Receipt Of Brief Intervention Research Articles

Alcohol-Related Care Among Veterans With Unhealthy Alcohol Use: The Role of Long-Term Opioid Therapy Receipt.

Long-term opioid therapy (LTOT) is potentially dangerous among patients with unhealthy alcohol use because of possible adverse interactions. We examined receipt of alcohol-related care among patients with unhealthy alcohol use receiving LTOT and without opioid receipt. We use data collected from 2009 to 2017 in the Women Veterans Cohort Study, a national cohort of Veterans engaged in Veterans Health Administration care. We included patients who screened positive for unhealthy alcohol use (score ≥5) using the Alcohol Use Disorder Identification Consumption questionnaire. Our primary exposure was LTOT (receipt of prescribed opioids for ≥90 days) versus no opioid receipt at the time of the first positive Alcohol Use Disorder Identification Consumption. Our primary outcome was receipt of brief intervention within 14 days of positive alcohol screen. Unadjusted and 4 adjusted modified Poisson regression models assessed prevalence and relative rates (RRs) of outcomes. Among eligible veterans, 6222 of 113,628 (5.5%) received LTOT at screening. Among patients receiving LTOT, 67.5% (95% confidence interval [CI], 66.3%-68.6%) had a documented brief intervention within 14 days of positive screen, compared with 70.1% (95% CI, 69.8%-70.4%) among patients without opioid receipt (RR, 0.96; 95% CI, 0.95-0.98; P < 0.001). Within adjusted models, the rate of brief intervention among patients receiving LTOT remained lower than patients without opioid receipt. Among patients with unhealthy alcohol use, patients receiving LTOT had significantly lower rates of brief intervention receipt compared with those without opioid receipt, and they should be a focus for interventions to improve alcohol-related care and safer opioid prescribing.

Patient and provider factors associated with receipt and delivery of brief interventions for unhealthy alcohol use in primary care.

Unhealthy alcohol use is a serious and costly public health problem. Alcohol screening and brief interventions are effective in reducing unhealthy alcohol consumption. However, rates of receipt and delivery of brief interventions vary significantly across healthcare settings, and relatively little is known about the associated patient and provider factors. This study examines patient and provider factors associated with the receipt of brief interventions for unhealthy alcohol use in an integrated healthcare system, based on documented brief interventions in the electronic health record. Using multilevel logistic regression models, we retrospectively analyzed 287,551 adult primary care patients (and their 2952 providers) who screened positive for unhealthy drinking between 2014 and 2017. We found lower odds of receiving a brief intervention among patients exceeding daily or weekly drinking limits (vs. exceeding both limits), females, older age groups, those with higher medical complexity, and those already diagnosed with alcohol use disorders. Patients with other unhealthy lifestyle activities (e.g., smoking, no/insufficient exercise) were more likely to receive a brief intervention. We also found that female providers and those with longer tenure in the health system were more likely to deliver brief interventions. These findings point to characteristics that can be targeted to improve universal receipt of brief intervention.

Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients

Background/objectiveEvidence-based alcohol-related care–brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)–should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. MethodsWe extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09–7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0–14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0–365 days following screening), and filled prescriptions for medications to treat AUD (documented 0–365 days following screening) for transgender patients, and compared to that of non-transgender patients. ResultsAmong transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2–78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7–17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1–20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98–1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12–1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06–1.28, p = 0.002). ConclusionsFindings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.

Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration

ObjectiveBrief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)—the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use. MethodsAmong 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender. ResultsRates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results. ConclusionsReceipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.

Alcohol use and receipt of alcohol screening and brief intervention in a representative sample of sexual minority and heterosexual adults receiving health care

BackgroundDespite evidence of alcohol disparities between sexual minority and heterosexual individuals in the general population, research has not examined whether there are disparities in receipt of alcohol screening and brief intervention − together considered one of the highest prevention priorities for US adults. This study examined differences in alcohol use and receipt of alcohol screening and brief intervention across sexual minority status. MethodsBehavioral Risk Factor Surveillance System 2014 data from eight US states were used to estimate patterns of alcohol use and receipt of alcohol screening and brief intervention among persons reporting sexual orientation and a checkup in the last two years (N=47,800). Analyses were conducted in 2016–2017. ResultsGay men and bisexual women reported higher rates of alcohol use on some measures compared to heterosexual men and women, respectively. There were some differences in screening and brief intervention by sexual orientation. Lesbian women were more likely to report being asked about heavy episodic drinking than heterosexual women, and among those reporting unhealthy alcohol use, gay men were less likely, and bisexual men were more likely, to report receiving brief intervention compared to heterosexual men. ConclusionsOverall similarities between sexual minorities and heterosexuals in alcohol use and receipt of screening and brief intervention are encouraging. Nonetheless, research is needed to confirm findings and understand mechanisms underlying disparities in receipt of brief intervention between gay and heterosexual men.

