"The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center

OBJECTIVES

Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics.

METHODS

SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively.

RESULTS

SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch).

CONCLUSIONS

SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.

Treating opioid use disorder in veterans with co-occurring substance use: a qualitative study with buprenorphine providers in primary care, mental health, and pain settings

BACKGROUND

Most people with opioid use disorder (OUD) have co-occurring substance use, which is associated with lower receipt of OUD medications (MOUD). Expanding MOUD provision and care linkage outside of substance use disorder (SUD) specialty settings is a key strategy to increase access. Therefore, it is important to understand how MOUD providers in these settings approach care for patients with co-occurring substance use. This qualitative study of Veterans Health Administration (VA) clinicians providing buprenorphine care in primary care, mental health, and pain settings aimed to understand (1) their approach to addressing OUD in patients with co-occurring substance use, (2) perspectives on barriers/facilitators to MOUD receipt for this population, and (3) support needed to increase MOUD receipt for this population.

METHODS

We interviewed a purposive sample of 27 clinicians (12 primary care, 7 mental health, 4 pain, 4 pharmacists) in the VA northwest network. The interview guide assessed domains of the Tailored Implementation for Chronic Diseases Checklist. Interviews were transcribed and qualitatively analyzed using inductive content analysis.

RESULTS

Participants reported varied approaches to identifying co-occurring substance use and addressing OUD in this patient population. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients with co-occurring substance use should receive MOUD. Some viewed their primary role as providing this care, others as facilitating linkage to OUD care in SUD specialty settings. Participants reported multiple barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use and linking them to SUD specialty care, including provider, patient, organizational, and external factors.

CONCLUSIONS

Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use. These could include clearer guidelines and policies, more specific training, and increased care integration or cross-disciplinary collaboration. Simultaneously, efforts are needed to improve linkage to specialty SUD care for patients who would benefit from and are willing to receive this care, which could include increased service availability and improved referral/hand-off processes. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.

Integrating Alcohol-Related Prevention and Treatment Into Primary Care: A Cluster Randomized Implementation Trial

Importance

Unhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment.

Objective

To test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration.

Design, Setting, and Participants

The Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021.

Interventions

The implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice's intervention period.

Main Outcomes and Measures

Coprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression.

Results

A total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P < .001). The proportion with AUD treatment engagement did not differ during intervention and usual care (1.4 vs 1.8 per 10 000 patients; P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P < .001), new AUD diagnosis (33.8 vs 28.8 per 10 000; P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04).

Conclusions and Relevance

In this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02675777.

Barriers and facilitators to changing drinking and receiving alcohol-related care: Interviews with Veterans Health Administration primary care patients who indicated interest but did not enroll in an alcohol care management intervention trial

Background: Most people with alcohol use disorder do not receive treatment, and primary care (PC)-based management of alcohol use disorder is a key strategy to close this gap. Understanding PC patients' perspectives on changing drinking and receiving alcohol-related care is important for this goal, particularly among those who decline alcohol-related care. This study examined perspectives on barriers and facilitators to changing drinking and receiving alcohol-related care among Veterans Health Administration (VA) PC patients who indicated interest but did not enroll in the Choosing Healthier drinking Options In primary CarE trial (CHOICE), which tested a PC-based alcohol care management intervention. Methods: VA PC patients with frequent heavy drinking who indicated interest in CHOICE but did not enroll were invited to participate. Twenty-seven patients completed in-person, semi-structured interviews. Interview transcripts were analyzed using iterative deductive and inductive content analysis. Results: Participants were mostly men (96%) and White (59%), and the mean age was 48. Seventy-four percent met criteria for alcohol use disorder, and the median number of past-week standard drinks was 41.5. Participants reported fewer alcohol-related problems, lower importance of/readiness to change drinking, and higher confidence in their ability to change than patients who enrolled in the CHOICE trial. Barriers fell into 5 domains: drinking fulfills need(s); reducing drinking or treatment is not needed; treatment is not effective/not acceptable; alcohol-related stigma; and practical barriers. Facilitators fell into 4 domains: reasons to change drinking; social support; treatment is acceptable/meets patients' needs; and practical facilitators. Participants discussed how Veteran identity and military experiences impacted drinking and willingness to receive care, which amplified multiple barriers/facilitators. Conclusions: This study identified barriers and facilitators to changing drinking and receiving alcohol-related care among VA PC patients who indicated interest but did not enroll in an alcohol care management trial. Findings can inform patient-centered interventions and support clinicians in engaging patients in care.

Opioid use disorder from poppy seed tea successfully treated with buprenorphine in primary care: a case report

BACKGROUND

Poppy seeds contain morphine and other opioid alkaloids and are commercially available in the United States. Users of poppy seed tea (PST) can consume several hundred morphine milligram equivalents per day, and opioid dependence from PST use can develop. We report a case of a patient with chronic pain and PST use leading to opioid use disorder (OUD). This case represents the first published report of OUD from PST successfully treated with buprenorphine (BUP) in a primary care setting. The provider in this case used a unique model of care with an opioid prescribing support team to deliver safe and effective care.

