|Home | About | Journals | Submit | Contact Us | Français|
Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point-of-care (POC).
Mixed methods, prospective cohort study conducted in a practice-based research network with licensed clinicians. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions.
Participants (N=12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are “at risk” drinkers vs. those with alcohol use disorders including dependence/abuse (21%; t=2.4, p=.04). Thematic analysis of interviews suggest that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology generally at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability may also be achieved through tool simplification and additional flexibility in POC use options.
A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.
Alcohol consumption is the leading cause of death in the United States among 15–45 year olds1 and is second only to tobacco use and unhealthy diet/physical inactivity in actual cause of death for all ages.2 An estimated 75,000 deaths per year are attributed to alcohol3 due to multiple adverse health consequences including increased risk of violence or injury, cirrhosis of the liver, cancer and other chronic illnesses, incurring $185 billion annually in healthcare expenditures in the U.S.2 The prevalence estimates for unhealthy alcohol use in primary care settings range from 2% to 9% of adults with alcohol dependence to a high of 29% with “risky use” of alcohol.4
Clinically appropriate and effective identification tools and treatment for alcohol problems have been developed.5 A U.S. Preventive Services Task Force review concluded that behavioral counseling interventions for risky/harmful alcohol use in primary care could reduce risky/harmful alcohol use.6 Brief interventions that include counseling, especially motivational interviewing approaches, have received empirical support7 and expert recommendation.8 Current recommendations are that all adults should be screened for unhealthy alcohol use with a validated screening instrument such as the CAGE or the AUDIT.9
Despite these recommendations, clinicians are not using valid identification tools and interventions for unhealthy alcohol in clinical practice and usage rates vary widely between locations and settings.10, 11 A survey of family physicians and internists found that only 64.9% of respondents screened 80–100% of their patients for unhealthy alcohol use during the initial visit and a mere 34.4% screened the same percentage of patients during an annual visit.12 Another national survey of primary care physicians reported similar findings: only 13% use a formal alcohol screening tool when asking new outpatients about alcohol use.13
Despite the proven success of physician-led interventions for alcohol misuse, ambitious efforts to implement primary care alcohol counseling have not succeeded.14, 15 These problems are caused by a number of barriers including: confusion as to what constitutes alcohol misuse16, fear that asking about drinking could harm the patient-provider relationship17–19, stigmatization of substance abuse16, 20, skepticism about the effectiveness of alcohol counseling16, 19, 21, lack of time17–19, 22, inadequate training16, 23, 24, and a belief that patients will not honestly disclose their drinking practices.18, 19, 25 These barriers may be exacerbated by evidence that moderate levels of drinking (1–2 drinks per day) have proven beneficial for health.26, 27
To address this clinical need and physician barriers to alcohol misuse and abuse counseling, we developed a point-of-care (POC) software tool to assist clinicians in providing patient-tailored alcohol counseling while facilitating provider adherence to evidence-based practice guidelines. While previous studies have examined electronic reminders,28, 29 electronic screening tools, 30 and internet-based programs for alcohol interventions,31–33 our study is the first known investigation assessing a tool to assist primary care physicians with screening and subsequent counseling for alcohol misuse. Study aims were to establish the feasibility and technical merit of the Alcohol Misuse Intervention Tool (AMIT) prototype by: conducting formal usability testing of the prototype with clinicians in primary care settings; measuring utilization of the prototype and pre- to post-intervention changes in clinician behavior, knowledge, attitudes, and perceived self-efficacy in applying evidence based counseling strategies; and qualitative evaluation of physician tool use in primary care settings.
The AMIT software tool was designed to assist clinicians in providing patient-tailored alcohol counseling while facilitating adherence to evidence-based practice guidelines. We have previously described our software development process in detail.34, 35 Briefly, a content development team was assembled and met bi-weekly for approximately four months. The team included three experts in behavioral change in addition to [Author 1], who led the team. The entire Content Development Team effort was coordinated and directed by [Author 1] who has led the development of several clinician behavioral change support tools. A prototype version of the tool was designed as an interactive, web-distributable, clinical decision support software application for computers running either the Palm® or Microsoft™ Pocket PC™ operating systems (e.g. personal digital assistants or PDA’s). The functionality was later extended during the trial to accommodate use on other computing systems (e.g. web-based for desktop PC and smartphone use). The tool included algorithms based on the 5 A’s, the Transtheoretical Model (TTM) of health behavior change, and Motivational Interviewing. Through a point-and-click interface, the AMIT was designed to: 1) guide clinicians in screening for alcohol abuse and dependence based on the National Institute on Alcohol Abuse and Alcoholism’s national guidelines36 2) assist them in delivering a scripted interview to assess the patient’s readiness to change; 3) provide a scripted motivational interview tailored to the patient’s stage of change; 4) provide stage-relevant tools including: risk calculators, drug information and dosing, abridged information on pertinent clinical guidelines, and local and national resources; and 5) track clinician behavior during the patient encounter (i.e., identify the clinician using the application, record a time and date stamp each time the application is opened, record which sections of the application are accessed, and time spent in each) (see figure 1).
