhealthy alcohol use during a routine screen in Veterans Health Administration primary care. We conducted medical record review to assess whether providers documented advice to reduce or abstain, feedback about risks to health, feedback about how patient drinking compares to norms or recommended limits, and discussion of drinking-related goals. BI elements were coded from 7 days before the date of the positive screen to 60 days after. We conducted baseline and 6-month follow-up telephone interviews to assess change in past 30-day drinking. We fit regression models examining each BI element and another model for the total count of instances of any combination of elements. RESULTS Of the 327 patients included, 86% had at least one documented instance of receiving advice, 86% had risk feedback, 55% had normative feedback, 38% had goal discussion, and 75% had three or more instances of any combination of elements of BI. None of the individual BI elements, nor the total number of instances, were significantly associated with decreased drinking. CONCLUSIONS Results suggest that provider documentation of elements of BI and increasing numbers of instances of BI elements were not associated with decreased heavy drinking at 6-month follow-up among patients identified with unhealthy alcohol use.
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Affiliation(s)
| | - Katherine J Hoggatt
- b VA Greater Los Angeles Health Services Research and Development (HSR&D), Center for the Study of Healthcare Innovation , Implementation & Policy , Los Angeles , California , USA.,c Department of Epidemiology , UCLA Fielding School of Public Health, University of California , Los Angeles , California , USA
| | - Andy Bogart
- a Health Unit, RAND Corporation , Santa Monica , California , USA
| | - Susan Paddock
- a Health Unit, RAND Corporation , Santa Monica , California , USA
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30
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Glass JE, Bobb JF, Lee AK, Richards JE, Lapham GT, Ludman E, Achtmeyer C, Caldeiro RM, Parrish R, Williams EC, Lozano P, Bradley KA. Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial). Implement Sci 2018; 13:108. [PMID: 30081930 PMCID: PMC6080376 DOI: 10.1186/s13012-018-0795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/12/2018] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA. .,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Julie E Richards
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Carol Achtmeyer
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,VA Puget Sound Health Care System, Center of Excellence in Substance Abuse Treatment and Education, Seattle, WA, USA
| | - Ryan M Caldeiro
- Behavioral Health Services Department, Kaiser Permanente Washington, Seattle, USA
| | - Rebecca Parrish
- Behavioral Health Services Department, Kaiser Permanente Washington, Seattle, USA
| | - Emily C Williams
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,VA Puget Sound, Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Paula Lozano
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training and Implementation: Perspectives from 4 Health Professions. J Addict Med 2018; 12:262-272. [DOI: 10.1097/adm.0000000000000410] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Owens MD, Ioannou GN, Tsui JL, Edelman EJ, Greene PA, Williams EC. Receipt of alcohol-related care among patients with HCV and unhealthy alcohol use. Drug Alcohol Depend 2018; 188:79-85. [PMID: 29754030 PMCID: PMC5999587 DOI: 10.1016/j.drugalcdep.2018.03.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alcohol use-particularly unhealthy alcohol use-exacerbates risks associated with Hepatitis C virus (HCV). However, whether unhealthy alcohol use is appropriately addressed among HCV+ patients is understudied. We examined receipt of alcohol-related care among HCV+ patients and unhealthy alcohol use. METHODS All positive alcohol screens (AUDIT-C score ≥5) documented 10/01/09-5/30/13 were identified from national electronic health records data from the Veterans Health Administration (VA). Regression models estimated unadjusted and adjusted proportions of HCV+ and HCV- patients receiving 1) brief intervention within 14 days of positive screening, 2) specialty addictions treatment, and 3) pharmacotherapy for alcohol use disorder (AUD) in the year following positive screening. Adjusted models included demographics, alcohol use severity, and mental health and substance use disorder comorbidities. RESULTS Among 830,825 VA outpatients with positive alcohol screening, 31,841 were HCV+. Among HCV+, unadjusted and adjusted prevalences were 69.2% (CI, 68.7-69.6) and 71.9% (CI, 71.4-72.4) for brief intervention, 29.9% (CI, 29.4-30.4) and 12.7% (CI 12.5-12.9) for specialty addictions treatment, and 5.9% (CI, 5.7-6.1) and 3.3% (CI, 3.1-3.4) for pharmacotherapy, respectively. Among the 20,320 (64%) patients with HCV and documented AUD, unadjusted and adjusted prevalences were 40.0% (CI, 39.3-40.6) and 26.7% (CI, 26.3-27.1) for specialty addictions treatment and 8.1% (CI, 7.7-8.4) and 6.4% (CI, 6.1-6.6) for pharmacotherapy, respectively. Receipt of alcohol-related care was generally similar across HCV status. CONCLUSIONS Findings highlight under-receipt of recommended alcohol-related care, particularly pharmacotherapy, among patients with HCV and unhealthy alcohol use who are particularly vulnerable to adverse influences of alcohol use.