CASE PRESENTATION

A 47-year-old man with chronic pain and prescription opioid use presented to primary care to discuss a flare of shoulder pain, and revealed in subsequent conversation a long-standing use of PST to supplement pain control. Attempts at cessation resulted in severe withdrawal symptoms, leading to return to PST use. The primary care provider consulted the VA Puget Sound SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) team to evaluate the patient for OUD. The patient discontinued all opioids, and initiated BUP under the supervision of the primary care provider. He remained on a stable dosage, without relapse, 24 months later.

CONCLUSIONS

PST, which can be made through purchase of readily available poppy pods, carries risk for development of OUD and overdose. Herein we highlight the utility of a primary care opioid prescribing support team in empowering a primary care provider to prescribe BUP to treat a patient with complex OUD.

Alcohol-Related Nurse Care Management in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Experts recommend that alcohol use disorders (AUDs) be managed in primary care, but effective approaches are unclear.

OBJECTIVE

To test whether 12 months of alcohol care management, compared with usual care, improved drinking outcomes among patients with or at high risk for AUDs.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 3 Veterans Affairs (VA) primary care clinics. Between October 11, 2011, and September 30, 2014, the study enrolled 304 outpatients who reported heavy drinking (≥4 drinks per day for women and ≥5 drinks per day for men).

INTERVENTIONS

Nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner-prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The comparison was usual primary care.

MAIN OUTCOMES AND MEASURES

Primary outcomes, assessed by blinded telephone interviewers at 12 months, were percentage of heavy drinking days in the prior 28 days measured by timeline follow-back interviews and a binary good drinking outcome, defined as abstinence or drinking below recommended limits in the prior 28 days (according to timeline follow-back interviews) and no alcohol-related symptoms in the past 3 months as measured by the Short Inventory of Problems.

RESULTS

Of 304 participants, 275 (90%) were male, 206 (68%) were white, and the mean (SD) age was 51.4 (13.8) years. At baseline, both the CHOICE intervention (n = 150) and usual care (n = 154) groups reported heavy drinking on 61% of days (95% CI, 56%-66%). During the 12-month intervention, 137 of 150 patients in the intervention group (91%) had at least 1 nurse visit, and 77 of 150 (51%) had at least 6 nurse visits. A greater proportion of patients in the intervention group than in the usual care group received alcohol-related care: 42% (95% CI, 35%-49%; 63 of 150 patients) vs 26% (95% CI, 19%-35%; 40 of 154 patients). Alcohol-related care included more AUD medication use: 32% (95% CI, 26%-39%; 48 of 150 patients in the intervention group) vs 8% (95% CI, 5%-13%; 13 of 154 patients in the usual care group). No significant differences in primary outcomes were observed at 12 months between patients in both groups. The percentages of heavy drinking days were 39% (95% CI, 32%-47%) and 35% (95% CI, 28%-42%), and the percentages of patients with a good drinking outcome were 15% (95% CI, 9%-22%; 18 of 124 patients) and 20% (95 % CI, 14%-28%; 27 of 134 patients), in the intervention and usual care groups, respectively (P = .32-.44). Findings at 3 months were similar.

CONCLUSIONS AND RELEVANCE

The CHOICE intervention did not decrease heavy drinking or related problems despite increased engagement in alcohol-related care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01400581.

Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics

BACKGROUND

Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely.

OBJECTIVE

This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications.

DESIGN

Qualitative, interview-based study.

PARTICIPANTS

Twenty-four providers from five VA PC clinics.

APPROACH

Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review.

KEY RESULTS

Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have.

CONCLUSIONS

We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

Differences in Perceptions of and Practices Regarding Treatment of Alcohol Use Disorders Among VA Primary Care Providers in Urban and Rural Clinics

BACKGROUND

Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas.

METHODS

A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources.

CONCLUSIONS

Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.

Survey of Primary Care and Mental Health Prescribers' Perspectives on Reducing Opioid and Benzodiazepine Co-Prescribing Among Veterans

Background

Due to the involvement of opioids and benzodiazepines in rising pharmaceutical overdoses, a reduction in coprescribing of these medications is a national priority, particularly among patients with substance use disorders and other high-risk conditions. However, little is known about primary care (PC) and mental health (MH) prescribers' perspectives on these medications and efforts being implemented to reduce coprescribing.

Design

An anonymous survey.

Setting

One multisite VA health care system.

Subjects

Participants were 55 PC and 31 MH prescribers.

Methods

Survey development was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework. PC and MH prescribers of opioids or benzodiazepines were invited to complete an anonymous electronic survey. Responses were collapsed to highlight agreement, disagreement, and neutrality and summarized with means and percentages.

Results

Over 80% of both prescriber groups reported concern about concurrent use and > 75% strongly agreed with clinical practice guidelines (CPG) that recommend caution in coprescribing among patients with high-risk conditions. More than 40% of both prescriber groups indicated that coprescribing continues because of beliefs that patients appear stable without adverse events and tapering/discontinuation is too difficult. Over 70% of prescribers rated strategies for addressing patients who refuse to discontinue, more time with patients, and identification of high-risk patients as helpful in reducing coprescribing.

