Abstract
Background: This study assessed patient-reported alcohol treatment offers by health care providers following routine annual screening for alcohol use in primary care.
Methods: A telephone interview within 30 days of the annual screen assessed demographics, alcohol and other drug use, mental health symptoms, and offers of formal treatment for alcohol by a Veterans Affairs health care provider. We included male patients (n = 349) at high risk for an alcohol use disorder (AUD) who had not received alcohol treatment in the past 3 months. We assessed self-reported receipt of any offers of formal treatment for alcohol use and associations of offers of formal treatment for alcohol with demographic and clinical variables.
Results: A total of 145 patients (41.5%) reported an offer of at least 1 type of formal treatment for alcohol use. More severe alcohol misuse (odds ratio, 1.07; 95% confidence interval, 1.03–1.11) and younger age (odds ratio, 0.97, 95% confidence interval, 0.95–0.99) were associated with reporting an offer of formal treatment.
Conclusion: Most primary care patients at high risk for an AUD were not offered treatment following annual screening. Our results highlight the importance of training primary care providers in what constitutes appropriate medical treatment for this population and the most effective ways of offering treatment.
- Alcohol Drinking
- Alcohol-Related Disorders
- Demography
- Health Personnel
- Mental Health
- Primary Health Care
- Self-Report
- Telephone
Alcohol use disorders (AUDs) are prevalent, disabling, and have significant negative consequences1; nonetheless, fewer than 20% of those who at some point in their life meet criteria for an AUD in the United States ever receive treatment.2 The availability of evidence-based treatments has become a health policy priority as a result of reforms focused on better access to and quality of behavioral health services.3 Alcohol treatment offered by health professionals during a primary care visit provides an opportunity to make evidence-based treatments more available to those with AUDs4⇓–6 and may be a precursor to primary care patients accessing alcohol treatment when needed.7,8
Health professionals in primary care settings are likely to encounter patients who demonstrate high risk for an AUD, such as those scoring ≥8 on the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) or have an AUD diagnosis yet are not receiving treatment.9⇓⇓–12 Clinical practice guidelines recommend offering these patients treatment for their AUD, such as referring them to specialty care, monitoring their drinking, and offering addiction-focused pharmacotherapy.13 Because patients with an AUD generally do not visit primary care to seek alcohol misuse–related treatment,14 it is important to examine whether clinicians offer treatment when high risk for an AUD is identified during screening, even if patients do not mention or ask for it.15 Health professionals in primary care settings may not be aware of the various evidence-based pharmacological or behavioral treatment options for patients with AUDs.16 Consequently, the type of treatment offered should also be examined to ensure that appropriate care is recommended.17,18
Patient-reported measures are useful for examining alcohol misuse–related treatment offers in primary care settings.19 Information on alcohol misuse–related treatment offered during clinical encounters is typically not captured in administrative data, may not be documented accurately by providers,20 and is expensive to examine via medical record review.21
Objectives
This study examined patient-reported receipt of alcohol misuse–related treatment offered by health care providers to patients identified as being at high risk for an AUD following routine annual screening for alcohol misuse in primary care. We assessed (1) the proportion of patients who reported receipt of an offer of formal treatment for alcohol use, (2) the types of treatment offers reported, and (3) the predictors of patient-reported treatment offers.
Methods
Research Procedures
Between February 2013 and February 2014 we conducted a telephone survey within 30 days of all patients screening positive for alcohol misuse (a score ≥5 on the AUDIT-C based on Veterans Affairs [VA] administrative data) during routine annual screening.9 Patients received alcohol screening in 1 of several outpatient clinics at the VA Greater Los Angeles Health Care System (GLA). The RAND Human Subjects Protection Committee and the GLA Institutional Review Board approved this study.
Eligibility Criteria
We restricted these analyses to the subset of male patients at high risk for an AUD, that is, patients receiving a score ≥8 on the AUDIT-C during the annual screen or with an AUD diagnosis on the screening date (clinician-recorded administrative claims data using International Classification of Diseases, 9th Revision, codes) who had not received alcohol treatment in the past 3 months.10⇓–12 The VA Clinical Practice Guideline recommends these criteria to identify individuals who should be referred to specialty care for a substance use disorder.13 Further eligibility criteria included age ≥18 years, no cognitive impairment (measured via administrative claims data using International Classification of Diseases, 9th Revision, codes), engagement in care at GLA, a telephone number recorded in the VA system, and completion of the interview within 30 days of the annual screen.
Measures
Demographics
We collected self-reported race/ethnicity, marital status, education level, employment status, income, insurance coverage outside VA, and whether participants received all or most of their care through VA or an outside provider. We obtained information on age and sex from VA administrative records, and all other information from the survey.
Clinical Measures
The full AUDIT22 was used to assess the severity of alcohol misuse. Participants were also asked whether they had used any illegal drug in the past 30 days. Depression symptoms were assessed using the 9-item Patient Health Questionnaire,23 and anxiety symptoms were assessed using the 7-item Generalized Anxiety Disorder Assessment.24 Items from the 12-item Short Form Health Survey were used to assess overall physical and mental health.25 Stage of change was assessed using the Readiness to Change questionnaire.26
Treatment Offers
Participants reported whether a VA doctor or other health care provider offered, in the past 30 days, the following specifically for their alcohol use: (1) therapy or counseling, (2) medication (eg, acamprosate, disulfiram, naltrexone), (3) referral to an intensive outpatient treatment or a residential program, or (4) unspecified medical treatment. We then derived a binary indicator for receiving an offer of at least 1 type of formal treatment.
