Primary care intervention improves management of unhealthy alcohol use

An intervention designed to enhance the management of unhealthy alcohol use in primary care improved prevention and treatment initiation but not treatment engagement, according to study results published in JAMA Internal Medicine.

Amy K. Lee, MPH, a mental health and wellness practice facilitator at Kaiser Permanente Washington, and colleagues wrote that unhealthy alcohol use — which can range from drinking above recommended limits to alcohol use disorder (AUD) — is prevalent in the United States. Among U.S. adults, 15% have a current AUD and up to 25% drink at unhealthy levels.

However, unhealthy alcohol use is often neglected in medical settings, despite the fact that it affects morbidity and mortality and there are prevention and treatment guidelines that health care professionals can look to, Lee and colleagues wrote.

The researchers conducted a stepped-wedge cluster randomized implementation trial known as Sustained Patient-Centered Alcohol-Related Care (SPARC) to test an intervention aiming to increase alcohol-related prevention and AUD treatment in a primary care setting.

The SPARC trial included 22 primary care practices in a Washington state integrated health system that did not previously have a population-based system that supported routine alcohol screening, AUD diagnosis or treatment.

The intervention included three strategies: performance feedback to identify gaps and successes in care and measure responses to improvement activities; practice facilitation, which included weekly meetings to aid the implementation of an effective workflow, increase motivation, decrease alcohol-related stigma and increase alcohol-related knowledge and skills; and electronic health record decision support to notify providers when to screen patients, offer brief interventions and more.

The intervention was designed to implement:

• population-based annual alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C);
• brief intervention for patients who screened positive;
• assessments with an alcohol symptom checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM-5) AUD;
• shared decision-making about AUD treatment options with a primary care provider; and
• support for AUD treatment initiation and engagement.

Lee and colleagues found that the SPARC intervention did not significantly increase engagement in alcohol treatment: 1.4 per 10,000 patients vs 1.8 per 10,000 patients.

However, it did increase:

• alcohol screening, 83.2% vs. 20.8% (P < .001);
• brief preventive alcohol counseling, 57 per 10,000 patients per month vs. 11 per 10,000 patients per month (P < .001);
• new AUD diagnosis, 33.8 per 10,000 vs. 28.8 per 10,000 (P = .003); and
• treatment initiation, 7.8 per 10,000 vs. 6.2 per 10,000 (P = .04).

“The SPARC trial is the first implementation trial, to our knowledge, to increase brief intervention, AUD diagnosis, and initiation of AUD treatment in primary care settings without the addition of research-supported clinicians,” the researchers wrote. “However, the absolute magnitudes of increases were relatively small.”

Lee and colleagues concluded that their trial “succeeded in increasing several important elements of evidence-based alcohol-related preventive care,” but “given the extent of the gaps in the quality of alcohol-related care, iterative quality improvement efforts will likely be needed.”