Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients

BACKGROUND

Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062).

METHODS

Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use.

RESULTS

Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use.

CONCLUSIONS

Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.

Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics

IMPORTANCE

Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations.

OBJECTIVE

To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021.

INTERVENTIONS

Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing.

MAIN OUTCOMES AND MEASURES

Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script.

RESULTS

Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%).

CONCLUSIONS AND RELEVANCE

In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02963948.

Genetic Consequences of the Transatlantic Slave Trade in the Americas

According to historical records of transatlantic slavery, traders forcibly deported an estimated 12.5 million people from ports along the Atlantic coastline of Africa between the 16th and 19th centuries, with global impacts reaching to the present day, more than a century and a half after slavery's abolition. Such records have fueled a broad understanding of the forced migration from Africa to the Americas yet remain underexplored in concert with genetic data. Here, we analyzed genotype array data from 50,281 research participants, which-combined with historical shipping documents-illustrate that the current genetic landscape of the Americas is largely concordant with expectations derived from documentation of slave voyages. For instance, genetic connections between people in slave trading regions of Africa and disembarkation regions of the Americas generally mirror the proportion of individuals forcibly moved between those regions. While some discordances can be explained by additional records of deportations within the Americas, other discordances yield insights into variable survival rates and timing of arrival of enslaved people from specific regions of Africa. Furthermore, the greater contribution of African women to the gene pool compared to African men varies across the Americas, consistent with literature documenting regional differences in slavery practices. This investigation of the transatlantic slave trade, which is broad in scope in terms of both datasets and analyses, establishes genetic links between individuals in the Americas and populations across Atlantic Africa, yielding a more comprehensive understanding of the African roots of peoples of the Americas.

Magnetic resonance profiling of human skin in vivo using GARField magnets

It is shown that one-dimensional magnetic resonance imaging (MRI-profiling) of human forearm and side-of-hand skin in vivo is possible using GARField magnets. Strong profile contrast originating from differing molecular mobility is seen for stratum corneum and viable epidermis. The first in vivo spatially-resolved field-gradient measurements of water self-diffusivity, D, in the stratum corneum (2.0 x 10(-6) cm(2)/s) and viable epidermis (8.5 x 10(-6) cm(2)/s) are reported. Also reported are spatially resolved measurements of the (1)H spin-lattice relaxation time, T(1), the spin-spin relaxation time, T(2). It is further shown that the application of moisturizing agents to the skin noticeably affects the profiles. However, universal behavior is not seen as both signal increases and decreases are observed dependent on agent and volunteer.

Steroid hormones during embryonic development in Japanese quail: plasma, gonadal, and adrenal levels

The purpose of this experiment was to measure plasma, gonad, and adrenal steroid hormones during embryonic and early posthatch development in Japanese quail. Blood plasma samples were collected from male and female Japanese quail embryos at 2-d intervals between Day 10 of incubation and Day 5 posthatch. Gonads and adrenal glands were collected from a separate set of embryos at the same ages. Concentrations of androgen (testosterone and 5alpha-dihydrotestosterone) and 17beta-estradiol (E2) were determined by RIA. Plasma androgen changed significantly (P < 0.001) with age in males and females, and there were significant differences (P < 0.001) between sexes in the hormonal patterns. Males had higher plasma androgen than females; conversely, females consistently had overall higher levels of estradiol than males. Adrenal gland steroid content remained relatively high and did not change significantly with age. In contrast, steroid content of gonads followed patterns similar to those observed for plasma levels. These results provide evidence for steroid hormone production by the gonads of both sexes, as well as for distinct differences in the patterns observed in the adrenal gland and gonads. These results provide evidence for gonadal regulation of changes in circulating hormone levels. Further, these hormonal patterns were associated with the timing of steroid-induced sexual differentiation in the Japanese quail, suggesting that plasma gonadal steroids are critical in sexual differentiation.

Changes in regional fat redistribution and the effects of estrogen during spontaneous weight gain in women with anorexia nervosa

BACKGROUND

Anorexia nervosa is a disease of severe acquired undernutrition with a high and increasing prevalence among young women in the United States.