Conclusion

Despite strong agreement with CPGs, prescribers reported several barriers that contribute to coprescribing of opioids and benzodiazepines and challenge their ability to taper these medications. Multiple interventions are likely needed to reduce opioid and benzodiazepine coprescribing.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial

BACKGROUND

Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample.

METHODS

The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs.

RESULTS

A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale.

CONCLUSION

The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science : Seattle, WA, USA. 24-26 September 2015

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Cara Lewis, Doyanne Darnell, Suzanne Kerns, Maria Monroe-DeVita, Sara J. Landes, Aaron R. Lyon, Cameo Stanick, Shannon Dorsey, Jill Locke, Brigid Marriott, Ajeng Puspitasari, Caitlin Dorsey, Karin Hendricks, Andria Pierson, Phil Fizur, Katherine A. Comtois

A1: A behavioral economic perspective on adoption, implementation, and sustainment of evidence-based interventions

Lawrence A. Palinkas

A2: Towards making scale up of evidence-based practices in child welfare systems more efficient and affordable

Patricia Chamberlain

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A5: Efficient synthesis: Using qualitative comparative analysis and the Consolidated Framework for Implementation Research across diverse studies

Laura J. Damschroder, Julie C. Lowery

A6: Establishing a veterans engagement group to empower patients and inform Veterans Affairs (VA) health services research

Sarah S. Ono, Kathleen F. Carlson, Erika K. Cottrell, Maya E. O’Neil, Travis L. Lovejoy

A7: Building patient-practitioner partnerships in community oncology settings to implement behavioral interventions for anxious and depressed cancer survivors

Joanna J. Arch, Jill L. Mitchell

A8: Tailoring a Cognitive Behavioral Therapy implementation protocol using mixed methods, conjoint analysis, and implementation teams

Cara C. Lewis, Brigid R. Marriott, Kelli Scott

A9: Wraparound Structured Assessment and Review (WrapSTAR): An efficient, yet comprehensive approach to Wraparound implementation evaluation

Jennifer Schurer Coldiron, Eric J. Bruns, Alyssa N. Hook

A10: Improving the efficiency of standardized patient assessment of clinician fidelity: A comparison of automated actor-based and manual clinician-based ratings

Benjamin C. Graham, Katelin Jordan

A11: Measuring fidelity on the cheap

Rochelle F. Hanson, Angela Moreland, Benjamin E. Saunders, Heidi S. Resnick

A12: Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy

Shannon Wiltsey Stirman, Cassidy A. Gutner, Jennifer Gamarra, Dawne Vogt, Michael Suvak, Jennifer Schuster Wachen, Katherine Dondanville, Jeffrey S. Yarvis, Jim Mintz, Alan L. Peterson, Elisa V. Borah, Brett T. Litz, Alma Molino, Stacey Young McCaughanPatricia A. Resick

A13: The video vignette survey: An efficient process for gathering diverse community opinions to inform an intervention

Nancy Pandhi, Nora Jacobson, Neftali Serrano, Armando Hernandez, Elizabeth Zeidler- Schreiter, Natalie Wietfeldt, Zaher Karp

A14: Using integrated administrative data to evaluate implementation of a behavioral health and trauma screening for children and youth in foster care

Michael D. Pullmann, Barbara Lucenko, Bridget Pavelle, Jacqueline A. Uomoto, Andrea Negrete, Molly Cevasco, Suzanne E. U. Kerns

A15: Intermediary organizations as a vehicle to promote efficiency and speed of implementation

Robert P. Franks, Christopher Bory

A16: Applying the Consolidated Framework for Implementation Research constructs directly to qualitative data: The power of implementation science in action

Edward J. Miech, Teresa M. Damush

A17: Efficient and effective scaling-up, screening, brief interventions, and referrals to treatment (SBIRT) training: a snowball implementation model

Jason Satterfield, Derek Satre, Maria Wamsley, Patrick Yuan, Patricia O’Sullivan

A18: Matching models of implementation to system needs and capacities: addressing the human factor

Helen Best, Susan Velasquez

A19: Agency characteristics that facilitate efficient and successful implementation efforts

Miya Barnett, Lauren Brookman-Frazee, Jennifer Regan, Nicole Stadnick, Alison Hamilton, Anna Lau

A20: Rapid assessment process: Application to the Prevention and Early Intervention transformation in Los Angeles County

Jennifer Regan, Alison Hamilton, Nicole Stadnick, Miya Barnett, Anna Lau, Lauren Brookman-Frazee

A21: The development of the Evidence-Based Practice-Concordant Care Assessment: An assessment tool to examine treatment strategies across practices

Nicole Stadnick, Anna Lau, Miya Barnett, Jennifer Regan, Scott Roesch, Lauren Brookman-Frazee

A22: Refining a compilation of discrete implementation strategies and determining their importance and feasibility

Byron J. Powell, Thomas J. Waltz, Matthew J. Chinman, Laura Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A23: Structuring complex recommendations: Methods and general findings

Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica J. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A24: Implementing prolonged exposure for post-traumatic stress disorder in the Department of Veterans Affairs: Expert recommendations from the Expert Recommendations for Implementing Change (ERIC) project

