Date Published: April 9, 2018
Publisher: BioMed Central
Author(s): Jennifer McNeely, Pritika C. Kumar, Traci Rieckmann, Erica Sedlander, Sarah Farkas, Christine Chollak, Joseph L. Kannry, Aida Vega, Eva A. Waite, Lauren A. Peccoralo, Richard N. Rosenthal, Dennis McCarty, John Rotrosen.
Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.
Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006).
Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.
Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.
The online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.
Alcohol and drug use are among the top ten causes of preventable death in the United States [1–4], but substance use disorders (SUDs) are greatly under-treated in the specialty addiction treatment system , and under-recognized in medical settings [6, 7]. Screening for alcohol use in adult primary care settings is recommended by the United States Preventive Services Task Force (USPSTF) and ranks as the third highest prevention priority for adults in the U.S [8–13]. The U.S. Surgeon General’s report on addiction recommends screening for other drug use as well as alcohol, which is the current approach of federally-funded ‘screening, brief intervention, and referral to treatment (SBIRT)’ programs [14, 15]. Yet despite over a decade of concerted efforts to integrate substance use screening and interventions into mainstream medical care , primary care patients are rarely screened, assessed or treated for SUDs [6, 7, 17–22].
Demographic characteristics of the 67 participants are included in Table 1. Among the PCP participants, 29 were faculty and 5 were internal medicine residents. Two PCPs participated in both a focus group and an individual interview. A total of 15 medical assistants and 3 registered nurses participated. Most of the patient participants were over 45 years of age and female, and were primarily recruited from the New York teaching practice (NY-1 clinic).Table 1Characteristics of the 67 participantsCharacteristicTotalN = 67MDsN = 34MAs and RNsN = 18PatientsN = 15Age—mean (SD)46 (SD = 12)39 (11)40 (SD = 9)52 (SD = 13)Age range27–7227–6827–5628–72Age group 26–35211461 36–45191063 46 +258511Missing2210Sex Female49211412 Male181343Hispanic No50301010 Yes14284Missing3201Race Caucasian231921 Asian141310 Black15069 Other10064Missing5231Medical specialtyN/AN/AN/A Internal medicine29 Family medicine2Missing3Patients seen per weekN/AN/AN/A 0–5018 51–10011 > 1001Missing4
Through interviews with key clinical stakeholders, this study characterized current substance use screening practices, barriers to screening, and recommendations for its implementation in primary care clinics. Our approach is unique in capturing the views of patients, as well as those of primary care providers, residents, MAs, and RNs. To be successful in practice, screening must be acceptable to all of these groups. By including participants from two health systems that differ markedly both in their geography, their health care environment, and their experience with SBIRT, we captured diverse views.
Our study has some limitations. While we included sites from very different parts of the U.S., both were academic medical centers located in urban areas. Individuals from rural areas, or in smaller community primary care practices, may have different views on substance use screening. Most interviews were done at the New York site, and we were not able to conduct any patient interviews or focus groups in Oregon, which gave us a more limited picture of stakeholder attitudes from this health system. PCPs in our sample included both residents and faculty, but all were physicians. This reflects the characteristics of our sites, in which the majority of primary care providers, and all individuals identified as having SBIRT or HIT expertise, were MDs. Licensed providers with different training, such as nurse practitioners or Doctors of Osteopathy, may have different views about screening. While we consider the inclusion of patients to be an important strength of the study, it proved difficult to recruit younger patients, and so their views may be underrepresented. This could be important, because younger patients may have higher rates of substance use, and greater concerns about issues such as the impact of screening on their employment or health insurance. Interviews were conducted only in English, which also excluded some patients. Because our objective was to capture the views of a general primary care patient population, we have little representation of patients with current alcohol and drug use disorders. Our interviews were conducted by the study PI (in New York) or the site Lead Investigator (in Oregon), which has the potential to introduce social desirability bias. However, we did not see direct evidence of this in the interviews, in which many participants spoke critically about the current system of care and about substance use screening and interventions.
This qualitative study can inform the design of substance use screening programs in primary care practices. Based on our findings, we have designed and are now testing a strategy that seeks to optimally utilize existing staff and resources to deliver screening in the participating clinics. We are implementing validated brief screening questionnaires, administered annually to all patients, using a patient self-administered approach when possible. Screening results will be paired with EHR-integrated clinical decision support to assist primary care providers in conducting a brief counseling intervention. We have improved the system for linking patients with high-risk substance use to care by identifying a clear process for referring patients to the clinic’s existing social workers, training the social workers in brief intervention, and improving their knowledge of referral sources for addiction treatment. We are hopeful that educating medical providers about substance use and interventions will begin to address providers’ negative attitudes toward patients with unhealthy alcohol and drug use, but more work is likely needed to address stigmatizing beliefs among providers and clinical staff. To directly address patient concerns about stigma, we plan to use signage and consistent language to communicate to patients that screening is universal, and is part of routine medical care.