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Affiliation(s)
- Mandy D. Owens
- Health Services Research & Development (HSR&D) Veterans Affairs (VA) Puget Sound Health Care System, Center of Innovation for Veteran-Centered Value-Driven Care (COIN) Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Department of Health Services, University of Washington, Seattle, WA
| | - George N. Ioannou
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Judith L. Tsui
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | | | - Preston A. Greene
- Health Services Research & Development (HSR&D) Veterans Affairs (VA) Puget Sound Health Care System, Center of Innovation for Veteran-Centered Value-Driven Care (COIN) Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA
| | - Emily C. Williams
- Health Services Research & Development (HSR&D) Veterans Affairs (VA) Puget Sound Health Care System, Center of Innovation for Veteran-Centered Value-Driven Care (COIN) Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Department of Health Services, University of Washington, Seattle, WA
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Increased Rates of Documented Alcohol Counseling in Primary Care: More Counseling or Just More Documentation? J Gen Intern Med 2018; 33:268-274. [PMID: 29047076 PMCID: PMC5834950 DOI: 10.1007/s11606-017-4163-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 07/21/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
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.
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Chen JA, Owens MD, Browne KC, Williams EC. Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort. J Subst Abuse Treat 2018; 85:1-9. [PMID: 29291765 PMCID: PMC5753430 DOI: 10.1016/j.jsat.2017.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/27/2017] [Accepted: 11/17/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA). METHODS National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age. RESULTS Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years). CONCLUSIONS In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Mandy D Owens
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Kendall C Browne
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
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Bensley KM, McGinnis KA, Fiellin DA, Gordon AJ, Kraemer KL, Bryant KJ, Edelman EJ, Crystal S, Gaither JR, Korthuis PT, Marshall BDL, Ornelas IJ, Chan KCG, Dombrowski JC, Fortney JC, Justice AC, Williams EC. Racial/ethnic differences in the association between alcohol use and mortality among men living with HIV. Addict Sci Clin Pract 2018; 13:2. [PMID: 29353555 PMCID: PMC6389249 DOI: 10.1186/s13722-017-0103-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Increasing alcohol use is associated with increased risk of mortality among patients living with HIV (PLWH). This association varies by race/ethnicity among general outpatients, but racial/ethnic variation has not been investigated among PLWH, among whom racial/ethnic minorities are disproportionately represented. METHODS VA electronic health record data from the Veterans Aging Cohort Study (2008-2012) were used to describe and compare mortality rates across race/ethnicity and levels of alcohol use defined by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire. Within each racial/ethnic group, Cox proportional hazards models, adjusted for age, disease severity, and comorbidities, compared mortality risk for moderate-risk (AUDIT-C = 4-7) and high-risk (AUDIT-C ≥ 8) relative to lower-risk (AUDIT-C = 1-3) alcohol use. RESULTS Mean follow-up time among black (n = 8518), Hispanic (n = 1353), and white (n = 7368) male PLWH with documented AUDIT-C screening (n = 17,239) was 4.3 years. Black PLWH had the highest mortality rate among patients reporting lower-risk alcohol use (2.9/100 person-years) relative to Hispanic and white PLWH (1.8 and 2.3, respectively) (p value for overall comparison = 0.011). Mortality risk was increased for patients reporting high-risk relative to lower-risk alcohol use in all racial/ethnic groups [black adjusted hazard ratio (AHR) = 1.36, 95% confidence interval (CI) 1.12-1.66; Hispanic AHR = 2.18, 95% CI 1.30-3.64; and white AHR = 2.04, 95% CI 1.61-2.58]. For only white PLWH, mortality risk was increased for patients reporting moderate-relative to lower-risk alcohol use (black AHR = 1.09, 95% CI 0.93-1.27; Hispanic AHR = 1.36, 95% CI 0.89-2.09; white AHR = 1.51, 95% CI 1.28-1.77). CONCLUSION Among all PLWH, mortality risk was increased among patients reporting high-risk alcohol use across all racial/ethnic groups, but mortality risk was only increased among patients reporting moderate-risk relative to lower-risk alcohol use among white PLWH, and black patients appeared to have higher mortality risk relative to white patients at lower-risk levels of alcohol use. Findings of the present study further underscore the need to address unhealthy alcohol use among PLWH, and future research is needed to understand mechanisms underlying observed differences.
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Affiliation(s)
- Kara M Bensley
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA. .,VA Health Services Research and Development (HSRD) Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
| | - Kathleen A McGinnis
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - David A Fiellin
- Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Adam J Gordon
- Salt Lake City VA, 500 Foothill Dr, Salt Lake City, UT, 84148, USA.,University of Utah, 201 Presidents Cir, Salt Lake City, UT, 84112, USA
| | - Kevin L Kraemer
- VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA.,University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Ln, Rockville, MD, 20852, USA
| | | | - Stephen Crystal
- Rutgers University, 7 College Ave, New Brunswick, NJ, 08901, USA
| | - Julie R Gaither
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - P Todd Korthuis
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Brandon D L Marshall
- Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA
| | - India J Ornelas
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA
| | - K C Gary Chan
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA
| | - Julia C Dombrowski
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - John C Fortney
- Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Emily C Williams
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA.,VA Health Services Research and Development (HSRD) Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA
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Chavez LJ, Liu CF, Tefft N, Hebert PL, Devine B, Bradley KA. The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition. J Behav Health Serv Res 2017; 44:602-624. [PMID: 27585803 PMCID: PMC5332352 DOI: 10.1007/s11414-016-9529-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.
