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Williams EC, Frost MC, Bounthavong M, Edmonds AT, Lau MK, Edelman EJ, Harvey MA, Christopher MLD. Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241243309. [PMID: 38634339 DOI: 10.1177/29767342241243309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives. METHODS Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation. RESULTS Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed. CONCLUSIONS AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.
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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 (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Madeline C Frost
- 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 (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Bounthavong
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Mathematica, Seattle, WA, USA
| | - Marcos K Lau
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | | | - Michael A Harvey
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Melissa L D Christopher
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
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Cannizzaro E, Cirrincione L, Malta G, Fruscione S, Mucci N, Martines F, Plescia F. The Influence of the COVID-19 Pandemic Emergency on Alcohol Use: A Focus on a Cohort of Sicilian Workers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4613. [PMID: 36901622 PMCID: PMC10001951 DOI: 10.3390/ijerph20054613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Abstract
The period between the beginning and the end of the COVID-19 pandemic emergency generated a general state of stress, affecting both the mental state and physical well-being of the general population. Stress is the body's reaction to events or stimuli perceived as potentially harmful or distressing. Particularly when prolonged over time, it can promote the consumption of different psychotropic substances such as alcohol, and thus the genesis of various pathologies. Therefore, our research aimed to evaluate the differences in alcohol consumption in a cohort of 640 video workers who carried out activities in smart working, subjects particularly exposed to stressful situations due to the stringent rules of protection and prevention implemented during the pandemic. Furthermore, based on the results obtained from the administration of the AUDIT-C, we wanted to analyse the different modes of alcohol consumption (low, moderate, high, severe) to understand whether there is a difference in the amount of alcohol consumed that could predispose individuals to health problems. To this end, we administered the AUDIT-C questionnaire in two periods (T0 and T1), coinciding with annual occupational health specialist visits. The results of the present research showed an increase in the number of subjects consuming alcohol (p = 0.0005) and in their AUDIT-C scores (p < 0.0001) over the period considered. A significant decrease in subgroups who drink in a low-risk (p = 0.0049) mode and an increase in those with high (p = 0.00012) and severe risk (p = 0.0002) were also detected. In addition, comparing the male and female populations, it emerged that males have drinking patterns that lead to a higher (p = 0.0067) health risk of experiencing alcohol-related diseases than female drinking patterns. Although this study provides further evidence of the negative impact of the stress generated by the pandemic emergency on alcohol consumption, the influence of many other factors cannot be ruled out. Further research is needed to better understand the relationship between the pandemic and alcohol consumption, including the underlying factors and mechanisms driving changes in drinking behaviour, as well as potential interventions and support strategies to address alcohol-related harm during and after the pandemic.
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Affiliation(s)
- Emanuele Cannizzaro
- Department of Health Promotion Sciences, Maternal and Child Care, Internal Medicine and Medical Specialties ‘Giuseppe D’Alessandro’, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy
| | - Luigi Cirrincione
- Department of Health Promotion Sciences, Maternal and Child Care, Internal Medicine and Medical Specialties ‘Giuseppe D’Alessandro’, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy
| | - Ginevra Malta
- Department of Health Promotion Sciences, Maternal and Child Care, Internal Medicine and Medical Specialties ‘Giuseppe D’Alessandro’, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy
| | - Santo Fruscione
- Department of Health Promotion Sciences, Maternal and Child Care, Internal Medicine and Medical Specialties ‘Giuseppe D’Alessandro’, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy
| | - Nicola Mucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy
| | - Francesco Martines
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), Section of Audiology, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Fulvio Plescia
- Department of Health Promotion Sciences, Maternal and Child Care, Internal Medicine and Medical Specialties ‘Giuseppe D’Alessandro’, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy
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Association Between Patterns of Alcohol Use and Short-Term Risk of Suicide Attempt Among Patients With and Without Reported Suicidal Ideation. J Addict Med 2021; 14:e160-e169. [PMID: 32142058 DOI: 10.1097/adm.0000000000000637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation. METHODS Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010-6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visit-level analyses, accounting for correlation between individuals' assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any vs none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year. RESULTS Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23-15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77-9.72). Among patients reporting no suicidal ideation, no associations were observed. CONCLUSIONS Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation.
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Williams EC, McGinnis KA, Rubinsky AD, Matson TE, Bobb JF, Lapham GT, Edelman EJ, Satre DD, Catz SL, Richards JE, Bryant KJ, Marshall BDL, Kraemer KL, Crystal S, Gordon AJ, Skanderson M, Fiellin DA, Justice AC, Bradley KA. Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence? AIDS Behav 2021; 25:203-214. [PMID: 32617778 DOI: 10.1007/s10461-020-02950-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.
- Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Kathleen A McGinnis
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Kidney Health Research Collaborative, University of California, San Francisco and VA San Francisco Health Care System, San Francisco, CA, USA
| | - Theresa E Matson
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Gwen T Lapham
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - E Jennifer Edelman
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Derek D Satre
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sheryl L Catz
- Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, CA, USA
| | - Julie E Richards
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kendall J Bryant
- National Institute On Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kevin L Kraemer
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Stephen Crystal
- Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Melissa Skanderson
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - David A Fiellin
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Katharine A Bradley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Healthcare System-Seattle Division, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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Roche AM, Chapman J, Duraisingam V, Phillips B, Finnane J, Pidd K. Construction workers' alcohol use, knowledge, perceptions of risk and workplace norms. Drug Alcohol Rev 2020; 39:941-949. [PMID: 32350917 DOI: 10.1111/dar.13075] [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: 10/17/2019] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION AND AIMS Globally, there is growing concern regarding workers' alcohol use and its implications for health, wellbeing and workplace safety. Male-dominated industries are more susceptible to risky alcohol consumption and its associated harms. This paper investigated the patterns, prevalence and predictors of risky drinking among construction workers. DESIGN AND METHODS Male construction workers (n = 511) completed a survey measuring alcohol-related measures including Alcohol Use Disorders Identification Test - Concise (AUDIT-C), which was compared with population data. Hierarchical multiple regression examined alcohol-related knowledge, perception of risk to workplace safety, psychological distress, job stress, general health, quality of life and workplace alcohol culture variables as predictors of risky drinking. RESULTS Prevalence of risky drinking was higher than the national average, particularly for younger (<25 years) and mid-aged (45-54 years) workers. One in six construction workers reported workmates being visibly affected by alcohol in the workplace. Key predictors of risky drinking were perception of alcohol-related risks to workplace safety, general health, alcohol knowledge and descriptive norms regarding workmates' alcohol use. DISCUSSION AND CONCLUSIONS These findings provide useful insights into the patterns and predictors of risky drinking in construction and can inform future preventive programs and interventions in high-risk workplaces. In addition to tailoring programs to both young and mid-aged workers, this work highlights the importance of implementing strategies to increase awareness of risks to workplace safety; and the adoption of norms that inhibit the social acceptability of risky drinking behaviour in the wider workplace.