Monica M. Matthieu, Craig S. Rosen, Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Enola K. Proctor, JoAnn E. Kirchner

A25: When readiness is a luxury: Co-designing a risk assessment and quality assurance process with violence prevention frontline workers in Seattle, WA

Sarah C. Walker, Asia S. Bishop, Mariko Lockhart

A26: Implementation potential of structured recidivism risk assessments with justice- involved veterans: Qualitative perspectives from providers

Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, Daniel M. Blonigen

A27: Developing empirically informed readiness measures for providers and agencies for the Family Check-Up using a mixed methods approach

Anne M. Mauricio, Thomas D. Dishion, Jenna Rudo-Stern, Justin D. Smith

A28: Pebbles, rocks, and boulders: The implementation of a school-based social engagement intervention for children with autism

Jill Locke, Courtney Benjamin Wolk, Colleen Harker, Anne Olsen, Travis Shingledecker, Frances Barg, David Mandell, Rinad S. Beidas

A29: Problem Solving Teletherapy (PST.Net): A stakeholder analysis examining the feasibility and acceptability of teletherapy in community based aging services

Marissa C. Hansen, Maria P. Aranda, Isabel Torres-Vigil

A30: A case of collaborative intervention design eventuating in behavior therapy sustainment and diffusion

Bryan Hartzler

A31: Implementation of suicide risk prevention in an integrated delivery system: Mental health specialty services

Bradley Steinfeld, Tory Gildred, Zandrea Harlin, Fredric Shephard

A32: Implementation team, checklist, evaluation, and feedback (ICED): A step-by-step approach to Dialectical Behavior Therapy program implementation

Matthew S. Ditty, Andrea Doyle, John A. Bickel III, Katharine Cristaudo

A33: The challenges in implementing muliple evidence-based practices in a community mental health setting

Dan Fox, Sonia Combs

A34: Using electronic health record technology to promote and support evidence-based practice assessment and treatment intervention

David H. Lischner

A35: Are existing frameworks adequate for measuring implementation outcomes? Results from a new simulation methodology

Richard A. Van Dorn, Stephen J. Tueller, Jesse M. Hinde, Georgia T. Karuntzos

A36: Taking global local: Evaluating training of Washington State clinicians in a modularized cogntive behavioral therapy approach designed for low-resource settings

Maria Monroe-DeVita, Roselyn Peterson, Doyanne Darnell, Lucy Berliner, Shannon Dorsey, Laura K. Murray

A37: Attitudes toward evidence-based practices across therapeutic orientations

Yevgeny Botanov, Beverly Kikuta, Tianying Chen, Marivi Navarro-Haro, Anthony DuBose, Kathryn E. Korslund, Marsha M. Linehan

A38: Predicting the use of an evidence-based intervention for autism in birth-to-three programs

Colleen M. Harker, Elizabeth A. Karp, Sarah R. Edmunds, Lisa V. Ibañez, Wendy L. Stone

A39: Supervision practices and improved fidelity across evidence-based practices: A literature review

Mimi Choy-Brown

A40: Beyond symptom tracking: clinician perceptions of a hybrid measurement feedback system for monitoring treatment fidelity and client progress

Jack H. Andrews, Benjamin D. Johnides, Estee M. Hausman, Kristin M. Hawley

A41: A guideline decision support tool: From creation to implementation

Beth Prusaczyk, Alex Ramsey, Ana Baumann, Graham Colditz, Enola K. Proctor

A42: Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach

Rosemary D. Meza, Shannon Dorsey, Shannon Wiltsey-Stirman, Georganna Sedlar, Leah Lucid

A43: Characterization of context and its role in implementation: The impact of structure, infrastructure, and metastructure

Caitlin Dorsey, Brigid Marriott, Nelson Zounlome, Cara Lewis

A44: Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder

Cassidy A. Gutner, Candice M. Monson, Norman Shields, Marta Mastlej, Meredith SH Landy, Jeanine Lane, Shannon Wiltsey Stirman

A45: Cross-validation of the Implementation Leadership Scale factor structure in child welfare service organizations

Natalie K. Finn, Elisa M. Torres, Mark. G. Ehrhart, Gregory A. Aarons

A46: Sustainability of integrated smoking cessation care in Veterans Affairs posttraumatic stress disorder clinics: A qualitative analysis of focus group data from learning collaborative participants

Carol A. Malte, Aline Lott, Andrew J. Saxon

A47: Key characteristics of effective mental health trainers: The creation of the Measure of Effective Attributes of Trainers (MEAT)

Meredith Boyd, Kelli Scott, Cara C. Lewis

A48: Coaching to improve teacher implementation of evidence-based practices (EBPs)

Jennifer D. Pierce

A49: Factors influencing the implementation of peer-led health promotion programs targeting seniors: A literature review

Agathe Lorthios-Guilledroit, Lucie Richard, Johanne Filiatrault

A50: Developing treatment fidelity rating systems for psychotherapy research: Recommendations and lessons learned

Kevin Hallgren, Shirley Crotwell, Rosa Muñoz, Becky Gius, Benjamin Ladd, Barbara McCrady, Elizabeth Epstein

