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...on Primary Care

www.ProjectCork.org

Summer 2003

Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project.

Aalto M; Pekuri P; Seppa K. Drug and Alcohol Dependence 69(1): 9-14, 2003. (24 refs.)
Aim: The study examined the change of primary health care professionals' activity in asking patients about alcohol and giving advice to heavy drinkers during a 3-year brief intervention implementation project. Method: A patient questionnaire survey after consultation blind to the primary health care professionals before and after the implementation project. Brief intervention implementation was based on action research. Subjects were 1000 consecutive 16-65-year-old patients consulting general practitioners at two primary health care centres at baseline and follow-up, of whom 655 and 768, respectively, participated. Results: No statistically significant differences were found regarding asking or advising about alcohol between baseline and 3-year follow-up. Of all patients, 19.1% (125/655) at baseline versus 19.7% (151/768) at follow-up were last asked about alcohol during the consultation in question or during past year (P = 0.784). Likewise, of heavy drinkers, 30.9% (30/97) versus 33.9 (38/112) were asked (P = 0.644). Of heavy drinkers, 13.4 (13/97) versus 14.9% (17/114) were advised about alcohol during the consultation in question (P = 0.754). Conclusion: The activity to do brief intervention remained stable. This may be due to the short follow-up time, the way brief intervention was implemented in the present study or the saturation in the activity reached already before the present study.

Pregnancy-related substance use in the United States during 1996-1998.

Ebrahim SH; Gfroerer J. Obstetrics and Gynecology 101(2): 374-379, 2003. (24 refs.)
OBJECTIVE: To provide a baseline estimate of the national prevalence of pregnancy-related illicit drug use and abstinence rates. METHODS: We analyzed data collected between 1996 and 1998 from the National Household Survey on Drug Abuse, a nationally representative sample survey of 22,303 noninstitutionalized women aged 18-44 years, of whom 1249 were pregnant. RESULTS: During 1996-1998, 6.4% of non-pregnant women of childbearing age and 2.8% of pregnant women reported that they used illicit drugs. Of the women who used drugs, the relative proportion of women who abstained from illicit drugs after recognition of pregnancy increased from 28% during the first trimester of pregnancy to 93% by the third trimester. However, because of post-pregnancy relapse, the net pregnancy-related reduction in illicit drug use at postpartum was only 24%. Marijuana accounted for three-fourths of illicit drug use, and cocaine accounted for one-tenth of illicit drug use. Of those who used illicit drugs, over half of pregnant and two- thirds of nonpregnant women also used cigarettes and alcohol. Among the sociodemographic subgroups, pregnant and nonpregnant women who were young (18-30 years) or unmarried, and pregnant women with less than high school education had the highest rates of illicit drug use. CON-CLUSION: The continued burden of illicit drug use during pregnancy calls for policy efforts to enable primary care providers to identify and refer women who use substances to treatment and support services. Prevention of uptake of illicit drug use should be an integral part of public health programs for young women.

Impact of patient characteristics on physician's smoking cessation strategies.

Ellerbeck EF; Choi WS; McCarter K; Jolicoeur DG; Greiner A; Ahluwalia JS. Preventive Medicine 36(4): 464-470, 2003. (26 refs.)
Background. The effectiveness of smoking cessation interventions may be influenced by a variety of patient characteristics, including level of nicotine addiction and readiness to change. We conducted this study to examine the relationship between these characteristics and the frequency of physician-initiated smoking cessation interventions. Methods. We identified smokers seen during office visits to I of 38 primary care physicians in rural Kansas. Trained students observed the frequency and nature of doctor-patient discussions related to tobacco. Telephone surveys were conducted with these patients I to 3 days after the office visit. Results. We completed observations and telephone surveys on 259 smokers. Tobacco-related discussions occurred during 66% of doctor-patient encounters. Although discussions overall were unrelated to a patient's readiness to quit, specific assistance with smoking cessation was offered less often to precontemplators (15%) than to contemplators (31%) or those preparing to quit (37%) (P < 0.05). While bupropion was discussed with 23% of smokers, nicotine replacement therapy was discussed with 12% and was unrelated to markers of nicotine addiction. Conclusions. Current efforts to promote smoking cessation are only marginally related to patient characteristics. Doctors are missing many opportunities to effectively intervene with patients who are contemplating smoking cessation or preparing to quit.