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Affiliation(s)
- Ann M Roche
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
| | - Janine Chapman
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
| | - Vinita Duraisingam
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
| | - Brooke Phillips
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia.,Building Trades Group Drug and Alcohol Program, Sydney, Australia
| | - Jim Finnane
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
| | - Ken Pidd
- National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
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HIV Disease Severity Is Sensitive to Temporal Changes in Alcohol Use: A National Study of VA Patients With HIV. J Acquir Immune Defic Syndr 2020; 81:448-455. [PMID: 30973541 DOI: 10.1097/qai.0000000000002049] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Alcohol use influences HIV disease severity through multiple mechanisms. Whether HIV disease severity is sensitive to changes in alcohol use among people with HIV (PWH) is understudied. SETTING National Veterans Health Administration. METHODS Pairs of AUDIT-C screens within 9-15 months (February 1, 2008-September 30, 2014) were identified among PWH from the Veterans Aging Cohort Study (VACS). Initial and follow-up VACS Index 2.0 pairs obtained 0-270 days after initial and follow-up AUDIT-Cs, respectively, determined change in VACS Index 2.0, a composite HIV severity measure. Change in VACS Index 2.0 was regressed on AUDIT-C change scores (-12 to +12) adjusted for demographics, initial VACS Index 2.0, and days between VACS Index measures. RESULTS Among 23,297 PWH (76,202 observations), most had no (51%) or low-level (38%) alcohol use initially. Most (54%) had no subsequent change; 21% increased and 24% decreased drinking. Initial VACS Index 2.0 scores ranged from 0 to 134, change scores ranged from -65 to +73, with average improvement of 0.76 points (SD 9.48). AUDIT-C change was associated with VACS Index 2.0 change (P < 0.001). Among those with stable alcohol use (AUDIT-C change ≤ │1│ point), VACS Index 2.0 improvements ranged 0.36-0.60 points. For those with maximum AUDIT-C increase (change from 0 to 12), VACS Index 2.0 worsened 3.74 points (95% CI: -4.71 to -2.78); for those with maximum AUDIT-C decrease (change from 12 to 0), VACS Index 2.0 changed minimally [-0.60 (95% CI: -1.43 to 0.23)]. CONCLUSIONS In this national sample, improvement in HIV severity was generally greatest among those with stable alcohol use (primarily those with no use).
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Short-term risk of suicide attempt associated with patterns of patient-reported alcohol use determined by routine AUDIT-C among adults receiving mental healthcare. Gen Hosp Psychiatry 2020; 62:79-86. [PMID: 31874300 PMCID: PMC7047881 DOI: 10.1016/j.genhosppsych.2019.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the association between alcohol use routinely reported during outpatient mental healthcare visits and short-term risk of subsequent suicide attempt. METHODS Using a longitudinal retrospective-cohort design, electronic health records identified adult outpatient visits to a mental health provider (1/1/2010-6/30/2015) at Kaiser Permanente Washington with a documented Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]. Suicide attempts within 90 days of AUDIT-C documentation were defined using death certificate cause-of-death and diagnosis codes (non-lethal). Visit-level analyses used generalized estimating equations to account for correlation between multiple AUDIT-Cs for individuals. Separate models evaluated the association between (1) level of consumption and (2) frequency of heavy drinking episodes and suicide attempts, adjusted for visit year, demographics, depressive symptom, and suicidal ideation. RESULTS Of 59,382 patient visits, 0.62% (N = 371) were followed by a suicide attempt within 90 days. Patients reporting high-level alcohol use were 1.77 times (95% CI, 1.22-2.57) more likely to attempt suicide than those reporting low-level use. Patients reporting daily or almost daily heavy drinking episodes were 2.33 times (95% CI, 1.38-3.93) more likely to attempt suicide than those reporting none. CONCLUSIONS AND RELEVANCE The AUDIT-C is a valuable tool for assessing patterns of patient-reported alcohol use associated with subsequent suicide attempt.
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Association Between Alcohol Use and Angina Symptoms Among Outpatients From the Veterans Health Administration. J Addict Med 2019; 12:143-149. [PMID: 29334512 DOI: 10.1097/adm.0000000000000379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alcohol use is associated with angina incidence, but associations between alcohol use and experience of angina among patients with coronary artery disease (CAD) have not been described. METHODS Outpatients with CAD from 7 clinics in the Veterans Health Administration were surveyed; alcohol use was measured using the validated Alcohol Use Disorders Identification Test-Consumption scores categorized into 6 groups: nondrinking, low-risk drinking, and mild, moderate, severe, and very severe unhealthy alcohol use. Three domains of self-reported angina symptoms (frequency, stability, and physical function) were measured with the Seattle Angina Questionnaire. Linear regression models evaluated associations between alcohol use groups and angina symptoms. Models were adjusted first for age and then additionally for smoking, comorbidities, and depression. RESULTS Patients (n = 8303) had a mean age of 66 years. In age-adjusted analyses, a U-shaped association was observed between alcohol use groups and all angina outcomes, with patients in nondrinking and severe unhealthy alcohol groups reporting the greatest angina symptoms and lowest functioning. After full adjustment, no clinically important and few statistically important differences were observed across alcohol use in angina stability or frequency. Patients in the nondrinking group had statistically greater functional limitation from angina than those in all groups of unhealthy alcohol use, though differences were small. Patients in all groups of unhealthy alcohol use did not differ significantly from those with low-risk drinking. CONCLUSIONS Alcohol use was associated with some small statistically but no clinically important differences in angina symptoms among patients with CAD. This cross-sectional study does not support a protective effect of low-level drinking on self-reported angina.
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Vickers Smith R, Kranzler HR, Justice AC, Tate JP. Longitudinal Drinking Patterns and Their Clinical Correlates in Million Veteran Program Participants. Alcohol Clin Exp Res 2019; 43:465-472. [PMID: 30592535 DOI: 10.1111/acer.13951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 12/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND A variety of measures have been developed to screen for hazardous or harmful drinking. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is one of the screening measures recommended by the U.S. Preventive Services Task Force. Annual administration of the AUDIT-C to all primary care patients is required by the U.S. Veterans Affairs Health System. The availability of data from the repeated administration of this instrument over time in a large patient population provides an opportunity to evaluate the utility of the AUDIT-C for identifying distinct drinking groups. METHODS Using data from the Million Veteran Program cohort, we modeled group-based drinking trajectories using 2,833,189 AUDIT-C scores from 495,178 Veterans across an average 6-year time period. We also calculated patients' age-adjusted mean AUDIT-C scores to compare to the drinking trajectories. Finally, we extracted data on selected clinical diagnoses from the electronic health record and assessed their associations with the drinking trajectories. RESULTS Of the trajectory models, the 4-group model demonstrated the best fit to the data. AUDIT-C trajectories were highly correlated with the age-adjusted mean AUDIT-C scores (rs = 0.94). Those with an alcohol use disorder diagnosis had 10 times the odds of being in the highest trajectory group (consistently hazardous/harmful) compared to the lowest drinking trajectory group (infrequent). Those with hepatitis C, posttraumatic stress disorder, liver cirrhosis, and delirium had 10, 7, 21, and 34%, respectively, higher odds of being classified in the highest drinking trajectory group versus the lowest drinking trajectory group. CONCLUSIONS Trajectories and age-adjusted mean scores are potentially useful approaches to optimize the information provided by the AUDIT-C. In contrast to trajectories, age-adjusted mean AUDIT-C scores also have clinical relevance for real-time identification of individuals for whom an intervention may be warranted.