This study was approved by the [Author 2’s Institution] Institutional Review Board (IRB). Clinicians were recruited from practices affiliated with the [PBRN], which includes 10 [Author 2’s Institution] academic practices and community-based practices in the [author 2’s location]. Clinicians who enrolled were consented and answered a pre-study questionnaire before they participated in a demonstration of features and functionality of the AMIT tool and role-play using the tool in a simulated patient encounter with the study coordinator.
We administered a questionnaire to determine clinician knowledge, attitudes, comfort and behaviors related to alcohol counseling based on previous instruments we have developed35 and other previously validated instruments.12,13 The questionnaire also included basic information about enrolled clinicians’ clinical training and experience. Behavioral theories informing construction of questionnaire items included the 5 A’s (ask, advise, assess, assist and arrange),37 Stages of Change38 (based on the Transtheoretical Model) and Motivational Interviewing.39 Content experts [Author 7, Author 5, Author 1] reviewed the questionnaire for content validity. The final questionnaire consisted of 34 pre-post items, with an additional four items designed to measure usability in the post-questionnaire.
Clinicians were asked to use the tool as they saw fit during the 12-month study period. Prototype usage was monitored during the study. For users of the PDA based tool, a data usage log was saved on the device and transmitted to a collection database via internet when the device was synchronized (synchronization is the process of connecting a handheld device to a desktop computer and updating data on both devices so that the information is the same in both locations). For participants who used the web-based tool this usage data was collected via web usage logs as each clinician had a unique username and password. Collective and individualized activity reports provided information on: synchronization, total synchronizations, and average sessions per synchronization. Data on each user’s total sessions, average pages viewed per session, unique pages viewed per session, and page contents was reviewed. Reviews of synchronizations and usage data were conducted and emails were sent to participants who had not synchronized offering assistance with technical or other barriers to use. At approximately 6–8 weeks after the web-based tool was introduced, an email reminder was sent to all participants who had limited or non-use of the tool. Another e-mail reminder was sent mid-way through the study offering technical support and additional practice. During the last half of the study, email reminders with tips and articles related to alcohol counseling were sent two additional times and a final reminder was sent two weeks before the study ended.
At the end of the study period, participants completed the post-study questionnaire and then participated in a 45 – 60 min interview about their use of and satisfaction with the tool. A semi-structured interview format was used by the study coordinator in one-on-one interviews with participants. Questions addressed use of tool, nature of use, strengths and weaknesses of the tool, barriers to use, and recommended changes. These interviews were audio recorded and transcribed by the study coordinator [author 2]. Content analysis and identification of themes was performed by the study coordinator and content and themes were reviewed and verified by content experts on the study team [author1, author 7]. Emergent design principles and an inductive approach40 were used due to limited data and theories on the use of clinical assessment and intervention tools for alcohol counseling by primary care physicians.
In addition to qualitative analysis of the structured interview results to identify and report general themes, paired t-tests were performed to assess mean differences in the three main sub-scales (physician knowledge, behaviors and comfort with alcohol screening and intervention practices) from pre- to post-test. Because this was a pilot study designed a priori to determine feasibility (not efficacy), the sample size was too small to have adequate power to make statistical inferences from the data. Therefore, we examined the results of the t-tests to identify trends and generate hypotheses to be tested in a larger, randomized controlled trial. All quantitative analyses were conducted using SPSS for Windows version 11.
Initial recruitment began in Feb 2008. In May 2008 recruitment was broadened to include clinicians interested in using a web-based tool and recruitment ended in July 2008. A total of 19 licensed clinicians were enrolled, including two family medicine faculty development fellows, three residents (1-PGY3, 2-PGY2) and one nurse practitioner. Participants practiced in three university affiliated practices (two urban, one rural) and three community based practices. 12 participants (63%) completed the trial based on returning pre-post surveys (see table 1 for demographics). 16 participants (84%) completed a post-trial semi-structured interview. Reasons for drop-outs included family medical leave (1), loss of pre-survey by participant (1), and non-completion of post-survey (5). The drop outs included one resident, three academic faculty, three community physicians and included four males and three females. Communication at the end of the study indicated reluctance to participate in follow-up due to limited use of the tool and the time lag since the start of the trial.
Clinicians had access to the tool for an average of 8.5 months (range: 7 to 12 months). Technical issues related to PDA use as well as recruitment issues led to adapting the tool so it could be accessed on any web-enabled computing device in May 2008. Some physicians had difficulties installing the PDA software, synchronizing data, and experienced PDA crashes resulting in data loss. In addition, desktop computers were made available in every patient examination room, making a web-enabled version more attractive to some users. Ten of the participants had access to the web-based version of the tool and 2 participants had access to both versions. Details of participant tool use are fully described in Table 2.
No statistically significant mean differences were found for physician knowledge (mean increase=.70, p=.35), physician comfort (mean increase=.09, p=.93) and physician counseling behaviors (mean increase=.25, p=.96). We were only able to analyze 11 completed pre-post surveys as one pre-survey was lost by the participant. However, there was an increase in physicians distinguishing between patients who are “at risk” drinkers vs. those with alcohol use disorders (e.g.dependence/abuse) (21%; t=2.4, p=.04).