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Affiliation(s)
- Laura J Chavez
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH, 43210, USA.
| | - Chuan-Fen Liu
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Nathan Tefft
- Bates College, 2 Andrews Rd, Lewiston, ME, 04240, USA
| | - Paul L Hebert
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Beth Devine
- Department of Pharmacy, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Katharine A Bradley
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
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Lehavot K, Blosnich JR, Glass JE, Williams EC. Alcohol use and receipt of alcohol screening and brief intervention in a representative sample of sexual minority and heterosexual adults receiving health care. Drug Alcohol Depend 2017; 179:240-246. [PMID: 28810195 PMCID: PMC7282398 DOI: 10.1016/j.drugalcdep.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite evidence of alcohol disparities between sexual minority and heterosexual individuals in the general population, research has not examined whether there are disparities in receipt of alcohol screening and brief intervention - together considered one of the highest prevention priorities for US adults. This study examined differences in alcohol use and receipt of alcohol screening and brief intervention across sexual minority status. METHODS Behavioral Risk Factor Surveillance System 2014 data from eight US states were used to estimate patterns of alcohol use and receipt of alcohol screening and brief intervention among persons reporting sexual orientation and a checkup in the last two years (N=47,800). Analyses were conducted in 2016-2017. RESULTS Gay men and bisexual women reported higher rates of alcohol use on some measures compared to heterosexual men and women, respectively. There were some differences in screening and brief intervention by sexual orientation. Lesbian women were more likely to report being asked about heavy episodic drinking than heterosexual women, and among those reporting unhealthy alcohol use, gay men were less likely, and bisexual men were more likely, to report receiving brief intervention compared to heterosexual men. CONCLUSIONS Overall similarities between sexual minorities and heterosexuals in alcohol use and receipt of screening and brief intervention are encouraging. Nonetheless, research is needed to confirm findings and understand mechanisms underlying disparities in receipt of brief intervention between gay and heterosexual men.
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Affiliation(s)
- Keren Lehavot
- VA Puget Sound Health Services Research and Development, Denver-Seattle Center of Innovation for Veteran-Centered Value-Driven Care, Seattle, WA, United States; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States.
| | - John R Blosnich
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, United States
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Emily C Williams
- VA Puget Sound Health Services Research and Development, Denver-Seattle Center of Innovation for Veteran-Centered Value-Driven Care, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
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Williams EC, Gupta S, Rubinsky AD, Glass JE, Jones-Webb R, Bensley KM, Harris AHS. Variation in receipt of pharmacotherapy for alcohol use disorders across racial/ethnic groups: A national study in the U.S. Veterans Health Administration. Drug Alcohol Depend 2017; 178:527-533. [PMID: 28728114 DOI: 10.1016/j.drugalcdep.2017.06.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pharmacologic treatment is recommended for alcohol use disorders (AUD), but most patients do not receive it. Although racial/ethnic minorities have greater AUD consequences than whites, whether AUD medication receipt varies across race/ethnicity is unknown. We evaluate this in a national sample. METHODS Electronic health records data were extracted for all black, Hispanic, and/or white patients who received care at the U.S. Veterans Health Administration (VA) during Fiscal Year 2012 and had a documented AUD diagnosis. Mixed effects regression models, with a random effect for facility, determined the likelihood of receiving AUD pharmacotherapy (acamprosate, disulfiram, topirimate or oral or injectable naltrexone ≤180days after AUD diagnosis) for black and Hispanic patients relative to white patients. Models were unadjusted and then adjusted for patient- and facility-level factors. RESULTS 297,506 patients had AUD; 26.4% were black patients, 7.1% were Hispanic patients and 66.5% were white patients; 5.1% received AUD medications. Before adjustment, black patients were less likely than white [Odds Ratio (OR) 0.77; 95% Confidence Interval (CI) 0.75 -0.82; (p<0.001)], while Hispanic patients were more likely than white (OR 1.09; 95% CI 1.01-1.16) to receive AUD medications. After adjustment, black patients remained less likely than white to receive AUD medications (OR 0.68; 95% CI 0.65-0.71; p<0.0001); no difference between Hispanic and white patients was observed (OR 0.94; 95% CI 0.87-1.00; p=0.07). CONCLUSIONS In this national study of patients with AUD, blacks were less likely to receive AUD medications than whites. Future research is needed to identify why these disparities exist.
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Affiliation(s)
- Emily C Williams
- Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Services Research and Development, United States; University of Washington, Department of Health Services, United States.