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Affiliation(s)
- Rachel Vickers Smith
- University of Louisville School of Nursing , Louisville, Kentucky.,Mental Illness Research, Education and Clinical Center , Crescenz VAMC, Philadelphia, Pennsylvania
| | - Henry R Kranzler
- Mental Illness Research, Education and Clinical Center , Crescenz VAMC, Philadelphia, Pennsylvania.,Department of Psychiatry, Center for Studies of Addiction, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Amy C Justice
- VA Connecticut Healthcare System , West Haven, Connecticut.,School of Medicine , Yale University, New Haven, Connecticut
| | - Janet P Tate
- VA Connecticut Healthcare System , West Haven, Connecticut.,School of Medicine , Yale University, New Haven, Connecticut
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Hobden B, Bryant J, Forshaw K, Oldmeadow C, Evans TJ, Sanson-Fisher R. Prevalence and characteristics associated with concurrent smoking and alcohol misuse within Australian general practice patients. AUST HEALTH REV 2018; 44:125-131. [PMID: 30543764 DOI: 10.1071/ah18126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/29/2018] [Indexed: 11/23/2022]
Abstract
Objectives This study sought to determine, among a large sample of Australian general practice patients: (1) the prevalence of smoking among different levels of alcohol misuse; and (2) whether the associations between demographic characteristics and alcohol use differ according to smoking status. Methods A cross-sectional survey was administered from 2010 to 2011 to 3559 patients from 12 Australian urban general practices. Patients reported their demographic details, smoking status and their alcohol intake. Results The overall prevalence of reported concurrent smoking and alcohol misuse was 7.8%. Smokers were 3.81-fold more likely to have a higher level of alcohol consumption than non-smokers (95% confidence interval 3.13-4.63; P<0.0001). There was evidence that smoking was an effect modifier of the relationship between alcohol misuse and chronic illness. Conclusions There was an increasing prevalence of smoking with increasing level of alcohol consumption. In addition, those with chronic conditions who smoked had greater odds of higher levels of alcohol consumption. Preventative interventions for these substances are needed to reduce the burden associated with concurrent smoking and alcohol misuse. What is known about the topic? Tobacco and alcohol are the most commonly used substances and contribute to over 10million deaths annually. The risk of disease is high when using either of these substances, however, concurrent use is associated with a greatly compounded risk. Australian data is limited regarding the prevalence of concurrent tobacco and alcohol misuse, however, international studies suggest variation in prevalence rates between different clinical settings. What does this paper add? This study examined the prevalence of concurrent smoking and alcohol misuse among different levels of alcohol misuse severity within an Australian general practice setting. Additionally it explored whether the associations between demographic characteristics and alcohol use differ according to smoking status. What are the implications for practitioners? This study has important implications for disease prevention and the delivery of preventive health services by general practitioners. Considering one in 100 clinical treatments provided in general practice relate to preventative smoking or alcohol counselling, it is critical that efforts are made to ascertain risk factors such as smoking and alcohol misuse to increase treatment rates. General practitioners should consider screening for smoking and alcohol misuse opportunistically during routine clinical encounters, as well as screening for smoking or alcohol misuse if one or the other is present.
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Affiliation(s)
- Breanne Hobden
- Health Behaviour Research Collaborative, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Jamie Bryant
- Health Behaviour Research Collaborative, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Kristy Forshaw
- Health Behaviour Research Collaborative, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Tiffany-Jane Evans
- Hunter Medical Research Institute, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
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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: 10] [Impact Index Per Article: 1.7] [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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12
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Changes in alcohol use associated with changes in HIV disease severity over time: A national longitudinal study in the Veterans Aging Cohort. Drug Alcohol Depend 2018; 189:21-29. [PMID: 29859388 PMCID: PMC6344121 DOI: 10.1016/j.drugalcdep.2018.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/06/2018] [Accepted: 04/23/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Among groups of persons living with HIV (PLWH), high-risk drinking trajectories are associated with HIV severity. Whether changes in individuals' alcohol use are associated with changes in HIV severity over the same period is unknown. METHODS Veterans Aging Cohort Study (VACS) data from VA's EHR (2/1/2008-9/30/2016) identified AUDIT-C screens for all PLWH. Pairs of AUDIT-C screens within 9-15 months were included if CD4 and/or viral load (VL) was measured within 9 months after baseline and follow-up AUDIT-Cs. Linear regression assessed change in HIV severity (CD4 and logVL) associated with AUDIT-C change adjusted for confounders. Mean changes in HIV severity were estimated for each AUDIT-C change value. For all measures of change, positive values indicate improvements (lower drinking and improved HIV severity). RESULTS Among PLWH, 21,999 and 22,143 were eligible for CD4 and VL analyses, respectively. Most had non- or low-level drinking and stable consumption over time (mean AUDIT-C change = .08, SD = 1.91). HIV severity improved over time [mean CD4 change = 20.5 (SD 180.8); mean logVL change = 0.12 (SD 0.71)]. AUDIT-C changes were associated non-linearly with changes in CD4 (p = 0.03) and logVL (p < 0.001). Improvement in HIV severity was greatest among those with stable AUDIT-C scores over time; those with greater AUDIT-C increases fared worse than those with smaller increases in or stable AUDIT-Cs. CONCLUSIONS Improvement in HIV severity was greatest among PLWH with relatively stable drinking, most of whom initially did not drink or drank at low levels. Those with large changes (especially increases) in drinking appear at greatest risk for poor HIV control.
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13
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Kuitunen-Paul S, Roerecke M. Alcohol Use Disorders Identification Test (AUDIT) and mortality risk: a systematic review and meta-analysis. J Epidemiol Community Health 2018; 72:856-863. [DOI: 10.1136/jech-2017-210078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 04/17/2018] [Accepted: 05/20/2018] [Indexed: 11/03/2022]
Abstract
BackgroundWe summarise the evidence for an association between screening scores from the Alcohol Use Disorders Identification Test (AUDIT) and all-cause mortality.MethodsUsing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, prospective cohort studies reporting all-cause mortality risk by AUDIT scores (complete AUDIT-10 or AUDIT-C) were identified through MEDLINE, Embase, PubMed and Web of Science up to September 2016. Risk estimates were pooled using random effects meta-analyses.ResultsSeven observational studies with 18 920 observed deaths among 309 991 participants were identified. At-risk drinking (ie, hazardous/harmful consumption, AUDIT-10 ≥8 and AUDIT-C ≥4) was associated with elevated mortality risk after 2–10 years of follow-up (pooled relative risk (RR)=1.24, 95% CI 1.12 to 1.37) compared with moderate drinking (AUDIT-10=1–7, AUDIT-C=1–3). Compared to past year abstainers (AUDIT=0), moderate drinkers had a lower mortality risk (RR=0.75, 95% CI 0.71 to 0.79) in US Veterans and a similar mortality risk (RR=0.99, 95% CI 0.72 to 1.38) in population-based studies. Most data came from studies among Veterans using the short AUDIT-C in men and showed a dose–response relationship (RR=1.04, 95% CI 1.04 to 1.05 for each AUDIT-C score among drinkers). Data for women and young adults were scarce.ConclusionAUDIT screening scores were associated with mortality risk. The association was differential depending on the population examined, which may be related to prevalence of former drinkers among current abstainers. Due to heterogeneity between studies and the small number of populations examined, generalisability may be limited.
