Better care for patients who drink alcohol

A new primary care approach improves alcohol-related preventive care as well as care for alcohol use disorder

In a new randomized trial published in JAMA Internal Medicine, Kaiser Permanente researchers found that a novel approach to integrating alcohol-related care into primary care increased annual alcohol screening and brief preventive counseling for unhealthy alcohol use as part of routine primary care across 22 sites. The program also increased assessment and diagnosis of alcohol use disorder and the number of patients beginning alcohol treatment.

“Around 90% of patients in the U.S. with unhealthy alcohol use don’t receive recommended care, despite good evidence for the success of prevention and treatment,” said Amy Lee, MPH, lead author of the study and a practice facilitator in Mental Health and Wellness at Kaiser Permanente Washington. “Brief counseling with people who report drinking above recommended limits is a top prevention priority, recommended by the U.S. Preventive Services Task Force. But alcohol use has not traditionally been addressed as part of routine primary care until patients have medical complications due to drinking. This trial shows a practical approach to implementing alcohol screening, assessment, diagnosis, and initiation of treatment in primary care.”

The Sustained Patient-centered Alcohol-related Care (SPARC) trial randomly assigned clinics within Kaiser Permanente Washington to “launch” dates for beginning the new program of care, and compared outcomes for primary care patients who received care during the usual care period with those who received care during the intervention period. For the intervention, each clinic received 6 months of support from a practice facilitator with expertise in alcohol-related care, including trainings and weekly meetings with clinic team members to help improve workflows and care. In addition, prompts and decision support in the electronic health record alerted primary care teams to screen patients, evaluate any symptoms they reported, offer preventive counseling with a handout, and initiate treatment if appropriate. Primary care teams also received weekly feedback on the percentage of patients being screened and assessed.

For every 10,000 primary care patients seen during SPARC intervention periods, compared to those seen in usual care periods:

• 8,320 versus 2,080 had documented alcohol screening
• 57 versus 11 had documented brief intervention (one of two primary outcomes of the study)
• 80.9 versus 4.1 were assessed with a DSM-5 Alcohol Symptom Checklist for an alcohol use disorder
• 33.8 versus 28.8 had new alcohol use disorder diagnoses documented
• 7.8 versus 6.2 initiated alcohol treatment

The intervention did not increase the number of patients who stayed in treatment (2 additional visits after initiation), the other primary outcome of the research. The authors noted that further improvements would likely require new processes focused specifically on treatment engagement.

The trial took place over 3.5 years at Kaiser Permanente Washington, an integrated health organization in Washington state, and was a partnership with leaders in Mental Health and Wellness — Ryan Caldeiro, MD, and Rebecca Parrish, LICSW — working together with primary care teams. Alcohol-related care was implemented as part of a broader integrated mental health program of screening and addressing depression, suicidality, and other drug use. Patients completed a screening questionnaire while they waited to see their primary care provider, which allowed providers to talk to patients about alcohol use or other mental health conditions during the visit.

The partnership between researchers and health care leaders allowed the study to apply a rigorous design while addressing the needs of the health care organization. For example, clinics were randomized in 2 phases because it was not initially clear that the program could be rolled out everywhere. “The statistical analysis was challenging given the trial design, the large number of primary care patients included, the rare study outcomes and complex statistical models,” said Jennifer Bobb, PhD, the trial’s co-lead author and lead statistician and an associate investigator at Kaiser Permanente Washington Health Research Institute (KPWHRI).

“We found that standardizing the screening process, in ways that reduced stigma, and implementing screening for unhealthy alcohol use along with other mental health conditions as a routine part of primary care visits, was very successful in helping to overcome challenges to addressing alcohol in primary care. It provided a more holistic, patient-centered approach to addressing alcohol use,” said Kathy Bradley, MD, MPH, senior author on the study and a senior investigator at KPWHRI.

Since the study ended in 2018, clinics have sustained high rates of screening and assessment for alcohol use disorder. The researchers also received positive feedback during and after the trial.  “This program has had a measurable impact on patient care and our understanding of our patients’ health,” said Tolani Mwatha, MD, an associate medical director and primary care provider at Smokey Point Medical Center and medical director of operations for communicable diseases at Kaiser Permanente Washington.

The next step for the research team is to continue the partnership with clinical leaders to test a decision aid with patients who screen positive for high-risk unhealthy alcohol use. The decision aid is designed to help patients reflect and consider whether they want to make changes, and if so, what treatments, if any, would help them make those changes.

“We’ve gotten such a positive response to this work, and are very hopeful that it is an approach that will be useful for other health care organizations,” said Lee.

Other KPWHRI coauthors on the study are Julie Richards, Evette Ludman, Malia Oliver, Paula Lozano, Gwen Lapham, Emily C. Williams, and Joseph Glass.

This study was funded by the Agency for Healthcare Research and Quality (AHRQ).​​​​​