Alcohol-Related Discussions in Primary Care
A Report from ASPN
METHODS: Nineteen clinicians in the Ambulatory Sentinel Practice Network (ASPN) collected data about alcohol-related discussions for 1 week following their usual office routine (Phase 1) and for 1 week with the addition of routine screening for problem drinking (Phase 2). Of those, 15 clinicians collected data for a third week after receiving training in brief interventions with problem drinkers (Phase 3). Clinicians collected data on standard ASPN reporting cards.
RESULTS: In Phase 1 the clinicians discussed alcohol during 9.6% of all visits. Seventy-three percent of those discussions were shorter than 2 minutes long, and only 10% lasted longer than 4 minutes. When routine screening was added (Phase 2), clinicians were more likely to discuss alcohol at acute-illness visits, but the frequency, duration, and intensity of such discussions did not change. Only 32% of Phase 2 discussions prompted by a positive screening result lasted longer than 2 minutes. After training, the duration increased (P <.004). In Phase 3, 58% of discussions prompted by a positive screening result lasted longer than 2 minutes, but only 26% lasted longer than 4 minutes.
CONCLUSIONS: Routine screening changed the kinds of visits during which clinicians discussed alcohol use. Training in brief-intervention techniques significantly increased the duration of alcohol-related discussions, but most discussions prompted by a positive screening result were still shorter than effective interventions reported in the literature.
Brief physician intervention with problem drinkers can be effective in primary care practice: Patients who receive it are twice as likely to moderate their alcohol intake as patients in a control group.1-4 Most problem drinkers, however, go unrecognized and untreated in medical encounters.5,6 Two separate surveys found that only 39% of patients reported being asked by their physician about their alcohol use.7,8 Several barriers to widespread adoption of brief physician-based intervention techniques have been hypothesized, including time constraints and physician reluctance to impose a new agenda on the patient;9-11 but the quantitative effects of those barriers on current physician practice have not been empirically explored.
In research trials brief interventions with problem drinkers have required one or more office visits, each lasting from 5 to 15 minutes.2,3 In those studies, patients were screened at one visit, and those identified as problem drinkers were recruited for the study by research personnel. If assigned to the intervention group, they returned for another office visit. This 2-stage approach (screening and intervention at separate visits) may miss some patients. In the Wisconsin study,2 30% of those patients willing to participate failed to complete the baseline interview, and 22% of those assigned to the intervention group did not keep the subsequent appointment. Furthermore, physicians may find the requirement of a second visit too burdensome. In a study in Scotland, half the general practitioners who were invited to participate did not join the study because they felt that a 10-minute intervention was too time consuming.12 These problems could be partially addressed by opportunistic intervention (screening and doing the brief intervention at the same office visit), but an Australian study13 found even that approach unsuccessful.
A better understanding of current alcohol-related discussions in primary care may facilitate adoption of brief interventions with problem drinkers, and we know of no study that has described them. We designed our study to describe the frequency, duration, intensity, and triggers of alcohol-related discussions in primary care routine practice. Then in a before-after design, we investigated changes in alcohol-related discussions with the addition of systematic screening of all adult patients for problem drinking, and then again after the clinicians received training in brief interventions with problem drinkers.
Methods
The Ambulatory Sentinel Practice Network (ASPN) included primary care clinicians in the United States and Canada; 86% were family physicians, and most of the rest were nurse practitioners and physician assistants. ASPN conducted more than 40 studies that spanned a broad spectrum of clinical and health services research that informed both clinical practice and health care policy.14 A comparison of key characteristics of ASPN patients with a probability sample of US family physicians participating in the 1991 National Ambulatory Care Survey suggests minimal selection bias associated with voluntary participation in ASPN.15
We recruited volunteer clinicians to collect data about alcohol-involved visits for 1 week without change in their routine practice (Phase 1). Clinicians recorded data about any patient they knew had an alcohol problem or if they discussed alcohol for any reason. On a pocket-sized card,16 they noted the patient’s age and sex, the type of visit (acute self-limited illness, acute serious, chronic illness, obstetrical care, or health maintenance), whether the presenting complaint seemed related to alcohol, whether the clinician had any previous knowledge or suspicion of an alcohol problem, what triggered the alcohol-related discussion, how long it lasted (<2, 2 to 4, 4 to 8, or >8 minutes), and how intense it was for the clinician and for the patient (coded as no, mild to moderate, or marked intensity).