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14
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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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15
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Hobden B, Bryant J, Sanson-Fisher R, Oldmeadow C, Carey M. Do rates of depression vary by level of alcohol misuse in Australian general practice? Aust J Prim Health 2017; 23:263-267. [PMID: 27938624 DOI: 10.1071/py16076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 11/03/2016] [Indexed: 11/23/2022]
Abstract
Limited data exist regarding co-occurring alcohol misuse and depression among general practice patients. This study examined the prevalence of depression by level of alcohol misuse, and the sociodemographic factors associated with depression and increased alcohol misuse severity. A cross-sectional survey was administered to 3559 Australian general practice patients. Patients completed their demographic details, the Patient Health Questionnaire (9-item) and the Alcohol Use Disorder Identification Test (Consumption items). The prevalence of alcohol misuse and depression was 6.7%, and depression prevalence varied significantly according to level of alcohol misuse (P<0.001). Age, gender, Aboriginality and number of chronic diseases were associated with depression and higher levels of alcohol misuse. These findings may assist General Practitioners in identifying those at risk of experiencing co-morbid depression and alcohol use, and aid in effective treatment and referral.
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Affiliation(s)
- Breanne Hobden
- Health Behaviour Research Group, HMRI Building, University of Newcastle, NSW 208, Australia
| | - Jamie Bryant
- Health Behaviour Research Group, HMRI Building, University of Newcastle, NSW 208, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Group, HMRI Building, University of Newcastle, NSW 208, Australia
| | - Christopher Oldmeadow
- Public Health Stream, Hunter Medical Research Institute, HMRI Building, NSW 2308, Australia
| | - Mariko Carey
- Health Behaviour Research Group, HMRI Building, University of Newcastle, NSW 208, Australia
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16
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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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17
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Bradley KA, Rubinsky AD, Lapham GT, Berger D, Bryson C, Achtmeyer C, Hawkins EJ, Chavez LJ, Williams EC, Kivlahan DR. Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population. Addiction 2016; 111:1975-1984. [PMID: 27349855 DOI: 10.1111/add.13505] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/27/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2). DESIGN Cohort study. SETTING Twenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention. PARTICIPANTS A total of 486 115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥ 12 months apart ('baseline' and 'follow-up'). MEASUREMENTS Independent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations ('GI hospitalizations') and (3) physical trauma, each in the years after baseline and follow-up. FINDINGS Baseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI) = 41.3-41.5] to 53.5 (95% CI = 51.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CI = 0.48-0.51%) to 1.8% (95% CI = 1.3-2.3%) and trauma from 3.0% (95% CI = 2.95-3.06%) to 6.0% (95% CI = 5.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all < 0.05). For example, among those with baseline low-risk use, in those with persistent low-risk use versus severe misuse at follow-up, the probabilities of subsequent trauma were 2.65% (95% CI = 2.54-2.75%) versus 5.15% (95% CI = 3.86-6.45%), respectively. However, for patients who decreased to lower AUDIT-C risk groups at follow-up, findings were inconsistent across outcomes, with only mean HDL decreasing in most groups that decreased use (P-values all < 0.05). CONCLUSIONS When AUDIT-C screening is conducted in clinical settings, baseline AUDIT-C scores and score increases to moderate-severe alcohol misuse at follow-up screening appear to have predictive validity for HDL cholesterol, alcohol-related gastrointestinal hospitalizations and physical trauma. Decreasing AUDIT-C scores collected in clinical settings appear to have predictive validity for only HDL.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA. .,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA. .,Group Health Research Institute, Seattle, WA, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Anna D Rubinsky
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,The Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Gwen T Lapham
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA
| | - Douglas Berger
- General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Bryson
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Carol Achtmeyer
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Eric J Hawkins
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Laura J Chavez
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Emily C Williams
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Daniel R Kivlahan
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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18
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Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions. Alcohol Clin Exp Res 2016; 40:2056-2072. [PMID: 27696523 PMCID: PMC5119641 DOI: 10.1111/acer.13204] [Citation(s) in RCA: 202] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/28/2016] [Indexed: 12/20/2022]
Abstract
Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
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Affiliation(s)
- Emily C Williams
- Veterans Health Administration (VA) Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Judith A Hahn
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kendall Bryant
- Consortiums for HIV/AIDS and Alcohol Research Translation (CHAART) National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey H Samet
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts. .,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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Hobden B, Bryant J, Sanson-Fisher R, Oldmeadow C, Carey M. Co-occurring depression and alcohol misuse is under-identified in general practice: A cross-sectional study. J Health Psychol 2016; 23:1085-1095. [DOI: 10.1177/1359105316643855] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Depression and alcohol misuse are common co-occurring conditions. This study aimed to determine the accuracy of general practitioner identification of depression and alcohol misuse. Participants from 12 Australian general practices reported demographic and health risk behaviour data. General practitioners were asked to indicate the presence or absence of six health risk factors for individual patients. Accuracy of general practitioner identification was low at 21 per cent. Those with severe alcohol misuse, no chronic diseases and lower education levels were more likely to be identified. Routine screening prior to patient appointments may be a simple and efficient way to increase identification rates.
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Justice AC, McGinnis KA, Tate JP, Braithwaite RS, Bryant KJ, Cook RL, Edelman EJ, Fiellin LE, Freiberg MS, Gordon AJ, Kraemer KL, Marshall BD, Williams EC, Fiellin DA. Risk of mortality and physiologic injury evident with lower alcohol exposure among HIV infected compared with uninfected men. Drug Alcohol Depend 2016; 161:95-103. [PMID: 26861883 PMCID: PMC4792710 DOI: 10.1016/j.drugalcdep.2016.01.017] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/19/2016] [Accepted: 01/20/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND HIV infected (HIV+) individuals may be more susceptible to alcohol-related harm than uninfected individuals. METHODS We analyzed data on HIV+ and uninfected individuals in the Veterans Aging Cohort Study (VACS) with an Alcohol Use Disorders Identification Test-Consumption AUDIT-C score from 2008 to 2012. We used Cox proportional hazards models to examine the association between alcohol exposure and mortality through July, 2014; and linear regression models to assess the association between alcohol exposure and physiologic injury based on VACS Index Scores. Models were adjusted for age, race/ethnicity, smoking, and hepatitis C infection. RESULTS The sample included 18,145 HIV+ and 42,228 uninfected individuals. Among HIV+ individuals, 76% had undetectable HIV-1 RNA (<500 copies/ml). The threshold for an association of alcohol use with mortality and physiologic injury differed by HIV status. Among HIV+ individuals, AUDIT-C score ≥4 (hazard ratio [HR] 1.25, 95% CI 1.09-1.44) and ≥30 drinks per month (HR, 1.30, 95% CI 1.14-1.50) were associated with increased risk of mortality. Among uninfected individuals, AUDIT-C score ≥5 (HR, 1.19, 95% CI 1.07-1.32) and ≥70 drinks per month (HR 1.13, 95% CI 1.00-1.28) were associated with increased risk. Similarly, AUDIT-C threshold scores of 5-7 were associated with physiologic injury among HIV+ individuals (beta 0.47, 95% CI 0.22, 0.73) and a score of 8 or more was associated with injury in uninfected (beta 0.29, 95% CI 0.16, 0.42) individuals. CONCLUSIONS Despite antiretroviral therapy, HIV+ individuals experienced increased mortality and physiologic injury at lower levels of alcohol use compared with uninfected individuals. Alcohol consumption limits should be lower among HIV+ individuals.