OBJECTIVE

The objective was to investigate the effects of spontaneous outpatient weight recovery and estrogen administration on fat distribution in patients with anorexia nervosa.

DESIGN

Twenty-seven amenorrheic women aged 26.6 +/- 1.2 y with anorexia nervosa were identified through an outpatient study of bone loss and were randomly assigned to receive or not receive estrogen without any dietary intervention other than calcium and multivitamin supplements. Body composition was measured at baseline and at 6 and 9 mo and was compared with cross-sectional values obtained in 20 healthy, eumenorrheic, age-matched (25.4 +/- 0.5 y) control subjects.

RESULTS

Twenty of the 27 patients with anorexia aged 27.0 +/- 1.3 y spontaneously gained weight (4.1 +/- 0.9 kg); body mass index (in kg/m(2)) increased from 16.1 +/- 0.3 to 17.5 +/- 0.4. Fat mass and lean mass accounted for 68% and 32% of the gain in total body mass, respectively. With spontaneous weight gain, there was a significant increase in the percentage of trunk fat from 32.4 +/- 1.3% at baseline to 36.5 +/- 1.0% at 9 mo (P = 0.03), which correlated with urinary free cortisol (r = 0.66, P = 0.003). Estrogen treatment was not protective against the gain in trunk fat with spontaneous weight gain.

CONCLUSIONS

In women with anorexia nervosa, spontaneous weight gain is associated with a significant increase in trunk adiposity, and estrogen administration may not protect against the accumulation of central fat with weight gain.

Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa

BACKGROUND

Anorexia nervosa is highly prevalent among young women.

OBJECTIVE

To determine prevalence and predictive factors for regional bone loss.

DESIGN

Prospective cohort analysis.

SETTING

University hospital.

PATIENTS

130 women with anorexia nervosa.

MEASUREMENTS

Dual-energy x-ray absorptiometry.

RESULTS

The prevalence of osteopenia (-1.0 SD >/= T-score > -2.5 SD) and osteoporosis (T-score </= -2.5 SD) was 50% and 13% for the anterior-posterior spine, 57% and 24% for the lateral spine, and 47% and 16% for the total hip, respectively. Bone mineral density (BMD) was reduced by at least 1.0 SD at one or more skeletal sites in 92% of patients and by at least 2.5 SD in 38% of patients. Weight was the most consistent predictor of BMD at all skeletal sites. Twenty-three percent of patients were current estrogen users, and 58% were previous estrogen users. Bone mineral density did not differ by history of estrogen use at any site.

CONCLUSIONS

Bone mineral density is reduced at several skeletal sites in most women with anorexia nervosa. Weight, but not estrogen use, is a significant predictor of BMD in this population at all skeletal sites.

Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea

Reduced bone density is observed in over half of women with anorexia nervosa (AN), in whom the risk of fracture is significantly increased even at a young age. It is unknown to what extent low bone density in AN differs from other conditions of premenopausal osteoporosis and is related to estrogen deficiency and/or other factors, such as nutritional status. We therefore investigated bone loss in nutritionally replete and nutritionally deplete amenorrheic women by comparing patients with AN (n = 30) to age-matched subjects with hypothalamic amenorrhea (HA; n = 19) in whom duration of amenorrhea, prior estrogen use, and age of menarche were comparable. Healthy, age-matched, eumenorrheic women were studied as a control group (NL; n = 30). Weight and nutritionally dependent factors including (body mass index, 20.7 +/- 0.3 vs. 16.7 +/- 0.3 kg/m2; P < 0.0001), insulin-like growth factor I (270 +/- 18 vs. 203 +/- 17 ng/mL; P < 0.01), percent body fat (26% vs. 19%; P < 0.0001), and lean body mass (38.7 +/- 1.1 vs. 34.3 +/- 0.8, P < 0.01) were significantly different between the HA and AN groups, respectively. The bone densities of the anterior-posterior (AP) spine, total hip, and total body measured by dual energy x-ray absortiometry were reduced in both amenorrheic groups compared to those in control subjects, but were significantly lower in women with AN than in those with HA. The t scores for AP spine and hip were -1.80 +/- 0.15 (AN), -0.80 +/- 0.22 (HA), and 0.28 +/- 0.19 SD (NL) for the AP spine and -1.62 +/- 0.17 (AN), -0.51 +/- 0.21 (HA), and 0.25 +/- 0.16 (NL) for the total hip, respectively (P < 0.01 for all comparisons). Among the amenorrheic subjects, duration of amenorrhea, age of menarche, and N-telopeptide were inversely correlated with bone density at all sites, whereas body mass index, insulin-like growth factor I, lean body mass, and fat intake were positively correlated with bone density at all sites measured. In multivariate regression analyses, bone density was most significantly related to lean body mass (P = 0.05 and P = 0.03 for the spine and hip, respectively), but not to the duration of amenorrhea or other indexes of estrogen status among patients with AN. In contrast, bone density of the lumbar spine was significantly related to weight and duration of amenorrhea among patients with HA. These data demonstrate that the severity of osteopenia in AN is greater than that in patients with HA and is critically dependent upon nutritional factors in addition to the degree or duration of estrogen deficiency itself. Lean body mass, independent of the duration or severity of estrogen deficiency, is an important predictor of bone loss among women with AN.

