Alcohol counseling by primary care physicians was associated with higher patient-perceived quality of care, specifically better communication, and whole-person knowledge. Higher quality of care, however, was not associated with decreased drinking of risky amounts at 6 months.
This study is novel as it assesses the relationships between (1) alcohol counseling and quality of primary care with a validated measure and (2) quality of primary care and drinking outcomes. Our study supports results from previous research indicating that patients are not bothered by, and often appreciate, being asked during primary care visits about their alcohol use3,10–12
. The magnitude of differences in quality we observed was similar to, though generally smaller than, those known to impact clinical outcomes17,21
. For example, Kim et al reported that single standard deviation increases in primary care quality were associated with a lower risk of subsequent substance use21
. While various studies have reported a link between primary care quality and health outcomes9,21
, ours did not. High-quality primary care may be necessary, but not sufficient, to help patients reduce their drinking. The lack of association between quality of primary care and decreased consumption is most likely because specific elements of brief interventions that are essential to change drinking (e.g., targeted advice) were not offered in this study.
Our study has several strengths. We used a standard measure of drinking in a sample with a range of unhealthy alcohol use and a well-validated measure of primary care quality that has been linked to clinical outcomes. The PCAS and its individual subscales have high internal consistency and reliability; each subscale has been validated17
. Lastly, we used a prospective design and assessed counseling and quality immediately after a primary care visit.
Several limitations should be considered. First, we could not determine whether alcohol counseling affects quality beyond the self-report measures assessed. However, the measures we chose are among the best ways to assess primary care quality and are particularly relevant to alcohol counseling17
. Second, we assessed the drinking outcome at only one timepoint. This method is similar to that used in studies supporting brief intervention for unhealthy alcohol use2
. Third, because this was an observational study, our ability to determine causality is limited; however, we did adjust analyses for potential confounding factors. Fourth, the initial research assessment may have sensitized subjects and influenced their responses to questions about perceived quality. Fifth, most subjects had visited their physicians and discussed alcohol previously. Therefore, the observed associations between counseling and quality of care may be biased towards the null; nonetheless, we observed some effects. Sixth, intervening influences (e.g., participation in Alcoholics Anonymous) could have affected drinking outcomes. Brief counseling, however, is known to reduce consumption beyond such influences. Lastly, the differences between the enrolled and nonenrolled patients limited generalizability and, along with the differences in those followed and lost to follow-up, may have biased analyses (the latter limited to the drinking analyses). However, the direction of bias resulting from these differences is difficult to predict.
Physicians should conduct alcohol counseling for unhealthy alcohol use for many reasons. Alcohol counseling has proven efficacy in outpatient settings and is recommended in practice guidelines. Furthermore, most patients want to receive advice about their drinking, and as indicated by this study, such a discussion does not diminish quality of care. These findings provide evidence that screening and intervention for unhealthy alcohol use may improve quality of care from the patient’s perspective.