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Affiliation(s)
- Amy C. Justice
- Veterans Aging Cohort Study Coordinating Center, West Haven VA Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA,Department of Internal Medicine, and the Center for Interdisciplinary Research on AIDS (CIRA), Yale School of Medicine, Yale University 367 Cedar Street, New Haven, Connecticut, 06510, USA,Corresponding author at: VA Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue, Building 35a Room 2-212 (11-ACSLG), West Haven, CT 06516, Tel.: 203.932.5711 x3541, Fax: 203.937.4926
| | - Kathleen A. McGinnis
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, Pennsylvania, 15240, USA
| | - Janet P. Tate
- Veterans Aging Cohort Study Coordinating Center, West Haven VA Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA,Department of Internal Medicine, and the Center for Interdisciplinary Research on AIDS (CIRA), Yale School of Medicine, Yale University 367 Cedar Street, New Haven, Connecticut, 06510, USA
| | - R. Scott Braithwaite
- Department of Population Health New York University School of Medicine, 227 East 30 street, New York, NY 10016, USA
| | - Kendall J. Bryant
- National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Lane, MSC 9304, Bethesda, MD 20892-9304, USA
| | - Robert L. Cook
- Department of Epidemiology, University of Florida, PO Box 100231, Gainesville, FL, USA
| | - E. Jennifer Edelman
- Veterans Aging Cohort Study Coordinating Center, West Haven VA Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA,Department of Internal Medicine, and the Center for Interdisciplinary Research on AIDS (CIRA), Yale School of Medicine, Yale University 367 Cedar Street, New Haven, Connecticut, 06510, USA
| | - Lynn E. Fiellin
- Department of Internal Medicine, and the Center for Interdisciplinary Research on AIDS (CIRA), Yale School of Medicine, Yale University 367 Cedar Street, New Haven, Connecticut, 06510, USA
| | - Matthew S. Freiberg
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA,Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, 2525 West End Avenue, Nashville, TN, USA
| | - Adam J. Gordon
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, Pennsylvania, 15240, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Suite 600, 230 McKee Place, Pittsburgh, Pennsylvania, 15213, USA
| | - Kevin L. Kraemer
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, Pennsylvania, 15240, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Suite 600, 230 McKee Place, Pittsburgh, Pennsylvania, 15213, USA
| | - Brandon D.L. Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA, 02912
| | - Emily C. Williams
- University of Washington School of Public Health, 325 Ninth Avenue, Box 359762, Seattle, WA, USA
| | - David A. Fiellin
- Veterans Aging Cohort Study Coordinating Center, West Haven VA Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA,Department of Internal Medicine, and the Center for Interdisciplinary Research on AIDS (CIRA), Yale School of Medicine, Yale University 367 Cedar Street, New Haven, Connecticut, 06510, USA
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Chavez LJ, Liu CF, Tefft N, Hebert PL, Clark BJ, Rubinsky AD, Lapham GT, Bradley KA. Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge. Drug Alcohol Depend 2016; 158:94-101. [PMID: 26644137 PMCID: PMC4749399 DOI: 10.1016/j.drugalcdep.2015.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits. METHODS Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009-10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization. RESULTS Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n=7,167) and nondrinking (n=357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0-14.6%; and 14.2%, 95% CI 14.1-14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7-13.0%). Only nondrinkers had increased risk for ED visits. CONCLUSIONS Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits.
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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, United States,Departments of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States,Corresponding author at: University of Washington, Department of Health Services, 1959 NE Pacific Street, Box 357660, Seattle, WA 98195, United States. Tel.: +1 678 371 2197; fax: +1 206 543 3964
| | - 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, United States; Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Nathan Tefft
- Bates College, 2 Andrews Rd, Lewiston, ME 04240, United States.
| | - 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, United States; Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Brendan J. Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, 12700 East 19th Ave, Aurora, CO 80045, United States
| | - Anna D. Rubinsky
- 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, United States,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States
| | - Gwen T. Lapham
- 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, United States,Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States
| | - 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, United States,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States,Departments of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States,Departments of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States,Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States
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22
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Simonetti JA, Lapham GT, Williams EC. Association Between Receipt of Brief Alcohol Intervention and Quality of Care among Veteran Outpatients with Unhealthy Alcohol Use. J Gen Intern Med 2015; 30:1097-104. [PMID: 25691238 PMCID: PMC4510248 DOI: 10.1007/s11606-015-3218-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships. OBJECTIVE The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use. DESIGN Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP). PARTICIPANTS The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009-2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care. MAIN MEASURES We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care--patient ratings of their VA provider and of overall VA healthcare (range 0-10, dichotomized as ≥ 9 indicating high quality)--for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year. KEY RESULTS Among 10,612 eligible veterans, 43.8% reported having received brief intervention, and 84.2% and 79.1% rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9% vs. 82.0%, p < 0.01) and the VA overall (82.7% vs. 75.9%, p < 0.01) as high. CONCLUSIONS In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients' perceptions of care.
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Affiliation(s)
- Joseph A Simonetti
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA,
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23
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Lapham GT, Rubinsky AD, Shortreed SM, Hawkins EJ, Richards J, Williams EC, Berger D, Chavez LJ, Kivlahan DR, Bradley KA. Comparison of provider-documented and patient-reported brief intervention for unhealthy alcohol use in VA outpatients. Drug Alcohol Depend 2015; 153:159-66. [PMID: 26072218 PMCID: PMC4620927 DOI: 10.1016/j.drugalcdep.2015.05.027] [Citation(s) in RCA: 14] [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: 12/03/2014] [Revised: 05/05/2015] [Accepted: 05/18/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Performance measures for brief alcohol interventions (BIs) are currently based on provider documentation of BI. However, provider documentation may not be a reliable measure of whether or not patients are offered clinically meaningful BIs. In particular, BI documented with clinical decision support in an electronic medical record (EMR) could appear identical irrespective of the quality of BI provided. We hypothesized that differences in how BI was implemented across health systems could lead to differences in the proportion of documented BI recalled and reported by patients across health systems. METHODS Male outpatients with unhealthy alcohol use identified by confidential satisfaction surveys (2009-2012) were assessed for whether they reported receiving BI in the past year (patient-reported BI) and whether they had BI documented in the EMR during the same period (documented BI). We evaluated and compared the prevalence of documented BI to patient-reported BI across 21 VA networks to determine whether documented BI had a variable association with patient-reported BI across the networks. RESULTS Of 9896 eligible male outpatients with unhealthy alcohol use, 59.0% (95% CI 57.4-60.5%) reported BI (50.4-64.9% across networks) and 37.4% (95% CI 36.0-38.9%) had BI documented in the EMR (28.0-44.2% across networks). Overall, 72.9% (95% CI 70.8-75.5%) of patients with documented BI also reported BI. The association between documented BI and patient-reported BI did not vary across VA networks in adjusted logistic regression models. CONCLUSIONS Performance measures of BI that rely on provider documentation in EMRs appear comparable to patient report for comparing care across VA networks.