Semi-structured interviews were conducted with 16 of the enrolled clinicians including nine of those analyzed in the pre/post analysis. We were able to analyze 12 interviews (four were unanalyzed due to technical problems with the audio recording) with five faculty physicians, two community-based physicians, two fellows, two residents and one nurse practitioner. Of these 12 participants, 7 had used the tool at least once during the trial, 2 only used it during training and we did not have use data for three of the participants due to technical issues with PDA use logs.
Overall, participants were satisfied with the tool (71%) and all participants stated they would use the tool if modified. Thematic analysis of interviews suggested that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology generally at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability may also be achieved through tool simplification and additional flexibility in POC use options (see figure 2).
We developed a computer-assisted screening and counseling tool for alcohol misuse and studied its use and uptake in primary care settings. Our study uncovered important barriers and suggestions for improvement that are necessary to achieve more widespread use and clinical utility for this point of care tool in primary care settings. When clinicians used the tool, the frequency, length of time and page views were consistent with brief counseling sessions in primary care as well as using it as an educational reference. The majority of study participants were satisfied with the tool and all participants stated that they would use this tool in practice if it was modified based on the feedback from the study. Suggestions for tool modifications and barriers to use are described in Figure 2.
Although most of these barriers have been previously cited, we were struck by the dissonance physicians seemed to exhibit regarding perceived prevalence of alcohol misuse and abuse among their patients as contrasted with epidemiological data supporting the high death toll2 and high prevalence of risky alcohol use in the general population.8 We did not find this barrier previously reported in our literature review and would recommend exploring physicians’ perceptions as a part of interventions aimed at increasing screening and counseling for alcohol use and misuse. Based on their perceptions, there may be a need for further education and training on the prevalence and public health impacts of unsafe alcohol use.
Additional training and practice with the tool were also identified as important components of successful implementation. Finally, providing resources that add value to using the tool (see Figure 2) may be an important trigger for successful implementation. These are components and approaches that are being integrated into similar behavioral counseling tools for smoking cessation and diet/exercise that we are currently developing41, 42 and their effect on implementation will be evaluated.
There are several limitations of this study that should be considered in interpreting these results. Only a small percentage of PBRN clinicians (approx. 9%) enrolled in the pilot trial to test the tool, potentially limiting generalizability of our findings. In addition, approximately one-third (37%) of participants dropped out of the study, also limiting generalizability and introducing bias. Another potential source of bias may have been introduced by having study team members conduct the post-intervention semi-structured interviews. We didn’t find statistically significant differences between pre- and post-test physician assessment, however the study was not powered to see small differences in study measures and could represent Type II error. Finally, due to multiple comparisons in our analysis, there is the possibility of a type I error in our statistically significant finding that physicians were more likely to report assessing for “at risk” drinkers vs. dependence/abuse. This was a limitation of the study from the outset and underscores that it was designed as a pilot for hypothesis generation and identifying trends. Nevertheless, finding at least one change in physician behavior may be important and is consistent with our previously tested tools. In a previous study, we developed a Modular Lifestyle Intervention Tool to address smoking cessation and unhealthy weight and found that physicians were more likely to advise patients to stop smoking and were more likely to arrange follow-up for overweight patients who wanted to lose weight. In addition, the tool increased overall use of the 5 A’s during patient encounters and increased general counseling behaviors for both smoking cessation and weight loss.43 We recommend further evaluation of the AMIT tool in a larger sample with suggested improvements to definitively explore efficacy of this approach with alcohol use/misuse.
Computer-assisted behavioral change counseling has the potential to enhance interventions in primary care settings and can assist physicians with tailoring interventions for individual patients. Results from several studies indicate that providing people with unhealthy behaviors with a personalized report based on patient readiness to change enhances cessation rates.44–50 A Cochrane review reported on a meta-analysis of seventeen trials using materials tailored to the characteristics of individual patients. While part of the effect could be due to the additional contact or assessment required to obtain individual data, there is evidence that tailored materials increase rates of addiction management rates over and above standard materials and untailored materials (OR 1.42, 95% CI 1.26 – 1.61).51 Implementing this approach using technologies such as smarthphones and integration with electronic medical records has the potential for increased reach of the intervention due to rapidly increasing physician adoption of these technologies at the point-of-care.
This pilot study illustrates challenges and potential solutions for implementing a computer-assisted counseling tool for alcohol misuse and abuse in primary care settings. Based on our experience with implementation we recommend evaluating integration of this tool within electronic medical records where it can be easily available during patient encounters and documentation can be accomplished automatically during the interview. We also recommend evaluating this approach with other medical staff and ancillary providers to determine if having other staff using this approach can augment and/or complement physician interventions. For example, other healthcare staff might complete a basic assessment and intervention with patients and have a tailored report that physicians could use to make key counseling points during an office visit. Our next steps are to conduct additional design enhancements and usability testing of the tool and test the tool in a randomized, controlled trial with sufficient power to determine differences in patient outcomes.
Funding: 1 R41 AA16030-01, NIAAA, Strayer, PI
Conflicting and Competing Interests: None