| | | | - Anna D Rubinsky
- The Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, United States
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States
| | - Rhonda Jones-Webb
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, United States
| | - Kara M Bensley
- Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Services Research and Development, United States; University of Washington, Department of Health Services, United States
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Williams EC, Lapham GT, Rubinsky AD, Chavez LJ, Berger D, Bradley KA. Influence of a targeted performance measure for brief intervention on gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the Veterans Health Administration. J Subst Abuse Treat 2017; 81:11-16. [PMID: 28847450 DOI: 10.1016/j.jsat.2017.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/09/2017] [Accepted: 07/18/2017] [Indexed: 11/26/2022]
Abstract
AIMS Women are less likely than men to receive brief intervention (BI) for unhealthy alcohol use. In 2007, the U.S. Veterans Health Administration (VA) used a national performance measure to implement BI. Although AUDIT-C scores ≥3 for women and ≥4 for men optimize sensitivity and specificity for identifying unhealthy alcohol use, VA's performance measure required BI only among a targeted subgroup defined by a non-gender-specific score threshold (AUDIT-C ≥5). This may have influenced gender differences in receipt of BI among those optimally eligible for BI. Therefore, we evaluate differences in proportions of women and men offered BI before and after BI implementation. METHODS National secondary chart review data (7/06-6/10) identified all outpatients with unhealthy alcohol use for whom BI would be indicated (AUDIT-C ≥3 women, ≥4 men). Logistic regression, including a time-by-gender interaction, estimated the prevalence and 95% confidence interval (CI) of BI for women and men pre- and post-implementation. FINDINGS Among patients optimally eligible for BI (n=51,272, 8206 women and 43,066 men), the prevalence of BI increased more steeply for men than women after implementation (interaction p-value <0.0001). Pre-implementation rates of BI were 21% (95% CI, 18-24) for women and 26% (95% CI, 24-29) for men, and post-implementation rates were 32% (95% CI, 30-34) for women and 47% (95% CI, 45-49) for men. CONCLUSIONS Healthcare systems implementing BI with performance measures may wish to consider that specifying a single alcohol screening threshold for men and women may increase gender differences in receipt of BI among patients likely to benefit.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Anna D Rubinsky
- The Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, United States.
| | - Laura J Chavez
- Ohio State University, School of Public Health, Columbus, OH, United States.
| | - Douglas Berger
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States.
| | - Katharine A Bradley
- Center of Excellence for Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
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Abstract
BACKGROUND Poor retention in HIV care is associated with worse clinical outcomes and increased HIV transmission. We examined the relationship between self-reported alcohol use, a potentially modifiable behavior, and retention. METHODS A total of 9694 people living with HIV from 7 participating US HIV clinical sites (the Centers for AIDS Research Network of Integrated Clinical Systems) contributed 23,225 observations from January 2011 to June 2014. The retention outcomes were (1) Institute of Medicine (IOM) retention: 2 visits within 1 year at least 90 days apart and (2) visit adherence [proportion of kept visits/(scheduled + kept visits)]. Alcohol use was measured with Alcohol Use Disorders Identification Test-C, generating drinking (never, moderate, and heavy) and binge frequency (never, monthly/less than monthly, weekly/daily) categories. Adjusted multivariable logistic models, accounting for repeat measures, were generated. RESULTS Of our sample, 82% was men, 46% white, 35% black, and 14% Hispanic. At first assessment, 37% of participants reported never drinking, 38% moderate, and 25% heavy, and 89% of the patients were retained (IOM retention measure). Participants' mean (SD) visit adherence was 84% (25%). Heavy alcohol use was associated with inferior IOM-defined retention (adjusted odds ratio 0.78, 95% confidence interval: 0.69 to 0.88), and daily/weekly binge drinking was associated with lower visit adherence (adjusted odds ratio = 0.90, 95% confidence interval: 0.82 to 0.98). CONCLUSIONS Both heavy drinking and frequent binge drinking were associated with worse retention in HIV care. Increased identification and treatment of heavy and binge drinking in HIV clinical care settings may improve retention in HIV care, with downstream effects of improved clinical outcomes and decreased HIV transmission.
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Glass JE, Andréasson S, Bradley KA, Finn SW, Williams EC, Bakshi AS, Gual A, Heather N, Sainz MT, Benegal V, Saitz R. Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA). Addict Sci Clin Pract 2017; 12:14. [PMID: 28490342 PMCID: PMC5425968 DOI: 10.1186/s13722-017-0079-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/14/2017] [Indexed: 11/29/2022] Open
Abstract
In 2016, the International Network on Brief Interventions for Alcohol & Other Drugs convened a meeting titled “Rethinking alcohol interventions in health care”. The aims of the meeting were to synthesize recent evidence about screening and brief intervention and to set directions for research, practice, and policy in light of this evidence. Screening and brief intervention is efficacious in reducing self-reported alcohol consumption for some with unhealthy alcohol use, but there are gaps in evidence for its effectiveness. Because screening and brief intervention is not known to be efficacious for individuals with more severe unhealthy alcohol use, recent data showing the lack of evidence for referral to treatment as part of screening and brief intervention are alarming. While screening and brief intervention was designed to be a population-based approach, its reach is limited. Implementation in real world care also remains a challenge. This report summarizes practice, research, and policy recommendations and key research developments from our meeting. In order to move the field forward, a research agenda was proposed to (1) address evidence gaps in screening, brief intervention, and referral to treatment, (2) develop innovations to address severe unhealthy alcohol use within primary care, (3) describe the stigma of unhealthy alcohol use, which obstructs progress in prevention and treatment, (4) reconsider existing conceptualizations of unhealthy alcohol use that may influence health care, and (5) identify efforts needed to improve the capacity for addressing unhealthy alcohol consumption in all world regions.