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Affiliation(s)
- Gwen T Lapham
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States; Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States.
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States.
| | - Susan M Shortreed
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Julie Richards
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Health Services, University of Washington, 1959 Pacific Street, Seattle, WA 98195, United States.
| | - Douglas Berger
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States; Primary and Specialty Medical Care Services, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States.
| | - Laura J Chavez
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Health Services, University of Washington, 1959 Pacific Street, Seattle, WA 98195, United States.
| | - Daniel R Kivlahan
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Katharine A Bradley
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States; Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, United States.
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Shah NP, Goel R, McGurk M, Maroo A, Sproat C. Brief advice on alcohol: as easy as A...B...I? Br Dent J 2015; 218:13-7. [PMID: 25571814 DOI: 10.1038/sj.bdj.2014.1138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 11/09/2022]
Abstract
Alcohol is widely consumed by the majority of the UK population and alcohol-related harm is estimated to cost society £21 billion per year in healthcare, lost productivity costs, crime and antisocial behaviour. The dental setting offers an ideal opportunity to screen for harmful alcohol consumption; however, current emphasis is on the management of acute complications and risk associated in treating patients with excessive alcohol intake rather than screening and patient education. This article outlines ways in which dentists could improve their recognition of 'at risk' patients and then offer practical advice to help reduce the harmful effects of alcohol.
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Affiliation(s)
| | | | - M McGurk
- King's College London Dental Institute
| | - A Maroo
- GPT, Hillingdon Hospital, Middlesex, UB8 3NN
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Larson MJ, Mohr BA, Adams RS, Wooten NR, Williams TV. Missed opportunity for alcohol problem prevention among army active duty service members postdeployment. Am J Public Health 2014; 104:1402-12. [PMID: 24922163 PMCID: PMC4103229 DOI: 10.2105/ajph.2014.301901] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified to what extent the Department of Defense postdeployment health surveillance program identifies at-risk drinking, alone or in conjunction with psychological comorbidities, and refers service members who screen positive for additional assessment or care. METHODS We completed a cross-sectional analysis of 333 803 US Army active duty members returning from Iraq or Afghanistan deployments in fiscal years 2008 to 2011 with a postdeployment health assessment. Alcohol measures included 2 based on self-report quantity-frequency items-at-risk drinking (positive Alcohol Use Disorders Identification Test alcohol consumption questions [AUDIT-C] screen) and severe alcohol problems (AUDIT-C score of 8 or higher)-and another based on the interviewing provider's assessment. RESULTS Nearly 29% of US Army active duty members screened positive for at-risk drinking, and 5.6% had an AUDIT-C score of 8 or higher. Interviewing providers identified potential alcohol problems among only 61.8% of those screening positive for at-risk drinking and only 74.9% of those with AUDIT-C scores of 8 or higher. They referred for a follow-up visit to primary care or another setting only 29.2% of at-risk drinkers and only 35.9% of those with AUDIT-C scores of 8 or higher. CONCLUSIONS This study identified missed opportunities for early intervention for at-risk drinking. Future research should evaluate the effect of early intervention on long-term outcomes.
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Affiliation(s)
- Mary Jo Larson
- Mary Jo Larson and Rachel Sayko Adams are with The Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, Waltham, MA. Beth A. Mohr is with The Heller School for Social Policy & Management, Schneider Institutes for Health Policy, Brandeis University. Nikki R. Wooten is with Military Social Work Research and Practice, University of South Carolina College of Social Work, Columbia. Thomas V. Williams is with Methods, Measures, Analyses, Defense Health Cost Assessment and Program Evaluation, Defense Health Agency, Department of Defense, Falls Church, VA
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Abstract
People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.
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27
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Williams EC, Rubinsky AD, Lapham GT, Chavez LJ, Rittmueller SE, Hawkins EJ, Grossbard JR, Kivlahan DR, Bradley KA. Prevalence of clinically recognized alcohol and other substance use disorders among VA outpatients with unhealthy alcohol use identified by routine alcohol screening. Drug Alcohol Depend 2014; 135:95-103. [PMID: 24360928 DOI: 10.1016/j.drugalcdep.2013.11.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/11/2013] [Accepted: 11/16/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of routine alcohol screening is to identify patients who may benefit from brief intervention, but patients who also have alcohol and other substance use disorders (AUD/SUD) likely require more intensive interventions. This study sought to determine the prevalence of clinically documented AUD/SUD among VA outpatients with unhealthy alcohol use identified by routine screening. METHODS VA patients 18-90 years who screened positive for unhealthy alcohol use (AUDIT-C ≥3 women; ≥4 men) and were randomly selected for quality improvement standardized medical record review (6/06-6/10) were included. Gender-stratified prevalences of clinically documented AUD/SUD (diagnosis of AUD, SUD, or alcohol-specific medical conditions, or VA specialty addictions treatment on the date of or 365 days prior to screening) were estimated and compared across AUDIT-C risk groups, and then repeated across groups further stratified by age. RESULTS Among 63,397 eligible patients with unhealthy alcohol use, 25% (n=2109) women and 28% (n=15,199) men had documented AUD/SUD (p<0.001). The prevalence of AUD/SUD increased with increasing AUDIT-C risk, ranging from 13% (95% CI 13-14%) to 82% (79-85%) for women and 12% (11-12%) to 69% (68-71%) for men in the lowest and highest AUDIT-C risk groups, respectively. Patterns were similar across age groups. CONCLUSIONS One-quarter of all patients with unhealthy alcohol use, and a majority of those with the highest alcohol screening scores, had clinically recognized AUD/SUD. Healthcare systems implementing evidence-based alcohol-related care should be prepared to offer more intensive interventions and/or effective pharmacotherapies for these patients.
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Affiliation(s)
- Emily C Williams
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States.
| | - Anna D Rubinsky
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Gwen T Lapham
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Group Health Research Institute, Seattle, WA, United States
| | - Laura J Chavez
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Stacey E Rittmueller
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States
| | - Eric J Hawkins
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Joel R Grossbard
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States
| | - Daniel R Kivlahan
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Katharine A Bradley
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Center of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States; Group Health Research Institute, Seattle, WA, United States
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Delaney KE, Lee AK, Lapham GT, Rubinsky AD, Chavez LJ, Bradley KA. Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples. Addict Sci Clin Pract 2014; 9:2. [PMID: 24468406 PMCID: PMC3946205 DOI: 10.1186/1940-0640-9-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 12/23/2013] [Indexed: 12/02/2022] Open
Abstract
Background The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice. Methods This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C. Results Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking. Limitations This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens. Conclusions Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.
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Affiliation(s)
| | | | | | | | | | - Katharine A Bradley
- VA HSR&D Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle WA, USA.