Influence of a targeted performance measure for brief intervention on gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the Veterans Health Administration

AimsWomen are less likely than men to receive brief intervention (BI) for unhealthy alcohol use. In 2007, the U.S. Veterans Health Administration (VA) used a national performance measure to implement BI. Although AUDIT-C scores ≥3 for women and ≥4 for men optimize sensitivity and specificity for identifying unhealthy alcohol use, VA's performance measure required BI only among a targeted subgroup defined by a non-gender-specific score threshold (AUDIT-C ≥5). This may have influenced gender differences in receipt of BI among those optimally eligible for BI. Therefore, we evaluate differences in proportions of women and men offered BI before and after BI implementation. MethodsNational secondary chart review data (7/06-6/10) identified all outpatients with unhealthy alcohol use for whom BI would be indicated (AUDIT-C ≥3 women, ≥4 men). Logistic regression, including a time-by-gender interaction, estimated the prevalence and 95% confidence interval (CI) of BI for women and men pre- and post-implementation. FindingsAmong patients optimally eligible for BI (n=51,272, 8206 women and 43,066 men), the prevalence of BI increased more steeply for men than women after implementation (interaction p-value <0.0001). Pre-implementation rates of BI were 21% (95% CI, 18–24) for women and 26% (95% CI, 24–29) for men, and post-implementation rates were 32% (95% CI, 30–34) for women and 47% (95% CI, 45–49) for men. ConclusionsHealthcare systems implementing BI with performance measures may wish to consider that specifying a single alcohol screening threshold for men and women may increase gender differences in receipt of BI among patients likely to benefit.

Association Between Receipt of Brief Alcohol Intervention and Quality of Care among Veteran Outpatients with Unhealthy Alcohol Use.

Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships. The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use. Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP). The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009-2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care. We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care--patient ratings of their VA provider and of overall VA healthcare (range 0-10, dichotomized as ≥ 9 indicating high quality)--for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year. Among 10,612 eligible veterans, 43.8% reported having received brief intervention, and 84.2% and 79.1% rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9% vs. 82.0%, p < 0.01) and the VA overall (82.7% vs. 75.9%, p < 0.01) as high. In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients' perceptions of care.

Predictive value of readiness, importance, and confidence in ability to change drinking and smoking

Visual analog scales (VASs) are used to assess readiness to change constructs, which are considered critical for change. We studied whether three constructs—readiness to change, importance of changing, and confidence in ability to change—predict risk status six months later in 20-year-old men with either or both of two behaviors: risky drinking and smoking. Five hundred and seventy-seven participants in a randomized trial of brief intervention (BI) were assessed at baseline and six months on alcohol and tobacco consumption, with three 1-10 VASs (readiness, importance, confidence) for each behavior. We used one regression model for each behavior and construct. Models controlled for receipt of BI and used the VAS lowest level (1-4) as the reference group (versus medium [5-7] and high [8-10] levels). Among the 475 risky drinkers, mean (SD) readiness, importance, and confidence in ability to change drinking were 4.0 (3.1), 2.8 (2.2), and 7.2 (3.0). Readiness was not associated with being free of alcohol risk at six months (OR 1.3 [0.7; 2.2] and 1.4 [0.8; 2.6] for medium and high readiness). High importance and confidence were associated with being risk free (OR 0.9 [0.5; 1.8] and 2.9 [1.2; 7.5] for medium and high importance; 2.1 [1.0; 4.8] and 2.8 [1.5; 5.6] for medium and high confidence). Among the 320 smokers, mean readiness, importance, and confidence to change were 4.6 (2.6), 5.3 (2.6), and 5.9 (2.6). Neither readiness nor importance was associated with being smoking free (OR 2.1 [0.9; 4.7] and 2.1 [0.8; 5.8] for medium and high readiness; 1.4 [0.6; 3.4] and 2.1 [0.8; 5.4] for medium and high importance). High confidence was associated with being smoking free (OR 2.2 [0.8; 6.6] and 3.4 [1.2; 9.8] for medium and high confidence). For drinking and smoking, high confidence in ability to change was associated, with similar magnitude, with a favorable outcome. This points to the value of confidence as a predictor of successful change.

Predictive value of readiness, importance, and confidence in ability to change drinking and smoking

BackgroundVisual analog scales (VAS) are sometimes used to assess change constructs that are often considered critical for change. Aims of Study: 1.) To determine the association of readiness to change, importance of changing and confidence in ability to change alcohol and tobacco use at baseline with the risk for drinking (more than 21 drinks per week/6 drinks or more on a single occasion more than once per month) and smoking (one or more cigarettes per day) six months later. 2.) To determine the association of readiness, importance and confidence with alcohol (number of drinks/week, number of binge drinking episodes/month) and tobacco (number of cigarettes/day) use at six months.MethodsThis is a secondary analysis of data from a multi-substance brief intervention randomized trial. A sample of 461 Swiss young men was analyzed as a prospective cohort. Participants were assessed at baseline and six months later on alcohol and tobacco use, and at baseline on readiness to change, importance of changing and confidence in ability to change constructs, using visual analog scales ranging from 1–10 for drinking and smoking behaviors. Regression models controlling for receipt of brief intervention were employed for each change construct. The lowest level (1–4) of each scale was the reference group that was compared to the medium (5–7) and high (8–10) levels.ResultsAmong the 377 subjects reporting unhealthy alcohol use at baseline, mean (SD) readiness, importance and confidence to change drinking scores were 3.9 (3.0), 2.7 (2.2) and 7.2 (3.0), respectively. At follow-up, 108 (29%) reported no unhealthy alcohol use. Readiness was not associated with being risk-free at follow-up, but high importance (OR 2.94; 1.15, 7.50) and high confidence (OR 2.88; 1.46, 5.68) were. Among the 255 smokers at baseline, mean readiness, importance and confidence to change smoking scores were 4.6 (2.6), 5.3 (2.6) and 5.9 (2.7), respectively. At follow-up, 13% (33) reported no longer smoking. Neither readiness nor importance was associated with being a non-smoker, whereas high confidence (OR 3.29; 1.12, 9.62) was.ConclusionsHigh confidence in ability to change was associated with favorable outcomes for both drinking and smoking, whereas high importance was associated only with a favorable drinking outcome. This study points to the value of confidence as an important predictor of successful change for both drinking and smoking, and shows the value of importance in predicting successful changes in alcohol use.Trial registration numberISRCTN78822107