Lessons Learned
The Unhealthy Alcohol Use initiative enrolled practices through July 16, 2022. Between September 2020 and May 2023, facilitators delivered 216 sessions and these are our findings.
Did tailored practice facilitation improve rates of recommended screening and management of unhealthy alcohol use (UAU) in primary care practices?
In this cluster randomized clinical trial of 76 primary care practices, use of recommended screening instruments for UAU increased by 41.6% 6 months after intervention practices received tailored education, tools, and workflows, and brief clinic-based counseling also improved by 35.6%. Primary care practices that are willing to address workflow and approach to screening and counseling for UAU can dramatically increase their delivery of this recommended preventive service, which will improve health outcomes for patients. Click on the image or this link for the full article.
Alcohol use screening and multiple chronic conditions
We performed a secondary analysis of electronic health record data for 11,789 patients from 67 primary care practices in Virginia and used CMS’ chronic disease framework to classify patients by multiple chronic condition (MCC) status: no MCC, physical MCC, mental MCC, and physical and mental MCC. Patients with physical and mental health MCC had lower odds of receiving an assessment for unhealthy alcohol use than patients with no MCC. Click on the image to read the full article.
Equitable practice enrollment
Participating practices are geographically distributed across Virginia. The practices are rural, suburban, and urban. Patient catchment and their demographics of the practices enrolled mirror those of the state overall.
Read about how we used population health data to promote equitable recruitment (click image to open).
Catchment area of practices enrolled in the program. Deeper blue indicates more patients in the zip code for all practices enrolled.
76
practices enrolled including family medicine, internal medicine, and OB-GYN offices.
Environmental impact of virtual practice meetings
The project started during the COVID-19 pandemic and practice facilitation, education, and meetings were provided virtually. Three practice facilitators provided an average of 3.4 sessions for 64 practices. Virtual facilitation averted 32,574.8 drive miles and prevented the release of 12.7 metric tons of carbon dioxide, an offset equivalent to growing 210 trees for 10 years. Practices reported that virtual facilitation fostered greater engagement and allowed more clinicians and staff to attend sessions.
Read our research letter “Considering the Environmental Impact of Practice-Based Research” published by JABFM in March 2024 (click to view).
Check out our poster from the 2021 International Conference on Practice Facilitation (click to view).
Using the Electronic Health Record
To date, we have implemented screening and intervention workflows in 12 electronic health record systems ranging from small, free EHRs to large, corporate EHRs.
Only 1 EHR allowed for clinic-specific tailoring of the AUDIT-C questionnaire
40 practices used one EHR system (3 health system instances), each had a different screening process, and multiple pathways (six in total) for unhealthy alcohol use.
The average rooming staff took between 2-8 clicks to enter screening data; the clincian reviewing the screener also took between 2-8 clicks.
One tailored EHR required 12 clicks for screening and 12 clicks for review.
4 screening options are available most commonly: CAGE, open ended volume of alcohol, AUDIT-C, and SAS-Q.
Read JAMA Viewpoint on Electronic Health Records from our PIs (click to open).
See our poster from the North American Primary Care Research Group annual meeting 2022 (click to open).
Read JAMA Internal Medicine Invited Commentary about screening and counseling (click to open).
Screening with a validated tool more effectively identifies risky alcohol use
60 patients (18-79 years old) were randomly selected from participating practices at three timepoints. Each patient was mailed a survey with 21 questions - including the AUDIT-C and whether their primary care provider asked about alcohol use or provided counseling. Chart review was conducted on the same patients to identify alcohol screening and counseling. 63 practices and 3,760 patients were analyzed. The patient survey (n = 846) screened using the AUDIT-C 100% of the time and clinicians according to the chart review (n = 3760) screened using the AUDIT-C 15.7% of the time. The proportion of patients with unhealthy alcohol use determined by a validated tool was 24% from the survey and 12.7% from the chart review. While clinicians did screen for alcohol, they failed to identify risky use in many patients as there was infrequent use of validated screening tools in practice. The AUDIT-C is a much more reliable tool to identify alcohol use; this can be readily implemented into practice.