Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use
Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes.
To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior
Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system.
A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews.
Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up.
The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated.
This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.
KEY WORDSalcoholism and addictive behavior primary care quality assessment substance abuse veterans
We thank the VA Greater Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy and Lisa Altman, MD, for their collaboration and organizational support of this research. Further, we are grateful for the extensive contribution of Daniel Kivlahan, PhD, to this study and for his critiques on earlier versions of this manuscript. Portions of this paper were presented at the 2017 Addiction Health Services Research (AHSR) conference, Madison, WI; the 2017 International Network on Brief Interventions for Alcohol and Other Drugs (INEBRIA) conference, New York, NY; and the 2017 Research Society on Alcoholism (RSA) conference, Denver, CO.
This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01AA019440). Dr. Hoggatt was funded through a Department of Veterans Affairs, Veterans Health Administration (VA) Health Services Research & Development/Quality Enhancement Research Initiative (HSR&D/QUERI) Career Development Award (CDA 11-261) at the VA Greater Los Angeles Healthcare System.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
The views expressed within are solely those of the authors, and do not necessarily represent the views of the Department of Veterans Affairs or of the United States government.
- 1.U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: Recommendation statement. AHRQ publication no. 12–05171-EF-3. Available at: http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuse/alcmisusefinalrs.htm. Accessed October 10, 2018.
- 7.National Institute for Health and Care Excellence. Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence (Clinical guideline [CG115]). Available at: https://www.nice.org.uk/guidance/cg115. Accessed October 10, 2018.
- 8.U.S. Department of Veterans Affairs and U.S. Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders - Version 3.0–2015. Available at: http://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf. Accessed October 10, 2018.
- 13.National Quality Forum. Measure evaluation criteria and guidance for evaluating measures for endorsement. Available at: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=79434. Accessed October 10, 2018.
- 15.Dunigan R, Acevedo A, Campbell K, et al. Engagement in outpatient substance abuse treatment and employment outcomes. J Behav Health Serv Res. 2014;41(1). https://doi.org/10.1007/s11414-013-9334-2.
- 23.Mattox T, Hepner KA, Kivlahan D, et al. Quality measures to assess care for alcohol misuse: Measure technical specifications (TL-197-NIAAA). Santa Monica, CA: RAND Corporation; 2016. http://www.rand.org/pubs/tools/TL197.html. . Accessed 21 Nov 2018.
- 24.Agency for Healthcare Research and Quality. Part II. Introduction to measures of quality. Available at: https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/perfmeasguide/perfmeaspt2.html. Accessed October 10, 2018.
- 27.National Institute on Alcohol Abuse and Alcoholism. What’s “low-risk” drinking? Available at: http://rethinkingdrinking.niaaa.nih.gov/IsYourDrinkingPatternRisky/WhatsLowRiskDrinking.asp. Accessed October 10, 2018.
- 28.Little RJA, Rubin DB. Statistical analysis with missing data. New York, NY: Wiley; 1987.Google Scholar
- 29.The American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys. 9. Oakbrook Terrace, IL: The American Association for Public Opinion Research; 2016.Google Scholar
- 30.Lumley T. Analysis of complex survey samples. J Stat Softw. 2004;9(1):1–19.Google Scholar
- 31.Lumley T. Survey: analysis of complex survey samples. 2014. R package version. 2014;3:5.Google Scholar
- 32.Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates; 1988.Google Scholar