Date Published: December 7, 2017
Publisher: BioMed Central
Author(s): Marcus A. Bachhuber, Megan A. O’Grady, Henry Chung, Charles J. Neighbors, Joseph DeLuca, Elenita M. D’Aloia, Arelis Diaz, Chinazo O. Cunningham.
Screening and brief intervention (SBI) for unhealthy drinking has not been widely implemented in primary care partly due to reliance on physicians to perform it.
We implemented a model of nursing staff-delivered SBI for unhealthy drinking for adult patients receiving primary care at an academically-affiliated Federally Qualified Health Center in the Bronx, NY. Our model consisted of nursing staff screening all patients with the alcohol use disorders identification test consumption questions (AUDIT-C) and, if screening positive, providing BI or referral to specialty services. We developed a clinical decision support tool integrated into the electronic health record to guide nursing staff and record SBI provision. To evaluate this model, we determined overall SBI delivery to patients and factors associated with receiving SBI.
Between October 2013 and September 2014, 9119 unique adult patients made 24,285 visits. Patients were majority women (67.5%) and Hispanic/Latino (54.5%). Overall, 46.2% were screened, with 19.0–35.8% of eligible patients screened in each month. Increasing age (OR: 0.82 [95% CI 0.80–0.85] for a 10-year increase), female sex (OR: 0.83 [95% CI 0.77–0.91]), and chronic conditions like hypertension (OR: 0.62 [95% CI 0.56–0.70]) and diabetes (OR: 0.66 [95% CI 0.58–0.75]), among others, were associated with a lower odds of being screened. Of all patients screened, 225 (5.3%) screened positive and of those patients, 122 (54.2%) received a BI. Patients with higher AUDIT-C scores were more likely to receive a BI (OR: 1.24 [95% CI 1.04–1.47] for a 1-point increase) and non-English speaking patients were less likely to receive a BI than those who spoke English (OR: 0.42 [95% CI 0.18–0.97]).
Our model of SBI resulted in screening of nearly half of all eligible patients and BI provision to over half of those screening positive. Future efforts to improve SBI delivery should focus on groups such as older adults, women, and those with chronic medical conditions.
Unhealthy alcohol use, defined as drinking at a level that can lead to negative health consequences , is a leading cause of preventable morbidity and mortality in the US . Screening and brief intervention for unhealthy drinking (SBI) can reduce self-reported drinking in primary care settings . Despite the US Preventive Services Task Force recommendation that all adults receive SBI , it is uncommonly provided, resulting in missed opportunities to improve outcomes . In a recent national study, while 71.1% of respondents reported that their doctor asked about alcohol use (not necessarily with standardized validated screening tools), only 4.4% of those with heavy episodic (i.e., binge) drinking reported being advised to cut back . This gap between evidence and practice is likely the result of several barriers, including competing clinical priorities, staff training and knowledge, and organizational factors .
Between October 2013 and September 2014, 9119 adult patients attended one or more visit. The mean number of visits per patient was 2.7 (range 1–32). Patients were majority women (67.5%) and Hispanic/Latino (54.5%; Table 1). Most patients preferred English (71.5%), followed by Spanish (25.4%). The most common chronic conditions among patients were hypertension (26.5%), diabetes (14.8%), and depression (13.1%).Table 1Demographic and clinical characteristics of adult medicine patients of an urban academic Federally Qualified Health Center during implementation of a screening and brief intervention initiative (n = 9119)Characteristicn (%)Age, median (IQR)48.8 (33.7, 60.9)Female sex6153 (67.5)Race/ethnicity Black, non-Hispanic945 (10.4) Hispanic, of any race4965 (54.5) Any other or undetermined racea3209 (35.2)Language English6518 (71.5) Spanish2316 (25.4) French285 (3.1)Chronic conditions Hypertension2420 (26.5) Diabetes1345 (14.8) Congestive heart failure162 (1.8) Chronic kidney disease305 (3.3) HIV255 (2.8) Hepatitis C virus113 (1.2) Depression1194 (13.1) Opioid or cocaine use disorder460 (5.0)aIncludes White, Asian/Pacific Islander, Native American/Alaskan Native, or more than one race
Using a model of nursing staff-delivered SBI with an integrated CDS tool, our adult medicine practice screened almost half of all patients and provided a BI to over half of patients who screened positive. Monthly rates of screening increased modestly over the 1-year study period. Our study is among the few published studies reporting SBI rates and factors associated with receipt of SBI, in which SBI is integrated into routine care and delivered by nursing staff that are not grant funded . As most clinical settings would not have additional grant funding available for SBI implementation, our findings are significant by showing that SBI can be integrated into routine care in an urban safety net setting without additional funding by using team-based models along with other implementation facilitators such as clinical champions, EHR CDS tools, and getting feedback and buy-in among all team members of the clinic.
In a Bronx Federally Qualified Health Center without dedicated grant-funded personnel, we integrated a model of nursing staff-delivered routine SBI for unhealthy drinking into primary care. Almost half of the patients presenting for one or more visit were screened, and of those who screened positive, over half received a BI. Patient characteristics including older age, female sex, and chronic illnesses were associated with lower odds of screening; non-English language was associated with lower odds of receiving a BI. While integrating SBI into routine primary care by nursing staff can lead to moderate screening rates, it is important to ensure that SBI is delivered to patients who could clinically benefit most (e.g., those with chronic diseases impacted by unhealthy alcohol use). Health care facilities need to continue to integrate models of SBI that are comprehensively delivered to patients in routine primary care.