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Affiliation(s)
- Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Kaiser Foundation Health Plan of Washington, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Sven Andréasson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Kaiser Foundation Health Plan of Washington, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.,Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Sara Wallhed Finn
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Ann-Sofie Bakshi
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Stockholm, Sweden
| | - Antoni Gual
- Addictions Unit, Psychiatry Department, ICN, Hospital Clínic, IDIBAPS, RTA, Barcelona, Spain
| | - Nick Heather
- Department of Psychology, Faculty of Health & Social Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Marcela Tiburcio Sainz
- Department of Social Sciences in Health, Ramón de la Fuente Muñiz, National Institute of Psychiatry, Mexico City, Mexico
| | - Vivek Benegal
- Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.,Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
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Among patients with unhealthy alcohol use, those with HIV are less likely than those without to receive evidence-based alcohol-related care: A national VA study. Drug Alcohol Depend 2017; 174:113-120. [PMID: 28324813 PMCID: PMC5444382 DOI: 10.1016/j.drugalcdep.2017.01.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcohol use has important adverse effects on people living with HIV (PLWH). This study of patients with recognized unhealthy alcohol use estimated and compared rates of alcohol-related care received by PLWH and HIV- patients. METHODS Outpatients from the Veterans Health Administration who had one or more positive screen(s) for unhealthy alcohol use (AUDIT-C≥5) documented in their medical records 10/2009-5/2013 were eligible. Primary and secondary outcomes were brief intervention documented ≤14days after a positive alcohol screen, and a composite measure of any alcohol-related care (brief intervention, specialty addictions treatment or pharmacotherapy documented ≤365 days), respectively. Unadjusted and adjusted regression analyses compared alcohol-related care outcomes in PLWH and HIV- patients. RESULTS The sample included 830,825 outpatients (3,514 PLWH), reflecting 1,172,606 positive screens (1-5 per patient). For PLWH, 57.0% (95% confidence interval 55.4-58.5%) of positive screens were followed by brief intervention, compared to 73.8% (73.7-73.9%) for HIV- patients [relative rate: 0.77 (0.75-0.79), p<0.001]. After adjustment, comparable proportions were 61.0% (59.3-62.6%) for PLWH and 73.7% (73.6-73.8%) for HIV- patients [adjusted RR=0.83 (0.80-0.85); p<0.001]. Secondary outcome results were similar: for PLWH and HIV- patients, 67.1% (65.7-68.6%) and 77.7% (95% CI 77.7-77.8%) of positive screens, respectively, were followed by any alcohol-related care after adjustment [adjusted RR=0.86 (0.85-0.88), p<0.001]. CONCLUSIONS In this large national sample of VA outpatients with unhealthy alcohol use, PLWH were less likely to receive alcohol-related care than HIV- patients. Special efforts may be needed to ensure alcohol-related care reaches PLWH.
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Williams EC, Lapham GT, Bobb JF, Rubinsky AD, Catz SL, Shortreed SM, Bensley KM, Bradley KA. Documented brief intervention not associated with resolution of unhealthy alcohol use one year later among VA patients living with HIV. J Subst Abuse Treat 2017; 78:8-14. [PMID: 28554608 DOI: 10.1016/j.jsat.2017.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Unhealthy alcohol use is particularly risky for patients living with HIV (PLWH). Brief interventions reduce drinking among patients with unhealthy alcohol use, but whether its receipt in routine outpatient settings is associated with reduced drinking among PLWH with unhealthy alcohol use is unknown. We assessed whether PLWH who screened positive for unhealthy alcohol use were more likely to resolve unhealthy drinking one year later if they had brief alcohol intervention (BI) documented in their electronic health record in a national sample of PLWH from the Veterans Health Administration. METHODS Secondary VA clinical and administrative data from the electronic medical record (EMR) were used to identify all positive alcohol screens (AUDIT-C score≥5) documented among PLWH (10/01/09-5/30/13) followed by another alcohol screen documented 9-15months later. Unadjusted and adjusted Poisson regression models assessed the association between brief intervention (advice to reduce drinking or abstain documented in EMR) and resolution of unhealthy alcohol use (follow-up AUDIT-C<5 with ≥2 point reduction). RESULTS Overall 2101 PLWH with unhealthy drinking (10/01/09-5/30/13) had repeat alcohol screens 9-15months later. Of those, 77% had brief intervention documented after their first screen, and 61% resolved unhealthy alcohol use at follow-up. Documented brief intervention was not associated with resolution [Adjusted incidence rate ratio 0.96, (95% CI 0.90-1.02)]. CONCLUSIONS Documented brief intervention was not associated with resolving unhealthy alcohol use at follow-up screening among VA PLWH with unhealthy alcohol use. Effective methods of resolving unhealthy alcohol use in this vulnerable population are needed.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Gwen T Lapham
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Kidney Health Research Collaborative, University of California, San Francisco, San Francisco VA Medical Center, San Francisco, CA, United States.
| | - Sheryl L Catz
- Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, CA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States; Department of Biostatistics, University of Washington; Seattle, WA, United States.
| | - Kara M Bensley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States.