Alcohol high risk drinking, abuse and dependence among tobacco smoking medical care patients and the general population.

John U; Hill A; Rumpf HJ; Hapke U; Meyer C. Drug and Alcohol Dependence 69(2): 189-195, 2003. (69 refs.)
Background: Little is known about the synergies of smoking and alcohol consumption in medical care patients. The objective, therefore, is to estimate the coincidence of hazardous and harmful alcohol consumption as well as alcohol abuse and dependence with tobacco smoking in a general hospital and general practices. Methods: Three samples of 18-64 year olds include 510 consecutively admitted currently smoking in-patients of a general hospital, 271 patients of a randomized sample of general practices, and 1567 current smokers from a regional population in Germany. Data include the number of cigarettes and a diagnosis of alcohol dependence and abuse (DSM), harmful or hazardous alcohol use. Results: The rates of current daily cigarette smokers with an alcohol dependence or abuse, harmful or hazardous alcohol consumption are 47.1% in the general hospital and 32.1% in the general practice sample compared with 18.4% in the general population. The rates increase from nonsmokers to smokers and with the number of cigarettes. Conclusions: The findings fit into the evidence about alcohol and tobacco interactions in morbidity and mortality. General medical care settings are appropriate for the detection of alcohol dependence or abuse via, smoking.

General practitioners and alcohol use disorders: Quantity without quality.

Malet L; Llorca PM; Boussiron D; Schwan R; Facy F; Reynaud M. Alcoholism: Clinical and Experimental Research 27(1): 61-66, 2003. (45 refs.)
Background: General medical practitioners are essential for the prevention, diagnosis, and management of alcohol use disorders. Studies to examine medical practice in this field, however, are very rare. Method: A cross-sectional study involving 2010 patients seen by a sample of 145 general practitioners in the Auvergne region of central France was conducted on a given day in May 1998. The purpose of the study was to evaluate the prevalence of alcohol use disorders (using the DSM-IV diagnostic criteria for alcohol abuse or dependence and the CAGE questionnaire) and so to estimate the proportion of nonsomatic alcohol-related care dispensed. Results: Sixteen percent of patients consulting their general practitioner had an alcohol problem, 27% of men and 5% of women. On average, a quarter of these patients had not been previously identified by the physician. Diagnosis seemed particularly difficult in women: 11% of women aged between 36 and 45 had an alcohol- related problem that went unidentified in 60% of cases. Care for alcohol-related health problems was therefore seriously inadequate. In one third of cases, patients with a diagnosed alcohol-related problem were not followed up by the physician for that problem. Two thirds received no medication, and in more than 80% of cases the physician did not refer to a specialist or prescribe admission to a specialized hospital ward. Conclusions: These results underline the diagnostic and therapeutic difficulties experienced by general practitioners. This study has led to the establishment of a pilot health care network for patients suffering from alcohol use disorders. This network involves voluntary doctors who have been trained and are better paid for their services. Care protocols have been established to which these practitioners have to adhere.

Understanding the potential of teachable moments: The case of smoking cessation.

McBride CM; Emmons KM; Lipkus IM. Health Education Research 18(2): 156-170, 2003. (118 refs.)
The label 'teachable moment' (TM) has been used to describe naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors. This manuscript summarizes the evidence of TMs for smoking cessation, and makes recommendations for conceptual and methodological refinements to improve the next generation of related research. TM studies were identified for the following event categories: office visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. Cessation rates associated with pregnancy, hospitalization and disease diagnosis were high (10-60 and 15-78%, respectively), whereas rates for clinic visits and abnormal test results were consistently lower (2-10 and 7-21%, respectively). Drawing from accepted conceptual models, a TM heuristic is outlined that suggests three domains underlie whether a cueing event is significant enough to be a TM for smoking cessation: the extent to which the event (1) increases perceptions of personal risk and outcome expectancies, (2) prompts strong affective or emotional responses, and (3) redefines self-concept or social role. Research in TMs could be improved by giving greater attention to assessment of conceptually grounded cognitive and emotional variables, appropriately timed assessment and intervention, and inclusion of appropriate target and comparison samples.