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Lapham GT, Rubinsky AD, Heagerty PJ, Achtmeyer C, Williams EC, Hawkins EJ, Maynard C, Kivlahan DR, Au D, Bradley KA. Probability and predictors of patients converting from negative to positive screens for alcohol misuse. Alcohol Clin Exp Res 2013; 38:564-71. [PMID: 24118025 DOI: 10.1111/acer.12260] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 07/26/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Medicare reimburses providers for annual alcohol screening. However, the benefit of rescreening patients a year after a negative screen for alcohol misuse is unknown. We hypothesized that some subgroups of patients who screen negative would have a very low probability of converting to a positive subsequent screen (e.g., <0.1%), calling into question the value of annual alcohol screening for some patient subgroups. METHODS This retrospective cohort study estimated the probability of converting to a positive screen for alcohol misuse a year after a negative screen among outpatients from 30 Veterans Health Administration (VA) medical centers. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screening scores (range 0 to 12 points) from 2004 to 2008 were obtained from electronic health record data. Eligible patients screened negative on their initial screen (AUDIT-C scores 0 to 3 for men; 0 to 2 for women). The main outcome was a positive subsequent screen (AUDIT-C scores ≥4 men; ≥3 women). RESULTS Among 21,081 women and 323,913 men who screened negative on an initial screen, 5.4% and 6.0%, respectively, screened positive a year later. The adjusted probability of converting to a positive subsequent screen varied from 2.1 to 38.9% depending on age, gender, and initial negative screen score. Women, older patients, and those with initial AUDIT-C scores of 0 were least likely to a convert to a positive subsequent screen, while younger men with AUDIT-C scores of 3 were most likely to a convert to a positive subsequent screen. CONCLUSIONS The probability of a positive subsequent screen varied depending on age, gender, and initial negative screen score but exceeded 2% in all patient subgroups. Annual rescreening appears reasonable for all VA patients who had a negative screen the year prior.
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Affiliation(s)
- Gwen T Lapham
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Group Health Research Institute, Seattle, Washington
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Berger D, Williams EC, Bryson CL, Rubinsky AD, Bradley KA. Alcohol questionnaires and HDL: screening scores as scaled markers of alcohol consumption. Alcohol 2013; 47:439-45. [PMID: 23886863 DOI: 10.1016/j.alcohol.2013.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/18/2013] [Accepted: 07/02/2013] [Indexed: 11/17/2022]
Abstract
Improving the quality of alcohol-related care requires practical approaches to assessing alcohol consumption to guide management and monitor outcomes. Given the increasing use of alcohol screening questionnaires to identify alcohol misuse it would be ideal if scores on screening questionnaires were also indicators of average alcohol consumption. However, the questionnaires were not designed for this purpose and include dimensions of drinking that may not reflect average consumption (e.g. heavy episodic drinking, alcohol-related problems). In a general population sample, scores on the AUDIT-C screen correlated with reports of alcohol consumption in detailed interviews, but the relationship is unknown for clinical populations and other questionnaires. Serum high-density lipoprotein cholesterol (HDL) is a biomarker routinely obtained in clinical care and is known to rise with average alcohol consumption. This cross-sectional study of 11,175 male U.S. Veterans Affairs patients enrolled in a primary care study used HDL as an objective biomarker to evaluate whether average alcohol consumption increased as scores increased on 3 brief alcohol screens - the AUDIT-C, AUDIT Question #3 (a single-item screen), and the CAGE questionnaire. Mean HDL progressively increased as screening scores increased for the AUDIT-C and AUDIT Question #3: about 12 mg/dL from the lowest to the highest scores. The association was much weaker for the CAGE questionnaire. Results were minimally affected by adjustment for covariates (e.g. age, race, medical comorbidity, smoking, medication count, and depression) but the association was modified (p = 0.008) and mildly attenuated by adherent use of lipid-lowering medications. This study using HDL as a biomarker of average alcohol consumption adds to evidence that some alcohol screening scores may also serve as scaled markers of average alcohol consumption.
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Affiliation(s)
- Douglas Berger
- General Medicine Service, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
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Abstract
BACKGROUND Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire as a screening instrument for identification of hazardous and harmful drinkers give some false-positive and negative results. Changes of answers decrease the number of false results. METHODS Changes in second and third questions with theoretical simulation of possible answers' combinations was made; cutoff scores have to be changed. Study with original and adapted AUDIT-C was conducted among 298 students to analyze the differences. RESULTS Adapted Slovenian version of AUDIT-C gives less false-positive and less false-negative results. CONCLUSIONS Changes of AUDIT-C questionnaire that give less false results means less potential disharmony in doctor-patient relationship, less unnecessary questioning, less time spent inadequately, and also less missed hazardous drinkers.
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Affiliation(s)
- Marko Kolšek
- Department of Family Medicine, Medical Faculty, University of Ljubljana , Ljubljana, SVN , Slovenia.
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Clark BJ, Williams A, Feemster LMC, Bradley KA, Macht M, Moss M, Burnham EL. Alcohol screening scores and 90-day outcomes in patients with acute lung injury. Crit Care Med 2013; 41:1518-25. [PMID: 23538449 PMCID: PMC4048714 DOI: 10.1097/ccm.0b013e318287f1bb] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test that correspond to past-year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with acute lung injury. DESIGN Secondary analysis. SETTING The Acute Respiratory Distress Syndrome Network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multicenter clinical trials in patients with acute lung injury. SUBJECTS Patients meeting consensus criteria for acute lung injury enrolled in one of three recent Acute Respiratory Distress Syndrome Network clinical trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,133 patients enrolled in one of three Acute Respiratory Distress Syndrome Network studies, 1,037 patients had an Alcohol Use Disorders Identification Test score available for analysis. Alcohol misuse was common with 70 (7%) of patients having Alcohol Use Disorders Identification Test scores in zone 3 and 129 (12%) patients in zone 4. There was a U-shaped association between validated Alcohol Use Disorders Identification Test zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients having Alcohol Use Disorders Identification Test zone 4 compared with those in zone 2 (adjusted odds ratio 1.70; 95% confidence interval 1.00, 2.87; p = 0.048). CONCLUSIONS Severe but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in acute lung injury patients.
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Affiliation(s)
- Brendan J Clark
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO, USA.
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Williams EC, Bradley KA, Gupta S, Harris AHS. Association between alcohol screening scores and mortality in black, Hispanic, and white male veterans. Alcohol Clin Exp Res 2012; 36:2132-40. [PMID: 22676340 DOI: 10.1111/j.1530-0277.2012.01842.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 03/11/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Scores on the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire are associated with mortality, but whether or how associations vary across race/ethnicity is unknown. METHODS Self-reported black (n = 13,068), Hispanic (n = 9,466), and white (n = 182,688) male Veterans Affairs (VA) outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1 to 4, 5 to 8, and 9 to 12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity. RESULTS Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1 to 4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p = 0.0022). Hispanic and white patients with scores of 0, 5 to 8, and 9 to 12 had significantly increased risk of death compared to those with scores of 1 to 4; Hispanic ORs: 1.93, 95% CI 1.50 to 2.49; 1.57, 1.07 to 2.30; 1.82, 1.04 to 3.17, respectively; white ORs: 1.34, 95% CI 1.29 to 1.40; 1.12, 1.03 to 1.21; 1.81, 1.59 to 2.07, respectively. Black patients with scores of 0 and 5 to 8 had increased risk relative to scores of 1 to 4 (ORs 1.28, 1.06 to 1.56 and 1.50, 1.13 to 1.99), but there was no significant increased risk for scores of 9 to 12 (ORs 1.27, 0.77 to 2.09). Post hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity. CONCLUSIONS Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically tailored feedback regarding medical consequences of drinking.