A51: Rapid translation of alcohol prevention science

John D. Clapp, Danielle E. Ruderman

A52: Factors implicated in successful implementation: evidence to inform improved implementation from high and low-income countries

Melanie Barwick, Raluca Barac, Stanley Zlotkin, Laila Salim, Marnie

Davidson

A53: Tracking implementation strategies prospectively: A practical approach

Alicia C. Bunger, Byron J. Powell, Hillary A. Robertson

A54: Trained but not implementing: the need for effective implementation planning tools

Christopher Botsko

A55: Evidence, context, and facilitation variables related to implementation of Dialectical Behavior Therapy: Qualitative results from a mixed methods inquiry in the Department of Veterans Affairs

Sara J. Landes, Brandy N. Smith, Allison L. Rodriguez, Lindsay R. Trent, Monica M. Matthieu

A56: Learning from implementation as usual in children’s mental health

Byron J. Powell, Enola K. Proctor

A57: Rates and predictors of implementation after Dialectical Behavior Therapy Intensive Training

Melanie S. Harned, Marivi Navarro-Haro, Kathryn E. Korslund, Tianying Chen, Anthony DuBose, André Ivanoff, Marsha M. Linehan

A58: Socio-contextual determinants of research evidence use in public-youth systems of care

Antonio R. Garcia, Minseop Kim, Lawrence A. Palinkas, Lonnie Snowden, John Landsverk

A59: Community resource mapping to integrate evidence-based depression treatment in primary care in Brazil: A pilot project

Annika C. Sweetland, Maria Jose Fernandes, Edilson Santos, Cristiane Duarte, Afrânio Kritski, Noa Krawczyk, Caitlin Nelligan, Milton L. Wainberg

A60: The use of concept mapping to efficiently identify determinants of implementation in the National Institute of Health--President’s Emergent Plan for AIDS Relief Prevention of Mother to Child HIV Transmission Implementation Science Alliance

Gregory A. Aarons, David H. Sommerfeld, Benjamin Chi, Echezona Ezeanolue, Rachel Sturke, Lydia Kline, Laura Guay, George Siberry

A61: Longitudinal remote consultation for implementing collaborative care for depression

Ian M. Bennett, Rinad Beidas, Rachel Gold, Johnny Mao, Diane Powers, Mindy Vredevoogd, Jurgen Unutzer

A62: Integrating a peer coach model to support program implementation and ensure long- term sustainability of the Incredible Years in community-based settings

Jennifer Schroeder, Lane Volpe, Julie Steffen

A63: Efficient sustainability: Existing community based supervisors as evidence-based treatment supports

Shannon Dorsey, Michael D Pullmann, Suzanne E. U. Kerns, Nathaniel Jungbluth, Lucy Berliner, Kelly Thompson, Eliza Segell

A64: Establishment of a national practice-based implementation network to accelerate adoption of evidence-based and best practices

Pearl McGee-Vincent, Nancy Liu, Robyn Walser, Jennifer Runnals, R. Keith Shaw, Sara J. Landes, Craig Rosen, Janet Schmidt, Patrick Calhoun

A65: Facilitation as a mechanism of implementation in a practice-based implementation network: Improving care in a Department of Veterans Affairs post-traumatic stress disorder outpatient clinic

Ruth L. Varkovitzky, Sara J. Landes

A66: The ACT SMART Toolkit: An implementation strategy for community-based organizations providing services to children with autism spectrum disorder

Amy Drahota, Jonathan I. Martinez, Brigitte Brikho, Rosemary Meza, Aubyn C. Stahmer, Gregory A. Aarons

A67: Supporting Policy In Health with Research: An intervention trial (SPIRIT) - protocol and early findings

Anna Williamson

A68: From evidence based practice initiatives to infrastructure: Lessons learned from a public behavioral health system’s efforts to promote evidence based practices

Ronnie M. Rubin, Byron J. Powell, Matthew O. Hurford, Shawna L. Weaver, Rinad S. Beidas, David S. Mandell, Arthur C. Evans

A69: Applying the policy ecology model to Philadelphia’s behavioral health transformation efforts

Byron J. Powell, Rinad S. Beidas, Ronnie M. Rubin, Rebecca E. Stewart, Courtney Benjamin Wolk, Samantha L. Matlin, Shawna Weaver, Matthew O. Hurford, Arthur C. Evans, Trevor R. Hadley, David S. Mandell

A70: A model for providing methodological expertise to advance dissemination and implementation of health discoveries in Clinical and Translational Science Award institutions

Donald R. Gerke, Beth Prusaczyk, Ana Baumann, Ericka M. Lewis, Enola K. Proctor

A71: Establishing a research agenda for the Triple P Implementation Framework

Jenna McWilliam, Jacquie Brown, Michelle Tucker

A72: Cheap and fast, but what is “best?”: Examining implementation outcomes across sites in a state-wide scaled-up evidence-based walking program, Walk With Ease

Kathleen P Conte

A73: Measurement feedback systems in mental health: Initial review of capabilities and characteristics

Aaron R. Lyon, Meredith Boyd, Abigail Melvin, Cara C. Lewis, Freda Liu, Nathaniel Jungbluth