| | - Katharine A Bradley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System - Seattle Division, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
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Alcohol brief intervention in primary care: Blood pressure outcomes in hypertensive patients. J Subst Abuse Treat 2017; 77:45-51. [PMID: 28476271 DOI: 10.1016/j.jsat.2017.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 03/17/2017] [Accepted: 03/21/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND In clinical trials alcohol brief intervention (BI) in adult primary care has been efficacious in reducing alcohol consumption, but we know little about its impact on health outcomes. Hypertension is a prevalent and costly chronic condition in the U.S. and worldwide, and alcohol use is a modifiable hypertension risk factor. OBJECTIVE To evaluate the effect of receiving BI for unhealthy drinking on blood pressure (BP) control among adult hypertensive patients by analyzing secondary data from a clustered, randomized controlled trial on alcohol screening, brief intervention and referral to treatment (SBIRT) implementation by primary care physicians (PCP intervention arm) and non-physician providers and medical assistants (NPP&MA intervention arm) in a large, integrated health care delivery system. DESIGN Observational, prospective cohort study. SUBJECTS 3811 adult hypertensive primary care patients screening positive for past-year heavy drinking at baseline, of which 1422 (37%) had an electronic health record BP measure at baseline and 18-month follow-up. MAIN OUTCOME MEASURES Change in BP and controlled BP (systolic/diastolic BP <140/90mmHg). RESULTS Overall no significant associations were found between alcohol BI and BP change at 18-month follow-up when analyzing the combined sample of subjects in both intervention arms. However, moderation analyses found that receiving BI for positive past-year unhealthy drinking was positively associated with better BP control at 18months in the PCP intervention arm, and for those with lower heavy drinking frequency and poor BP control at the index screening. CONCLUSIONS Our findings suggest that hypertensive patients may benefit from receiving physician brief intervention for unhealthy alcohol use in primary care. Findings also highlight potential population-level benefits of alcohol BI if widely applied, suggesting a need for the development of innovative strategies to facilitate SBIRT delivery in primary care settings.
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Wigham S, Bauer A, Robalino S, Ferguson J, Burke A, Newbury-Birch D. A systematic review of the effectiveness of alcohol brief interventions for the UK military personnel moving back to civilian life. J ROY ARMY MED CORPS 2017; 163:242-250. [DOI: 10.1136/jramc-2016-000712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/12/2016] [Accepted: 12/19/2016] [Indexed: 11/04/2022]
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Cowell AJ, Dowd WN, Landwehr J, Barbosa C, Bray JW. A time and motion study of Screening, Brief Intervention, and Referral to Treatment implementation in health-care settings. Addiction 2017; 112 Suppl 2:65-72. [PMID: 28074563 DOI: 10.1111/add.13659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/02/2015] [Accepted: 02/04/2016] [Indexed: 12/21/2022]
Abstract
AIMS Screening and brief intervention for harmful substance use in medical settings is being promoted heavily in the United States. To justify service provision fiscally, the field needs accurate estimates of the number and type of staff required to provide services, and thus the time taken to perform activities used to deliver services. This study analyzed the time spent in activities for the component services of the substance misuse Screening, Brief Intervention and Referral to Treatment (SBIRT) program implemented in emergency departments, in-patient units and ambulatory clinics. DESIGN Observers timed activities according to 18 distinct codes among SBIRT practitioners. SETTING Twenty-six US sites within four grantees. PARTICIPANTS Five hundred and one practitioner-patient interactions; 63 SBIRT practitioners. MEASUREMENTS Timing of practitioner activities. INTERVENTIONS Delivery of component services of SBIRT. FINDINGS The mean (standard error) time to deliver services was 1:19 (0:06) for a pre-screen (n = 210), 4:28 (0:24) for a screen (n = 97) and 6:51 (0:38) for a brief intervention (n = 66). Estimates of service duration varied by setting. Overall, practitioners spent 40% of their time supporting SBIRT delivery to patients and 13% of their time delivering services. CONCLUSIONS In the United States, support activities (e.g. reviewing the patient's chart, locating the patient, writing case-notes) for substance abuse Screening, Brief Intervention and Referral to Treatment require more staff time than delivery of services. Support time for screens and brief interventions in the emergency department/trauma setting was high compared with the out-patient setting.
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Affiliation(s)
| | | | | | | | - Jeremy W Bray
- Bryan School of Business and Economics, University of North Carolina at Greensboro, Greensboro, NC, USA
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Lent MR, Hoffman SN, Kirchner HL, Urosevich TG, Boscarino JJ, Boscarino JA. Attitudes about Future Genetic Testing for Posttraumatic Stress Disorder and Addiction among Community-Based Veterans. Front Psychiatry 2017; 8:76. [PMID: 28555114 PMCID: PMC5430945 DOI: 10.3389/fpsyt.2017.00076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/20/2017] [Indexed: 01/16/2023] Open
Abstract
This study explored attitudes toward hypothetical genetic testing for posttraumatic stress disorder (PTSD) and addiction among veterans. We surveyed a random sample of community-based veterans (n = 700) by telephone. One year later, we asked the veterans to provide a DNA sample for analysis and 41.9% of them returned the DNA samples. Overall, most veterans were not interested in genetic testing neither for PTSD (61.7%) nor for addiction (68.7%). However, bivariate analyses suggested there was an association between having the condition of interest and the likelihood of genetic testing on a 5-point scale (p < 0.001 for PTSD; p = 0.001 for alcohol dependence). While ordinal regressions confirmed these associations, the models with the best statistical fit were bivariate models of whether the veteran would likely test or not. Using logistic regressions, significant predictors for PTSD testing were receiving recent mental health treatment, history of a concussion, younger age, having PTSD, having alcohol dependence, currently taking opioids for pain, and returning the DNA sample during the follow-up. For addiction testing, significant predictors were history of concussion, younger age, psychotropic medication use, having alcohol dependence, and currently taking opioids for pain. Altogether, 25.9% of veterans reported that they would have liked to have known their genetic results before deployment, 15.6% reported after deployment, and 58.6% reported they did not want to know neither before nor after deployment. As advancements in genetic testing continue to evolve, our study suggests that consumer attitudes toward genetic testing for mental disorders are complex and better understanding of these attitudes and beliefs will be crucial to successfully promote utilization.
