From 2006–2007, study personnel contacted 47 of 55 eligible providers with 45 agreeing to participate (meeting recruitment goals) and two refusing. Study personnel identified 617 eligible patients during clinic visits occurring. Provider discretion excluded 18 possible participants due to feeling too rushed (n=12), the patient was too sick (n=5), or the visit was only for return of lab values (n=1). Of approached subjects (599), 434 consented to participate and completed the study (72%). The most common reason for refusal to participate was lack of time to complete the interview (106 individuals).
For the current analysis, 21 additional patients were excluded: 17 for missing or incomplete audio-recordings, three for missing all substance use data, and one for missing demographic data, leaving a final analytic sample of 413 encounters. Additionally, one provider was excluded from the provider analysis as they only had a single patient participate in the study (final provider n=44).
The patient study sample was mostly male (65%), African American (59%), with a mean age of 45 years (standard deviation [SD]= 9.3, range 20–77 years). (). The majority were on antiretroviral therapy (77%) with their last CD4 count > 200 (80%). Current illicit drug use was reported by 27% of patients (predominantly marijuana use), with 9.5% reporting current problematic alcohol use. One third did not complete high school or obtain an equivalent degree.
Patient Participant Descriptors and Bivariate Associateions With High Patient Comfort Discussiong Substance Use*
Providers were evenly split by gender (57% female) with a majority of white race/ethnicity (68%) and a mean age of 44 years (SD=8.6) (). Three quarters of the providers were physicians.
Provider Sample Descriptors and Bivariate Associations With High Provider Comfort Discussing Substance Use
The majority of patients (76%) and providers (73%) reported high comfort discussing substance use.
Associations With High Patient Comfort Discussing Substance Issues
In unadjusted analysis (), only 56% of current problematic drinkers reported high comfort compared to 78% of non-problematic or non-drinkers (X2, P=.003). Two thirds of patients with current drug use reported high comfort compared to 79% of patients without current drug use (X2, P=.005). Among patients reporting less than high comfort, 38% had used drugs in the past month, and 17% had consumed alcohol to intoxication in the past month.
Patients with high communication self-efficacy or high patient activation were more likely to report high comfort. Being on ARVs was strongly associated with high comfort, with 80% reporting high comfort compared to 65% of patients not on ARVs (X2, P=.003). Patients with greater depression symptoms were less likely to report high comfort (X2, P=.010). No provider characteristics were associated with high patient comfort discussing substance use.
In multivariable analysis (), patients reporting current drug or problematic alcohol use had lower odds of endorsing high comfort (aOR=0.46, 95% CI=0.28–0.77 for drug use, aOR=0.32, CI=0.15–0.66, for alcohol use) after adjusting for demographics, education, self-efficacy, patient activation, depression, ARV status, site, and clustering by provider. A patient on ARVs had twice the odds of reporting high comfort compared to a patient not on ARVs (aOR=2.15, 95% CI=1.18–3.40). Patients who did not graduate high school were half as likely to report high comfort compared to graduates (aOR=0.45, 95% CI=0.22–0.93). Female patients were twice as likely to report high comfort (aOR=2.05, 95% CI=1.13–3.72).
High patient activation was associated with increased odds of reporting high comfort (aOR=2.66, 95% CI=1.24–5.69). Also, each 10-minute increase in the length of the patient’s office visit was associated with nearly a quarter decrease in the odds of high comfort (aOR=0.78, 95% CI=0.64–0.99).
A sensitivity analysis limiting the multivariable analysis to only those with current drug or alcohol use yielded similar results, though there was insufficient power to detect a difference in self-efficacy or patient activation due to the smaller sample size.
Associations With High Provider Comfort Discussing Substance Use
In unadjusted analysis, providers with high comfort were younger (40 versus 46 years, 2-sided t test, P=.025). All midlevel providers, compared to 65% of physicians, reported high comfort (Fischer’s exact test P=.041). Providers with a greater proportion of patients with a high school degree (75% versus 62%, two-sided t test P=.015) and those with fewer patients on ARV (74% versus 85%, tow-sided t test, P=.059) more frequently reported high comfort discussing patient substance use. the odds of a provider reporting
In multivariable analyses (), no provider characteristics were associated with provider comfort. However, as a provider’s proportion of patients on ARV increased, the odds of a provider reporting high comfort discussing substance use decreased (aOR: 0.38, 95% CI: 0.15–0.97). As the proportion of patients in the highest patient activation tertile increased, so did the odds of a provider reporting high comfort discussing substance use (aOR 2.87, 95% CI: 1.01–8.14).
Multivariable Associations of High Provider Comfort