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Affiliation(s)
- Emily C Williams
- Northwest Center of Excellence for Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington 98101, USA.
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Broyles LM, Gordon AJ, Sereika SM, Ryan CM, Erlen JA. Predictive Utility of Brief Alcohol Use Disorders Identification Test (AUDIT) for human immunodeficiency virus antiretroviral medication nonadherence. Subst Abus 2012; 32:252-61. [PMID: 22014256 DOI: 10.1080/08897077.2011.599255] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Alcohol use negatively affects adherence to antiretroviral therapy (ART), thus human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care providers need accurate, efficient assessments of alcohol use. Using existing data from an efficacy trial of 2 cognitive-behavioral ART adherence interventions, the authors sought to determine if results on 2 common alcohol screening tests (Alcohol Use Disorders Identification Test--Consumption [AUDIT-C] and its binge-related question [AUDIT-3]) predict ART nonadherence. Twenty-seven percent of the sample (n = 308) were positive on the AUDIT-C and 34% were positive on the AUDIT-3. In multivariate analyses, AUDIT-C-positive status predicted ART nonadherence after controlling for race, age, conscientiousness, and self-efficacy (P = .036). Although AUDIT-3-positive status was associated with ART nonadherence in unadjusted analyses, this relationship was not maintained in the final multivariate model. The AUDIT-C shows potential as an indirect screening tool for both at-risk drinking and ART nonadherence, underscoring the relationship between alcohol and chronic disease management.
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Affiliation(s)
- Lauren Matukaitis Broyles
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, USA.
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Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between Alcohol Screening Results and Hospitalizations for Trauma in Veterans Affairs Outpatients. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 38:73-80. [DOI: 10.3109/00952990.2011.600392] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Emily C. Williams
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
| | - Chris L. Bryson
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Haili Sun
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Ryan B. Chew
- Overlake Hospitalist Practice, Overlake Hospital Medical Center,
Bellevue, WA, USA
| | - Lisa D. Chew
- Department of Medicine, University of Washington,
Seattle, WA, USA
- Adult Medicine Clinic, Harborview Medical Center,
Seattle, WA, USA
| | - David K. Blough
- Department of Pharmacy, University of Washington,
Seattle, WA, USA
| | - David H. Au
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Katharine A. Bradley
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
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Harris AHS, Bradley KA, Bowe T, Henderson P, Moos R. Associations between AUDIT-C and mortality vary by age and sex. Popul Health Manag 2011; 13:263-8. [PMID: 20879907 DOI: 10.1089/pop.2009.0060] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1-4, 5-8, 9-12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9-12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5-8 and 9-12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or "vital sign" that might facilitate the detection and management of alcohol-related risks and problems.
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Affiliation(s)
- Alex H S Harris
- Center for Health Care Evaluation, VA Palo Alto Health Care System and Stanford University School of Medicine . Menlo Park, CA 94025, USA.
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Bradley KA, Lapham GT, Hawkins EJ, Achtmeyer CE, Williams EC, Thomas RM, Kivlahan DR. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med 2011; 26:299-306. [PMID: 20859699 PMCID: PMC3043188 DOI: 10.1007/s11606-010-1509-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 07/26/2010] [Accepted: 08/30/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings. OBJECTIVE The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results. DESIGN Cross sectional. PARTICIPANTS A national sample of 6,861 VA outpatients (fiscal years 2007-2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen). MAIN MEASURES Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens). KEY RESULTS Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks. CONCLUSION Use of a validated alcohol screening questionnaire does not-by itself-ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Harris AHS, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. J Bone Joint Surg Am 2011; 93:321-7. [PMID: 21325583 DOI: 10.2106/jbjs.i.01560] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The risks associated with preoperative alcohol misuse by patients before undergoing total joint arthroplasty are not well known, yet alcohol misuse by surgical patients is common and has been linked to an increased risk of complications after other procedures. The purpose of this study was to evaluate the association between a patient's preoperative standardized alcohol-misuse screening score and his or her risk of complications after total joint arthroplasty. METHODS The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is an alcohol-misuse screening instrument administered annually to all patients receiving care through the Veterans Health Administration (VHA). The scores range from 0 to 12, with higher scores signifying greater and more frequent consumption. In a study of 185 male patients who had alcohol screening scores recorded in the year preceding surgery at a Palo Alto VHA facility, and who reported at least some alcohol use, we estimated the association between preoperative screening scores and the number of surgical complications in an age and comorbidity-adjusted regression analyses. RESULTS Of the 185 patients reporting at least some drinking in the year before their total joint replacement, 17% (thirty-two) had an alcohol screening score suggestive of alcohol misuse; six of those thirty-two patients had one complication, four had two complications, and two had three complications. The screening scores were significantly related to the number of complications in a negative binomial regression analysis (exp[β] = 1.29, p = 0.035), which demonstrated a 29% increase in the expected number of complications with every additional point of the screening score above 1, although with wide confidence intervals for the higher scores. CONCLUSIONS Complications following total joint arthroplasty were significantly related to alcohol misuse in this group of male patients treated at a VHA facility. The AUDIT-C has three simple questions that can be incorporated into a preoperative evaluation and can alert the treatment team to patients with increased postoperative risk. Preoperative screening for alcohol misuse, and perhaps preoperative counseling or referral to treatment for heavy drinkers, may be indicated for patients who are to undergo total joint arthroplasty.
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Affiliation(s)
- Alex H S Harris
- VA Palo Alto Health Care System, Palo Alto, California, USA.
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Bradley KA, Rubinsky AD, Sun H, Bryson CL, Bishop MJ, Blough DK, Henderson WG, Maynard C, Hawn MT, Tønnesen H, Hughes G, Beste LA, Harris AHS, Hawkins EJ, Houston TK, Kivlahan DR. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med 2011; 26:162-9. [PMID: 20878363 PMCID: PMC3019325 DOI: 10.1007/s11606-010-1475-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. OBJECTIVE To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications. DESIGN This is a cohort study. SETTING AND PARTICIPANTS Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. MAIN OUTCOME MEASURE One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. RESULTS Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10. CONCLUSIONS AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA 98101, USA.
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Bradley KA, Kivlahan DR, Williams EC. Brief approaches to alcohol screening: practical alternatives for primary care. J Gen Intern Med 2009; 24:881-3. [PMID: 19495888 PMCID: PMC2695519 DOI: 10.1007/s11606-009-1014-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Katharine A. Bradley
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Primary and Specialty Medical Care Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA USA
- Department of Health Services, University of Washington, Seattle, WA USA
| | - Daniel R. Kivlahan
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA USA
| | - Emily C. Williams
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Health Services, University of Washington, Seattle, WA USA
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