A74: A qualitative investigation of case managers’ attitudes toward implementation of a measurement feedback system in a public mental health system for youth

Amelia Kotte, Kaitlin A. Hill, Albert C. Mah, Priya A. Korathu-Larson, Janelle R. Au, Sonia Izmirian, Scott Keir, Brad J. Nakamura, Charmaine K. Higa-McMillan

A75: Multiple pathways to sustainability: Using Qualitative Comparative Analysis to uncover the necessary and sufficient conditions for successful community-based implementation

Brittany Rhoades Cooper, Angie Funaiole, Eleanor Dizon

A76: Prescribers’ perspectives on opioids and benzodiazepines and medication alerts to reduce co-prescribing of these medications

Eric J. Hawkins, Carol A. Malte, Hildi J. Hagedorn, Douglas Berger, Anissa Frank, Aline Lott, Carol E. Achtmeyer, Anthony J. Mariano, Andrew J. Saxon

A77: Adaptation of Coordinated Anxiety Learning and Management for comorbid anxiety and substance use disorders: Delivery of evidence-based treatment for anxiety in addictions treatment centers

Kate Wolitzky-Taylor, Richard Rawson, Richard Ries, Peter Roy-Byrne, Michelle Craske

A78: Opportunities and challenges of measuring program implementation with online surveys

Dena Simmons, Catalina Torrente, Lori Nathanson, Grace Carroll

A79: Observational assessment of fidelity to a family-centered prevention program: Effectiveness and efficiency

Justin D. Smith, Kimbree Brown, Karina Ramos, Nicole Thornton, Thomas J. Dishion, Elizabeth A. Stormshak, Daniel S. Shaw, Melvin N. Wilson

A80: Strategies and challenges in housing first fidelity: A multistate qualitative analysis

Mimi Choy-Brown, Emmy Tiderington, Bikki Tran Smith, Deborah K. Padgett

A81: Procurement and contracting as an implementation strategy: Getting To Outcomes® contracting

Ronnie M. Rubin, Marilyn L. Ray, Abraham Wandersman, Andrea Lamont, Gordon Hannah, Kassandra A. Alia, Matthew O. Hurford, Arthur C. Evans

A82: Web-based feedback to aid successful implementation: The interactive Stages of Implementation Completion (SIC)^TM tool

Lisa Saldana, Holle Schaper, Mark Campbell, Patricia Chamberlain

A83: Efficient methodologies for monitoring fidelity in routine implementation: Lessons from the Allentown Social Emotional Learning Initiative

Valerie B. Shapiro, B.K. Elizabeth Kim, Jennifer L. Fleming, Paul A. LeBuffe

A84: The Society for Implementation Research Collaboration (SIRC) implementation development workshop: Results from a new methodology for enhancing implementation science proposals

Sara J. Landes, Cara C. Lewis, Allison L. Rodriguez, Brigid R. Marriott, Katherine Anne Comtois

A85: An update on the Society for Implementation Research Collaboration (SIRC) Instrument Review Project

Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study

BACKGROUND

Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics.

OBJECTIVE

We aimed to understand factors that might contribute to low sensitivity of alcohol screening.

DESIGN

This was an observational, qualitative study.

PARTICIPANTS

Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S.

APPROACH

Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes.

KEY RESULTS

We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort.

CONCLUSIONS

This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.

Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff

BACKGROUND AND OBJECTIVE

Population-based alcohol screening, followed by brief intervention for patients who screen positive for unhealthy alcohol use, is widely recommended for primary care settings and considered a top prevention priority, but is challenging to implement. However, new policy initiatives in the U.S., including the Affordable Care Act, may help launch widespread implementation. While the nationwide Veterans Health Administration (VA) has achieved high rates of documented alcohol screening and brief intervention, research has identified quality problems with both. We conducted a qualitative key informant study to describe local implementation of alcohol screening and brief intervention from the perspectives of frontline adopters in VA primary care in order to understand the process of implementation and factors underlying quality problems.

METHODS

A purposive snowball sampling method was used to identify and recruit key informants from 5 VA primary care clinics in the northwestern U.S. Key informants completed 20-30 minute semi-structured interviews, which were recorded, transcribed, and qualitatively analyzed using template analysis.

RESULTS

Key informants (N=32) included: clinical staff (n=14), providers (n=14), and administrative informants (n=4) with varying participation in implementation of and responsibility for alcohol screening and brief intervention at the medical center. Ten inter-related themes (5 a priori and 5 emergent) were identified and grouped into 3 applicable domains of Greenhalgh's conceptual framework for dissemination of innovations, including values of adopters (theme 1), processes of implementation (themes 2 and 3), and post-implementation consequences in care processes (themes 4-10). While key informants believed alcohol use was relevant to health and important to address, the process of implementation (in which no training was provided and electronic clinical reminders "just showed up") did not address critical training and infrastructure needs. Key informants lacked understanding of the goals of screening and brief intervention, believed referral to specialty addictions treatment (as opposed to offering brief intervention) was the only option for following up on a positive screen, reported concern regarding limited availability of treatment resources, and lacked optimism regarding patients' interest in seeking help.

