Alcohol-Related Discussions in Primary Care

Clinicians who completed Phase 1 were invited to participate in a second week of data collection, this time with the addition of routine screening of all adult patients presenting for care (Phase 2). As in Phase 1, data were recorded for any patient who had a known alcohol problem, any patient with whom the clinician discussed alcohol, and any patient who had a positive screening result for problem drinking. The screening question—“When was the last time you had more than 5 drinks on one occasion?”¹⁷—was asked between questions regarding tobacco and seat belt use. An answer indicating any time within the past 3 months was considered a positive screening result for problem drinking.

We invited clinicians who participated in Phase 2 to receive training in brief interventions with problem drinkers. We mailed them a copy of The Physicians’ Guide to Helping Patients with Alcohol Problems¹⁸ and a videotaped lecture illustrating the steps in that guide. We also telephoned each participating clinician to address any concerns or perceived barriers and to practice brief intervention skills. Following training, each clinician collected card data for a third week (Phase 3), that included routine screening of all adult patients as in Phase 2. The 3 weeks of data collection were not consecutive in any practice, and each phase was not done in the same week across practices.

In comparing data from clinicians participating in more than one phase of card data collection, we assessed statistical significance with confidence interval analysis and with nonparametric tests (chi square, Fisher exact, and Mann-Whitney U) because most distributions were skewed.¹⁹

Results

A total of 114 clinicians collected data in Phase 1. During that week (which varied among practices), they saw a total of 7695 patients and had an alcohol-related discussion with 732 of them (9.5% of all visits). Among those 732 patients, the average age was 40 years (standard deviation = 18); 52.1% were women. Of the visits at which alcohol was discussed, 40% were for health maintenance, 28% for chronic illness, and 23% for acute self-limited illness. The clinician had previously seen the patient in 69% of the cases.

Nineteen clinicians participated in both Phases 1 and 2. They saw 1685 patients in Phase 1 and 1719 in Phase 2. Compared with clinicians who did not participate, more of the participants’ Phase 1 alcohol-related discussions were with patients they knew or suspected had an alcohol problem (34% vs 15%, P <.001 by chi square). Their alcohol-related discussions were longer (P = .008 by Mann-Whitney U), more likely to be prompted by their own concern (29% vs 20%) and were perceived as having greater intensity for the patient (6% perceived as having marked intensity vs 1%). However, the proportion of visits during which those 19 clinicians discussed alcohol was not significantly different from clinicians in Phase 1 who did not participate in Phase 2.

Table 1 shows comparisons of Phase 1 and Phase 2 for the 19 clinicians who completed data collection for both. Although we had anticipated a significant increase in the frequency, duration, and perceived intensity of alcohol-related discussions, the results from the first 2 phases were surprisingly similar. The addition of routine screening was associated with a shift in the triggers noted, especially from “clinician screening” to “primary prevention,” a decrease in the proportion that occurred in health maintenance visits, and an increase in the proportion in acute-care visits. Notably, of the 168 patients who had a positive screening result for problem drinking, the clinician did not discuss alcohol with 61, usually because of discussions at previous visits or a lack of time. The clinician had no previous knowledge or suspicion of an alcohol problem in 41 of those 61 instances; approximately one fourth (41 of 168) of the positive screening results were unexpected but were not addressed at the screening visit.

Of the 19 clinicians who participated in Phases 1 and 2, 15 participated in Phase 3 Table 2. We anticipated that training would increase the frequency and duration of alcohol-related discussions with patients who had a positive screening result and decrease the clinicians’ perceived discomfort with the intervention. Although these 15 clinicians were slightly more likely to address a positive screening result in Phase 3 than in Phase 2, the difference was not statistically significant. The discussions, however, were significantly longer. This was especially evident if the discussion was in response to a positive screening result: only 32% of those discussions lasted longer than 2 minutes in Phase 2, 58% in Phase 3 (P <.001). However, only 26% lasted longer than 4 minutes, and “not enough time” was checked more often in Phase 3 than in Phase 2 as a reason for not addressing a positive screening result.