Implementation of Screening and Interventions for Unhealthy Alcohol Use Dan Jonas, MD, MPH
Our team Shana Ratner, MD Colleen Barclay, MPH Julia Tompkins, MSW,LCSW-A Bailey Minish Tamrah Watson, MSN, RN, FNP Not pictured: Eve Schon, RN; Nancy McElveen, Patient Advisor Britta Starke, MSW, LCSW Scott Rose, MD Katie Doss, MD Garrett Thompson
Project Aim To implement and test an evidence-based system for delivery and tracking of high-quality screening and interventions for unhealthy alcohol use in our general internal medicine clinic» Aiming to screen 50% of all patients (N = 12,603) seen in our clinic during the year-long project
Why screen for unhealthy alcohol use?» Unhealthy alcohol use is 3 rd leading cause of preventable deaths among adults in the U.S.» Over 20% of U.S. adults drink more than the recommended daily, weekly, or per-occasion amounts.» The U.S. Preventive Services Task Force and other national organizations recommend screening adults for unhealthy alcohol use, and providing counseling for persons with risky drinking behavior.
Definitions of unhealthy alcohol use use Term Unhealthy alcohol use* Risky use* Alcohol use disorder (AUD), mild, moderate, or severe Definition Overarching term that includes risky drinking and alcohol use disorder. Consumption levels that increase the risk for health consequences. Consumption of alcohol above recommended daily, weekly, or per-occasion amounts. Use of alcohol that is characterized by presence of 2 of 11 DSM-5 criteria. *Jonas et al., May 2014; Jonas et al., 2012 DSM-5, American Psychiatric Association, 2013
Term Definitions of unhealthy alcohol use Definitions of unhealthy alcohol use Unhealthy alcohol use* Definition Men < 65: 4 drinks in a day and 14 per week All women, and men 65+: 3 drinks in a day and 7 per week Overarching term that includes risky drinking and alcohol use disorder. Risky use* Alcohol use disorder (AUD), mild, moderate, or severe Consumption levels that increase the risk for health consequences. Consumption of alcohol above recommended daily, weekly, or per-occasion amounts. Use of alcohol that is characterized by presence of 2 of 11 DSM-5 criteria. *Jonas et al., May 2014; Jonas et al., 2012 DSM-5, American Psychiatric Association, 2013
Definitions of unhealthy alcohol use use Term Unhealthy alcohol use* Risky use* Alcohol use disorder (AUD), mild, moderate, or severe Definition Overarching term that includes risky drinking and alcohol use disorder. Consumption levels that increase the risk for health consequences. Consumption of alcohol above recommended daily, weekly, or per-occasion amounts. Use of alcohol that is characterized by presence of 2 of 11 DSM-5 criteria. *Jonas et al., May 2014; Jonas et al., 2012 DSM-5, American Psychiatric Association, 2013 e.g., drinking more than intended, craving, tolerance, withdrawal, continued use despite problems
Easier said than done» National data show that less than a third of patients are asked about alcohol use by their primary care providers, and less than 20% of adults report ever discussing it with a health care professional.» After implementing the new electronic health record, our practice did not have a system to screen for unhealthy alcohol use.
Flow of Process No Document. Screen again in 5 years. Nurse asks patient, Do you sometimes drink beer, wine, or other alcoholic beverages? Yes Nurse asks, How many times over the past year have you had 4 (for women and 65) or 5 (for men <65) drinks in a day? None Document. Screen again in 12 months. Counseling Risky drinking 1 times Nurse asks patient to complete AUDIT Provider reviews and scores AUDIT AUD likely Goal assessment Counseling Shared decision making about treatment options Referral
Quality Improvement Approach Built to resemble depression screening workflow To test protocols, we used low-tech, rapid cycle PDSAs before launching any permanent Epic tools» Pilot protocols with a limited number of providers and staff» Flag patients eligible for screening in the clinic schedule» Develop a temporary Epic tool (Dot Phrase) for screening» Develop paper-based decision support tools and provider Dot Phrases to guide assessment, counseling, or referral of patients with positive screens
Positive unintended consequences» Nurse familiarization with dot phrases» Closer relationship between GIM and the Alcohol & Substance Abuse Program (ASAP)» Updated an extensive list of resources in NC for people with AUD
Nurse Dot Phrases
New Epic tools: Nurse BPAs Prevention, Alcohol Screening: No initial alcohol screen or AUDIT documented in the past year. Click Doc Flowsheet to administer screen and document results. Alcohol Incomplete Screen: No AUDIT documented after patient screened positive on initial screen. Provide paper AUDIT and document results.» Visit-based reminders» Data entry in Flowsheets (searchable in EHR databases)
Provider Support for Counseling» Guidance for behavioral counseling interventions» Paper versions in rooms» Now also available for providers in dot phrases (developed by Scott Rose during QI month) What exactly is one drink?.imcalcoholavs
Mean rate = 80%
Mean rate = 42%
Celebrating achievements
Sustainability plan» The nurse BPAs will help ensure sustainability of the screening step Volume of screenings will decrease over time, e.g., BPA suppressed 5 years for nondrinkers» Streamlining and automating data collection» Physician Leadership in Quality & Safety Scholarly Concentration Garrett Thompson, MD/MPH student
Sustainability plan: Provider BPA and SmartSet
Sustainability plan
Key challenge: Competing demands New project designed to» Test screening via MyChart» Offer those with positive screens a virtual counseling intervention» Deliver information to providers Arlene Chung Co-PI
Thank you!