CONCLUSIONS

Findings suggest that the local process of implementing alcohol screening and brief intervention may have inadequately addressed important adopter needs and thus may have ultimately undermined, instead of capitalized on, staff and providers' belief in the importance of addressing alcohol use as part of primary care. Additional implementation strategies, such as training or academic detailing, may address some unmet needs and help improve the quality of both screening and brief intervention. However, these strategies may be resource-intensive and insufficient for comprehensively addressing implementation barriers.

An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration

AIMS

The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.

DESIGN

Observational, retrospective cohort study using secondary clinical and administrative data.

SETTING

Thirty VA facilities.

PARTICIPANTS

Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%).

MEASUREMENTS

Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).

FINDINGS

Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50).

CONCLUSIONS

During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

When quality indicators undermine quality: bias in a quality indicator of follow-up for alcohol misuse

OBJECTIVE

Valid quality indicators are needed to monitor and encourage identification and management of mental health and substance use conditions (behavioral conditions). Because behavioral conditions are frequently underidentified, quality indicators often evaluate the proportion of patients who screen positive for a condition who also have appropriate follow-up care documented. However, these "positive-screen-based" quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality ("denominator bias") and could reward identification of fewer patients with the behavioral conditions of interest. This study evaluated denominator bias in the performance of Veterans Health Administration (VHA) networks on a quality indicator of follow-up for alcohol misuse that used the number of patients with positive alcohol screens as the denominator.

METHODS

Two quality indicators of follow-up for alcohol misuse--a positive-screen-based quality indicator and a population-based quality indicator-were compared among 21 VHA networks by review of 219,119 medical records.

RESULTS

Results for the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7% and 65.4% follow-up) even though one network identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% versus 7.4%, respectively).

CONCLUSIONS

A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.

Feedback from recently returned veterans on an anonymous web-based brief alcohol intervention

Background

Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are at increased risk for alcohol misuse, and innovative methods are needed to improve their access to alcohol screening and brief interventions (SBI). This study adapted an electronic SBI (e-SBI) website shown to be efficacious in college students for OEF/OIF veterans and reported findings from interviews with OEF/OIF veterans about their impressions of the e-SBI.

Methods

Outpatient veterans of OEF/OIF who drank ≥3 days in the past week were recruited from a US Department of Veterans Affairs (VA) Deployment Health Clinic waiting room. Veterans privately pretested the anonymous e-SBI then completed individual semistructured audio-recorded interviews. Their responses were analyzed using template analysis to explore domains identified a priori as well as emergent domains.

Results

During interviews, all nine OEF/OIF veterans (1 woman and 8 men) indicated they had received feedback for risky alcohol consumption. Participants generally liked the standard-drinks image, alcohol-related caloric and monetary feedback, and the website’s brevity and anonymity (a priori domains). They also experienced challenges with portions of the e-SBI assessment and viewed feedback regarding alcohol risk and normative drinking as problematic, but described potential benefits derived from the e-SBI (emergent domains). The most appealing e-SBIs would ensure anonymity and provide personalized transparent feedback about alcohol-related risk, consideration of the context for drinking, strategies to reduce drinking, and additional resources for veterans with more severe alcohol misuse.

Conclusions

Results of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.

Evaluation of an electronic clinical reminder to facilitate brief alcohol-counseling interventions in primary care

OBJECTIVE

Brief intervention for patients with unhealthy alcohol use is a prevention priority in the United States, but most eligible patients do not receive it. This study evaluated an electronic alcohol-counseling clinical reminder at a single Veterans Affairs general medicine clinic.

METHOD

The systems-level intervention evaluated in this study consisted of making the clinical reminder, which facilitated medical record documentation of brief intervention among patients who screened positive for unhealthy alcohol use, available to providers on one (of two) randomly selected hallways. Secondary electronic data were extracted for all patients who visited the clinic (October 1, 2002, to September 30, 2005). The proportion of patients with clinical-reminder use was evaluated among patients who screened positive for unhealthy drinking and were assigned to intervention hallway providers ("descriptive cohort"). Adjusted logistic regression evaluated the association between the intervention and resolution of unhealthy drinking at follow-up among all screen-positive patients who completed a second Alcohol Use Disorders Identification Test Consumption questionnaire 18 months or longer after the first ("outcomes cohort").

RESULTS

Eligible patients (N= 22,863) included 10,392 controls and 12,471 in the intervention group. Fifteen percent (398 of 2,640) of descriptive cohort patients with unhealthy drinking had clinical-reminder use, which varied by severity (14% [n = 302 of 2,165] with mild/moderate and 20% [n = 96 of 475] with severe unhealthy drinking,p = .001). Only 39% (156 of 398) of patients with clinical-reminder use had documented brief intervention; advice to abstain was most common. Access to the clinical reminder was not significantly associated with resolution of unhealthy drinking in 1,358 patients in the outcomes cohort.

CONCLUSIONS

Availability of a clinical reminder to facilitate brief intervention did not, alone, result in substantial use of the clinical reminder. More active implementation efforts may be needed to get brief interventions onto the agenda of busy primary care providers.

Quality concerns with routine alcohol screening in VA clinical settings

BACKGROUND

Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings.

OBJECTIVE

The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results.