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Affiliation(s)
- Michelle R Lent
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, PA, USA
| | | | - H Lester Kirchner
- Department of Biomedical and Translational Informatics, Geisinger Clinic, Danville, PA, USA
| | | | | | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, PA, USA
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Grossbard J, Malte CA, Lapham G, Pagulayan K, Turner AP, Rubinsky AD, Bradley KA, Saxon AJ, Hawkins EJ. Prevalence of Alcohol Misuse and Follow-Up Care in a National Sample of OEF/OIF VA Patients With and Without TBI. Psychiatr Serv 2017; 68:48-55. [PMID: 27476804 PMCID: PMC5704906 DOI: 10.1176/appi.ps.201500290] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Information on prevalence and management of alcohol misuse among Afghanistan and Iraq veterans with traumatic brain injury (TBI) is limited. This study compared rates of alcohol misuse and follow-up care-brief intervention (BI) and addiction treatment-among Afghanistan and Iraq veterans with and without TBI receiving care from the Department of Veterans Affairs (VA). METHODS The sample included veterans ages 18 and older screened with the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) in 2012 who received VA health care in the prior year (N=358,417). Overall and age-specific estimates of alcohol misuse (AUDIT-C score ≥5) were compared for men and women with and without TBI by logistic regression. BI and addiction treatment after screening were compared between groups by using multivariable logistic regression. RESULTS Alcohol misuse was higher among men with TBI than among men without TBI (20.3%, 95% confidence interval [CI]=19.9-20.8, versus 16.4%, CI=16.3-16.6) and among women with TBI than among women without TBI (6.8%, CI=5.8-8.1, versus 5.6%, CI=5.4-5.8); younger (age <30) patients with TBI had the highest rates. BI rates did not differ by TBI status (76.4%-80.2%). Addiction treatment rates for those with severe misuse were higher among those with TBI (men, 20.0%, CI=18.4-21.6, versus 15.4%, CI=14.9-15.9; women, 36.6%, CI=21.8-51.3, versus 21.1%, CI=18.2-24.0). CONCLUSIONS Alcohol misuse is common among Iraq and Afghanistan veterans with TBI, particularly young men. BI rates were high and did not vary by TBI status, although addiction treatment rates were higher among patients with TBI than among those without TBI.
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Affiliation(s)
- Joel Grossbard
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Carol A Malte
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Gwen Lapham
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Kathleen Pagulayan
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Aaron P Turner
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Anna D Rubinsky
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Katharine A Bradley
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Andrew J Saxon
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
| | - Eric J Hawkins
- Dr. Grossbard, Ms. Malte, Dr. Turner, Dr. Rubinsky, Dr. Saxon, and Dr. Hawkins are with the Department of Veterans Affairs (VA) Center of Excellence in Substance Abuse Treatment and Education, Puget Sound Health Care System, Seattle. Dr. Turner is also with the Department of Rehabilitation Medicine, University of Washington, Seattle. Dr. Saxon and Dr. Hawkins are also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Pagulayan is affiliated. Dr. Rubinsky is also with the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development (HSR&D), Seattle. Dr. Lapham and Dr. Bradley are with the Group Health Research Institute, Seattle. Dr. Bradley is also with the Department of Health Services, University of Washington, Seattle. Send correspondence to Dr. Hawkins (e-mail: )
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Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Dziura J, Fiellin LE, O'Connor PG, Bedimo R, Gibert C, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Justice AC, Bryant KJ, Fiellin DA. The Starting Treatment for Ethanol in Primary care Trials (STEP Trials): Protocol for Three Parallel Multi-Site Stepped Care Effectiveness Studies for Unhealthy Alcohol Use in HIV-Positive Patients. Contemp Clin Trials 2016; 52:80-90. [PMID: 27876616 DOI: 10.1016/j.cct.2016.11.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/14/2016] [Accepted: 11/17/2016] [Indexed: 01/20/2023]
Abstract
Unhealthy alcohol use is common among HIV-positive patients, yet effective evidence-based treatments are rarely provided in clinical settings providing HIV care. Further, given patient variability in response to initial treatments, stepped care approaches may be beneficial. We describe the rationale, aims and study design for the current StartingTreatment forEthanol inPrimary care Trials (STEP Trials); three parallel randomized controlled effectiveness trials being conducted in five Infectious Disease Clinics. Participants meeting criteria for: 1) at-risk drinking, 2) moderate alcohol use with liver disease (MALD), or 3) alcohol use disorder (AUD) are randomized to integrated stepped care versus treatment as usual. For those with at-risk drinking or MALD, integrated stepped care starts with a one session brief intervention and follow-up 2-week telephone booster. Based on pre-specified nonresponse criteria, participants may be "stepped up" at week 4 to receive four sessions of motivational enhancement therapy (MET) and "stepped up" again at week 12 for addiction physician management (APM) and consideration of alcohol pharmacotherapy. For those with AUD, integrated stepped care begins with APM. Non-responders may be "stepped up" at week 4 to receive MET and again at week 12 for a higher level of care (e.g. intensive outpatient program). The primary outcome is alcohol consumption assessed at 24weeks, and secondary outcome is the VACS Index, a validated measure of HIV morbidity and mortality risk. Results from the STEP Trials should inform future research and the implementation of interventions to address unhealthy alcohol use among HIV-positive individuals.