Lessons learned» We can successfully screen our patients» We were able to refine protocols and train staff, using low tech approaches, before making changes in Epic» Multiple positive unintended consequences Nurse familiarization with dot phrases Closer relationship between GIM and the Alcohol & Substance Abuse Program (ASAP) Updated an extensive list of resources in NC for people with AUD
Adults who have had at least one drink of alcohol within the past 30 days Percentage of respondents reporting Yes in 2014 Crude Prevalence (%) Data Source: Behavioral Risk Factor Surveillance System (BRFSS) 30
Binge drinkers (males having 5 drinks on one occasion, females having 4 drinks on one occasion) Crude Prevalence (%)
Heavy drinkers (adult men having more than two drinks per day and adult women having more than one drink per day) Percentage of respondents reporting Yes in 2014 Crude Prevalence (%) Data Source: Behavioral Risk Factor Surveillance System (BRFSS) 32
The Alcohol Use Disorders Test (AUDIT) Please circle your answer for each question: Points per response 0 1 2 3 4 1. How often do you have a drink containing alcohol? Never Monthly 2 to 4 times a month 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 5 or more drinks on one occasion? Never Less than monthly 2 to 3 times a week 4 or more times a week 1 or 2 3 or 4 5 or 6 7 to 9 10 or more Monthly Weekly Daily or almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily 5. How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year
DSM-5 diagnostic criteria for alcohol use disorder Severity: mild, 2-3 criteria; moderate, 4-5 criteria; severe, 6 criteria. 1 Alcohol is taken in larger amounts or over a longer period than intended. 2 Persistent desire or unsuccessful efforts to cut down or control alcohol use. 3 A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4 Craving, or a strong desire or urge to use alcohol. 5 Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6 Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7 Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8 Recurrent alcohol use in situations in which it is physically hazardous. 9 Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10 Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. (b) A markedly diminished effect with continued use of the same amount of alcohol. 11 Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for alcohol. (b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. Unlike DSM-III and DSM IV, DSM-5 (American Psychiatric Association, 2013) describes a single alcohol use disorder category measured on a continuum from mild to severe, and no longer has separate categories for alcohol abuse and dependence. Diagnosis of alcohol use disorder requires at least 2 of the 11 criteria listed.