DESIGN

Cross sectional.

PARTICIPANTS

A national sample of 6,861 VA outpatients (fiscal years 2007-2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen).

MAIN MEASURES

Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens).

KEY RESULTS

Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks.

CONCLUSION

Use of a validated alcohol screening questionnaire does not-by itself-ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.

Implementation of evidence-based alcohol screening in the Veterans Health Administration

BACKGROUND

Despite evidence-based guidelines, brief alcohol screening and counseling have not been routinely integrated into most primary care practices in the United States.

OBJECTIVE

To describe the results of the implementation of evidence-based alcohol screening by the Veterans Health Administration (VA) in 2004, as the first step toward implementation of brief alcohol counseling.

STUDY DESIGN

This observational study of outpatients from all 21 VA networks relied on the following 2 data sources from the VA Office of Quality and Performance: (1) Medical record reviews, designed to compare VA networks quarterly, evaluated whether established VA patients had documented screening for alcohol misuse and documented follow-up assessment for alcohol use disorders among those who screened positive for alcohol misuse (January-March 2005); and (2) Mailed patient satisfaction surveys from 2004, which oversampled patients new to the VA (response rate, >70%), included the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questions and asked about past-year advice "to drink less or not to drink alcohol" from a VA provider.

RESULTS

Based on 10 115 medical record reviews, 93% (range, 89%-96% across networks) of outpatients were screened for alcohol misuse, and 25% (range, 11%-36%) screened positive. Among screen-positive patients, 42% (range, 5%-84%) had documented follow-up assessment, but absolute numbers of screen-positive patients evaluated were small (27-80 patients per network). Based on 235 481 patient surveys, the prevalence of alcohol misuse was 22% (range, 15%-27% across networks), and 28% (range, 20%- 36%) of screen-positive patients reported receiving alcohol-related advice. Alcohol-related advice increased as AUDIT-C scores increased.

CONCLUSION

The VA successfully implemented evidence-based alcohol screening, but the rate of follow-up among screen-positive patients remained low.

Readiness to change in primary care patients who screened positive for alcohol misuse

PURPOSE

Readiness to change drinking may influence the content or effectiveness of brief alcohol counseling. This study was designed to assess readiness to change and its relationship to alcohol misuse severity among primary care patients whose screening questionnaire was positive for alcohol misuse.

METHODS

This study was a cross-sectional analysis of data collected from 2 consecutive mailed questionnaires. Male outpatients at 7 Veterans Affairs (VA) general medicine clinics were eligible if they returned both questionnaires, screened positive for alcohol misuse (augmented CAGE Questionnaire > or =1 point), responded to 3 readiness-to-change questions, and completed the Alcohol Use Disorders Identification Test (AUDIT). A validated algorithm based on 3 standardized questions categorized participants into 3 readiness groups (precontemplation, contemplation, action). Measures of alcohol misuse severity included AUDIT, CAGE, and the 3 consumption questions from the AUDIT (AUDIT-C). Analyses were descriptive; linear-by-linear associations between alcohol misuse severity and readiness were tested with chi2 statistics.

RESULTS

Response rates to the first and second surveys were 59% and 55%, respectively. Of the 6,419 eligible outpatients who screened positive for alcohol misuse, 4,797 (75%) reported any readiness to change (contemplation 24%, action 51%). Among patients with AUDIT scores >8, more than 90% indicated that they drank more than they should and/or had contemplated drinking less. Greater readiness was significantly associated with greater alcohol misuse severity (P <.001 for all measures).

CONCLUSIONS

Most primary care patients who screen positive for alcohol misuse indicate some readiness to change. Contrary to stereotypes of denial, those with greater alcohol misuse severity are more likely to report readiness to change.

Computer order entry system decreased use of sliding scale insulin regimens

OBJECTIVES

Despite evidence documenting their ineffectiveness, sliding scale insulin is a commonly used regimen for glucose management for hospitalized patients with diabetes mellitus. At the Veterans Affairs Puget Sound Medical Center, where computer order entry has been mandated, we tested the hypothesis that an evidence-based minimal intervention order (supplemental insulin only when fasting serum glucoses exceeded 400 mg/dl) would decrease the use of sliding scale insulin orders.

METHODS

Using a computerized order entry system, providers were initially offered a traditional sliding scale order or their own ad hoc orders for glycemic control of inpatients. After 34 weeks providers were offered a third option; a "minimal intervention order" with supplemental insulin only for glucose > 400 mg/dl. We extracted all regular insulin orders and performed a retrospective review of insulin sliding scale orders written between December 1, 1998 and November 16, 1999. We compared the frequency of traditional insulin sliding scale orders before and after the introduction of the minimal intervention order.

RESULTS

Nearly all orders in the first 34 weeks were traditional insulin sliding scales. We found a significant decrease in the number of traditional insulin sliding scale orders in the 16 weeks after the introduction of a computerized quick-order for minimal intervention, from 978/1007 (97.1%) to 254/398 (63.8%) (P < 0.001).

CONCLUSIONS

A simple, evidenced-based quick-order in a computer order entry system rapidly and significantly reduced use of sliding scale insulin regimens for glycemic control of inpatients.