External validation of the Ottawa knee rules in an urban trauma center in the United States

OBJECTIVE

We evaluated the Ottawa knee rules in a high-volume teaching hospital in the United States to determine whether the rules could be safely used to decide whether patients with acute blunt knee trauma should undergo radiography.

SUBJECTS AND METHODS

During a 13-month period, 378 patients with acute blunt knee trauma were prospectively examined using the Ottawa knee rules. Data collected included the presence or absence of fracture predictors and the results of radiography.

RESULTS

A fracture was seen in 43 (11%) of the 378 patients who met inclusion criteria. The knee rules predicted 42 of the 43 fractures; sensitivity was 98%, and specificity was 19%. Radiography of 65 patients (17%) who had no predictors for fracture could have been avoided if the knee rules had been used to screen for radiography.

CONCLUSION

The Ottawa knee rules are highly sensitive for fracture in this setting and may safely be used to decide whether patients with acute blunt knee trauma should undergo radiography.

Heinz dilemma? Let the subject choose!

This description of a novel approach for studying the validity of Kohlberg's sequential and hierarchical theory of moral development involved 138 boys and 113 girls (14 to 18 years old) choosing a solution among 12 to Kohlberg's Heinz dilemma instead of being assigned one by an interviewer. The results were not supportive of the theory. The methodology of research on moral development needs to be examined.

Human purine nucleoside phosphorylase and adenosine deaminase: gene transfer into cultured cells and murine hematopoietic stem cells by using recombinant amphotropic retroviruses

Cell lines were established which produced high titers (approximately 10(6) infectious units per ml) of amphotropic, replication-defective recombinant retroviruses which transduced sequences encoding either human purine nucleoside phosphorylase (PNP) or adenosine deaminase (ADA). These viruses also contained a human hypoxanthine phosphoribosyltransferase gene as a selectable marker and a mouse metallothionein promoter (MMP) sequence just upstream from the PNP or ADA genes. Virus structure was maintained through the replication cycle if a short (216-base pair) MMP sequence was used. However, the use of a longer (1,834-base pair) MMP sequence resulted in the deletion of a significant portion of the recombinant virus genome, including the transcriptional regulatory elements of the MMP sequence. Northern analysis indicated a predominance of genome length transcripts in cells infected with deleted virus. The demonstration of substantial human PNP or ADA activity in virus-infected mouse fibroblasts by isozyme analysis suggested that active gene product was translated from either spliced or bicistronic message. The deleted ADA and PNP viruses were introduced into mouse hematopoietic stem cells by cocultivating freshly explanted bone marrow with virus producer cells. The infected marrow cells were injected into irradiated, syngeneic recipient mice, and the presence of integrated ADA or PNP proviral sequences was demonstrated in the DNA of spleen colonies by Southern analysis. Failure of these integrated proviral sequences to express active, human isozyme in spleen colony tissue indicated the existence of some regulatory constraint not active in cultured mouse cells.