Care Team Member and Patient Story From Julia George, clinic social worker The tools we ve developed have facilitated discussion of options for AUD counseling and treatment Julia described a story where the tools helped her and the PCP more efficiently discuss options and determine the plan of care Ultimately decided on inpatient treatment After detox in hospital, patient was referred to UNC ASAP, has attended follow-up appointments, and has maintained sobriety since discharge Julia noted that when she is not available to meet with patients in clinic, the referral information developed in our project allows resources to be delivered in a timely manner after counseling, when patients are likely to be more receptive
HELPING PATIENTS WHO DRINK TOO MUCH Introduction (cont d) How Much Is is Too Much? The Guide was written for Individual Drinking primary care becomes responses and mental too to much health alcohol when vary it Drinking clinicians. Causes at or It lower elevates is produced levels the may risk by the for be problematic alcoholrelated Institute problems, on many on factors; Alcohol for example depending National Abuse Complicates Patient s and Alcoholism age management (NIAAA), of other health a component problems Co-existing of the conditions, National and There Institutes Use are of increased medication Health (NIH), risks with for alcoholrelated guidance problems from physicians, for nurses, Note: advanced The practice U.S. nurses, Surgeon General urges abstinence physician Men <65 assistants, who drink from drinking and > 4 clinical standard drinks in a day for women researchers. (or >14 per week) and who All women are or and may men become 65 who pregnant. drink > 3 standard drinks in a day (or > 7 per week) #
WHAT S A STANDARD DRINK? What s a Standard Drink? (page 24) In the U.S., a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). #
Prevalence Among American Physicians % with symptoms of alcohol abuse/dependence Adapted from Oreskovich et al., 2014, Am J on Addictions *AUDIT-C score 5 (men) or 4 (women)
Health problems Epidemiologic literature consistently relates high average alcohol consumption and heavy peroccasion use to an increased risk of Cancers (oral cavity, esophagus, larynx, colon, rectum, liver, and breast) Gastrointestinal problems, e.g., liver cirrhosis, pancreatitis, gastritis, ulcers Cardiovascular problems, e.g., heart disease, hypertension, cardiomyopathy, stroke Mental health problems: e.g., depression, suicide, anxiety, cognitive impairment Preterm birth complications, fetal alcohol syndrome Injuries and violence Mortality 39
Condition Neoplastic conditions (cancer site) 25 g/day (1.8 drinks/d) RR (and 95% CI) a 50 g/day (3.6 dr/d) 100 g/day (7.3 dr/d) Oral cavity and pharynx 1.86 (1.76 1.96) 3.11 (2.85 3.39) 6.45 (5.76 7.24) Esophagus 1.39 (1.36 1.42) 1.93 (1.85 2.00) 3.59 (3.34 3.87) Colon 1.05 (1.01 1.09) 1.10 (1.03 1.18) 1.21 (1.05 1.39) Rectum 1.09 (1.08 1.12) 1.19 (1.14 1.24) 1.42 (1.30 1.55) Liver 1.19 (1.12 1.27) 1.40 (1.25 1.56) 1.81 (1.50 2.19) Breast 1.25 (1.20 1.29) 1.55 (1.44 1.67) 2.41 (2.07 2.80) Non-neoplastic conditions Coronary heart disease 0.81 (0.79 0.83) 0.87 (0.84 0.90) 1.13 (1.06 1.21) Ischemic stroke 0.90 (0.75 1.07) 1.17 (0.97 1.44) 4.37 (2.28 8.37) Hemorrhagic stroke 1.19 (0.97 1.49) 1.82 (1.46 2.28) 4.70 (3.35 6.59) Liver cirrhosis 2.90 (2.71 3.09) 7.13 (6.35 8.00) 26.52 (22.26 31.59) Chronic pancreatitis 1.34 (1.16 1.54) 1.78 (1.34 2.36) 3.19 (1.82 5.59) Injuries and violence 1.12 (1.06 1.18) 1.26 (1.13 1.40) 1.58 (1.27 1.95) a reference: non-alcohol drinkers; adjusted estimates Using 13.7gm per drink: 25g=1.8 drinks; 50g=3.6 drinks; 100g=7.3 drinks; 41.1g = 3 drinks; 54.8g = 4 drinks; 95.9g = 7 drinks 40 Corrao et al, Alcohol Consumption and Risk of 15 Diseases. Preventive Medicine, 2004
Relationship of all-cause mortality to usual alcohol intake in standard drinks per day based on pooled results of 14 cohort studies Alcohol intake (drinks per day) None 0-0.9 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0+ Men RR (95% CI) 1.00 0.88 (0.86-0.90) 0.84 (0.82-0.86) 0.93 (0.91-0.95) 1.01 (0.98-1.04) 1.06 (1.03-1.10) 1.20 (1.15-1.26) 1.37 (1.33-1.40) Women RR (95% CI) 1.00 0.88 (0.86-0.90) 0.94 (0.93-0.96) 1.13 (1.10-1.16) 1.33 (1.27-1.39) 1.47 (1.39-1.56) 1.47 (1.33-1.62) 1.58 (1.49-1.69) CI=confidence interval; RR=relative risk Holman, English, Milne et al, 1996 41
Significant increased RRs at 25g/day 13.7g of alcohol is 1 drink (often rounded to 14) Corrao et al, Alcohol Consumption and Risk of 15 Diseases. Preventive Medicine, 2004 42