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States.
| | | | - Nathan B Hansen
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States; College of Public Health, University of Georgia, Athens, GA 30602, United States
| | | | - James Dziura
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT 06511, United States
| | - Lynn E Fiellin
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States
| | | | - Roger Bedimo
- Veterans Affairs North Texas Health Care System and UT Southwestern, Dallas, TX 75216, United States
| | - Cynthia Gibert
- D.C. Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences, Washington, D.C. 20422, United States
| | - Vincent C Marconi
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Decatur, GA 30033, United States
| | - David Rimland
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Decatur, GA 30033, United States
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas Houston, TX 77030, United States
| | - Michael S Simberkoff
- VA NY Harbor Healthcare System and New York University School of Medicine, New York, NY 10010, United States
| | - Amy C Justice
- Yale University School of Medicine, New Haven, CT 06510, United States; VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT 06516, United States
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD 20892-7003, United States
| | - David A Fiellin
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States
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50
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McGinnis KA, Tate JP, Williams EC, Skanderson M, Bryant KJ, Gordon A, Kraemer KL, Maisto SA, Crystal S, Fiellin DA, Justice AC. Comparison of AUDIT-C collected via electronic medical record and self-administered research survey in HIV infected and uninfected patients. Drug Alcohol Depend 2016; 168:196-202. [PMID: 27694059 PMCID: PMC5086273 DOI: 10.1016/j.drugalcdep.2016.09.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/12/2016] [Accepted: 09/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Using electronic medical record (EMR) data for clinical decisions, quality improvement, and research is common. While unhealthy alcohol use is particularly risky among HIV infected individuals (HIV+), the validity of EMR data for identifying unhealthy alcohol use among HIV+ is unclear. Among HIV+ and uninfected, we: (1) assess agreement of EMR and research AUDIT-C at validated cutoffs for unhealthy alcohol use; (2) explore EMR cutoffs that maximize agreement; and (3) assess subpopulation variation in agreement. METHODS Using data from the Veterans Aging Cohort Study (VACS), EMR AUDIT-C cutoffs of 2+, 3+, and 4+ for men (2+ and 3+ for women) were compared to research AUDIT-C 4+ for men (3+ for women). Agreement was compared by demographics, HIV, hepatitis C infection, and alcohol related diagnosis. RESULTS Among 1082 HIV+ and 1160 uninfected men, 14% and 22% had an EMR and research AUDIT-C 4+, respectively. Among 32 HIV+ and 115 uninfected women, 9% and 14% had an EMR and research AUDIT-C 3+. For men, EMR agreement with the research AUDIT-C 4+ was highest at a cutoff of 3+ (kappa=0.49). For women, EMR agreement with AUDIT-C 3+ was highest at a cutoff of 2+ (kappa=0.46). Moderate agreement was consistent across subgroups. CONCLUSIONS EMR AUDIT-C underestimates unhealthy alcohol use compared to research AUDIT-C in both HIV+ and uninfected individuals. Methods for improving quality of clinical screening may be in need of investigation. Researchers and clinicians may consider alternative EMR cutoffs that maximize agreement given limitations of clinical screening.
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Affiliation(s)
- Kathleen A. McGinnis
- Veterans Aging Cohort Study Coordinating Center, VA CT Healthcare System, West Haven, CT
| | - Janet P. Tate
- Veterans Aging Cohort Study Coordinating Center, VA CT Healthcare System, West Haven, CT,Division of General Internal Medicine, Yale University School of Medicine, New Haven CT,Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven CT
| | - Emily C. Williams
- Health Services Research & Development; Veterans Affairs Puget Sound Health Care System, Seattle, WA, Department of Health Services, University of Washington, Seattle, WA
| | - Melissa Skanderson
- Veterans Aging Cohort Study Coordinating Center, VA CT Healthcare System, West Haven, CT
| | | | - Adam Gordon
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Kevin L. Kraemer
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Steven Crystal
- Health Services Research, Rutgers University, New Brunswick, NJ
| | - David A. Fiellin
- Veterans Aging Cohort Study Coordinating Center, VA CT Healthcare System, West Haven, CT,Division of General Internal Medicine, Yale University School of Medicine, New Haven CT,Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven CT
| | - Amy C. Justice
- Veterans Aging Cohort Study Coordinating Center, VA CT Healthcare System, West Haven, CT,Division of General Internal Medicine, Yale University School of Medicine, New Haven CT,Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven CT
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