Statistical Analyses
We calculated descriptive statistics for all measures. We then conducted a multivariable logistic regression to assess associations of any formal treatment offer with demographic and clinical variables27; we chose model adjustment variables based on scientific grounds, before estimation, with the intent to control for potential confounding. We did not use any automated variable selection procedures.
Results
Of 1922 patients who were approached, 112 (5.8%) were ineligible, 435 (22.6%) could not be reached, 324 (16.9%) declined to participate, and 19 (1.0%) could not participate because of a health condition. Therefore only 973 (50.6%) participated in our survey. Logistic regressions did not indicate nonresponse bias by age, sex, income, marital status, or period of military service. Of all participants in our survey, 349 (35.9%) were eligible for the analysis: 146 (41.8%) met only the AUDIT-C criterion, 116 (33.2%) met only the AUD diagnosis criterion, and 87 (24.9%) met both criteria. Of this sample, 342 (98.0%) participants were seen in primary care, and the remaining participants were seen in other outpatient settings. The average age was 55 years (standard deviation, 15 years); the majority was white (52.7%), was not married or living as married (62.8%), completed at least some college education (60.8%), received all or most of their medical care through the VA (84.3%), and was not using illegal drugs in the past month (89.1%) (Table 1).
Participant Demographics (n = 349)
Overall, 145 (41.5%) patients reported receiving an offer of at least 1 type of formal treatment for alcohol misuse from a VA health care provider in the previous 30 days. Patients were offered 1 or more of the following: therapy/counseling (n = 121; 34.2%), medication (n = 18; 5.1%), referral to intensive outpatient treatment or a residential program (n = 19; 5.4%), or unspecified medical treatment (n = 20; 5.7%). Only 17 patients (5%) reported both an offer of therapy or counseling and referral to either a residential program or intensive outpatient treatment program. Only more severe alcohol misuse (ie, higher full AUDIT scores) (odds ratio, 1.07; 95% confidence interval, 1.03–1.11) and younger age (odds ratio, 0.97; 95% confidence interval, 0.95–0.99) were associated with reporting an offer of at least 1 type of formal treatment (Table 2).
Multivariate Logistic Regression of Formal Treatment Offer Receipt on Demographic and Clinical Variables
Discussion
In our sample of patients at high risk for an AUD, over half (58.5%) did not report being offered formal treatment for alcohol misuse following routine annual screening for alcohol misuse in primary care. This result conforms with research demonstrating low rates of offering patients information about formal treatment following alcohol screening.19 When offered, therapy/counseling was most prevalent, whereas offers of medication and referral to intensive outpatient treatment or a residential program were rare. Moreover, although, as expected, patients' severity of alcohol misuse was significantly associated with patient-reported offers of medical treatment, we also found that older populations—the least likely age group to seek alcohol treatment28,29—were less likely to report being offered treatment.
In another article we found that some patients reported receiving advice to drink less or abstain from drinking (n = 262),30 or a referral to a self-help group (n = 70) (unpublished data). Although such interventions are likely not sufficient for individuals at high risk for an AUD, these findings suggest that, even when providers did not offer formal treatment, most were aware that the patient was drinking at unhealthy levels and provided some type of intervention. Our results highlight the importance of training primary care providers in what constitutes appropriate medical treatment for this population, and then in the most effective ways of making a treatment offer.7,31
Patient-reported measures can be used in conjunction with medical records and administrative data for a more complete assessment of treatment offers.32 A limitation of these measures, however, is retrospective recall bias. It is possible that patients' inability to remember recent treatment offers indicates the need for providers to better engage patients during treatment encounters about their alcohol use. A potential limitation regarding the generalizability of this study involves the number of approached patients who could not be reached via phone (22.6%) or who declined to participate in the phone survey (16.9%). While analyses indicated that nonresponse did not seem related to key demographic variables, future research may wish to involve sampling and survey methods other than phone calls.
Reimbursement for formal treatment will be important to consider in future research as well, given that reimbursement varies by payer. For instance, reimbursement limitations may be an issue particularly for patients with unhealthy alcohol use that does not meet formal diagnostic criteria and therefore may not qualify for reimbursement depending on the health insurance provider. Future research could also examine additional predictors of patient-reported treatment offers (eg, provider- and setting-level variables), the degree to which patient-reported measures differ from other data sources (eg, medical records),27,33,34 and the impact of different criteria for a new treatment episode than the criterion used in this study (ie, no AUD treatment in the previous 3 months). Such research would inform efforts to provide timely, quality treatment for AUDs that is in accord with patients' treatment preferences.16,35
Acknowledgments
The authors thank their collaborators on the larger project to develop quality measures for alcohol misuse, particularly Daniel Kivlahan, Harold Pincus, Katherine Hoggatt, and Praise Iyiewuare for their comments and assistance with this manuscript. The authors also thank the VA Greater Los Angeles HSR&D Center for the Study of Health care Innovation, Implementation & Policy for their administrative support of this work.
Notes
This article was externally peer reviewed.
Funding: This research was supported by the National Institute on Alcohol Abuse and Alcoholism (grant R01AA019440; Kimberly A. Hepner, principal investigator).
Conflict of interest: SG's spouse is a salaried employee of Eli Lilly & Co and owns stock. SG has accompanied his spouse on company-sponsored travel. All other authors declare no conflicts of interest.
- Received for publication January 18, 2016.
- Revision received May 16, 2016.
- Accepted for publication May 19, 2016.