Screening and counseling for adolescent alcohol use among primary care physicians in the United States.

Millstein SG; Marcell AV. Pediatrics 111(1): 114-122, 2003. (45 refs.)
The authors examined the quality and prevalence of alcohol prevention services delivered to adolescents in the United States. A national, stratified random sample of pediatricians and family practitioners was drawn from the American Medical Association Masterfile. The response rate was 63 percent, and the final sample size was 1842 physicians. Quality of services delivered was assessed by two scales: quality of screening (percentage of patients screened and depth of screening questions used) and quality of education (level of effectiveness of educational methods used and frequency of use). Most physicians reported providing some degree of alcohol prevention services, however, their efforts were typically inconsistent, not in enough depth, and they failed to incorporate the most effective educational methods. Reported rates of universal screening and counseling were low, and younger adolescents were less likely to receive services. Physicians' beliefs about their alcohol management skills and percept-ions of resource availability were the most consistent correlates of higher quality service. Prospective studies that elucidate the conditions under which individual physicians do and do not screen, as well as future efforts to educate physicians about the most effective brief intervention approaches, seem warranted.

Utilization and cost impact of integrating substance abuse treatment and primary care.

Parthasarathy S; Mertens J; Moore C; Weisner C. Medical Care 41(3): 357-367, 2003. (41 refs.)
OBJECTIVE. To examine the impact of integrating medical and substance abuse treatment on health care utilization and cost. RESEARCH DESIGN. Randomized clinical trial assigning patients to one of two treatment modalities: an Integrated Care model where primary health care is provided along with substance abuse treatment within the unit and an Independent Care model where medical care is provided in the HMO's primary care clinics independently from substance abuse treatment. SUBJECTS. Adult patients entering treatment at the outpatient Chemical Dependency Recovery Program in Kaiser Sacramento. MEASURES. Medical utilization and cost for 12 months pretreatment and 12 months after treatment entry. RESULTS. For the full, randomized cohort, there were no statistically significant differences between the two treatment groups over time. However, among the subset of patients with substance abuse related medical conditions (SAMC), Integrated Care patients had significant decreases in hospitalization rates (P = 0.04), inpatient days (P = 0.05) and ER use (P = 0.02). Total medical costs per member-month declined from $431.12 to $200.03 (P = 0.02). Among SAMC Independent Care patients, there was a downward trend in inpatient days (P = 0.08) and ER costs (P = 0.05) but no statistically significant decrease in total medical cost. CONCLUSIONS. (Non)findings for the full sample suggest that integrating substance abuse treatment with primary care, may not be necessary or appropriate for all patients. However, it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine. There appear to be large cost impacts of providing integrated care for such patients.

Addressing alcohol problems in primary care: A cluster randomized, controlled trial of a systems intervention: The Screening and Intervention in Primary Care (SIP) study.

Saitz R; Horton NJ; Sullivan LM; Moskowitz MA; Samet JH. Annals of Internal Medicine 138(5): 372-382, 2003. (138 refs.)
Background: screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented. Objective: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use. Design: Cluster randomized, controlled trial. Setting: Urban academic primary care practice. Participants: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking. Interventions: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommenda-tions for their patients at a visit. Measurements: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later. Results: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.71 versus 11.6 [CI, 5.4 to 17.7]). Conclusions: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

Linking alcohol- and drug-dependent adults to primary medical care: A randomized controlled trial of a multi-disciplinary health intervention in a detoxification unit.

Samet JH; Larson MJ; Horton NJ; Doyle K; Winter M; Saitz R. Addiction 98(4): 509-516, 2003. (34 refs.)
Aim: Pragmatic approaches to integration of medical care and substance abuse treatment are desired. We assessed the effectiveness of a novel multi-disciplinary clinic for linking patients in a residential detoxification program to primary medical care. Participants We enrolled patients undergoing in-patient detoxification from alcohol, heroin or cocaine who had no primary care physician into a randomized controlled trial. The intervention consisted of a clinical evaluation at the detoxification unit in the health evaluation and linkage to primary care (HELP) clinic by a nurse, social worker and physician and facilitated referral to an off-site primary care clinic. The primary outcome of interest was attendance at a primary care appointment within 12 months. Secondary outcomes assessed over 24 months were addiction severity, health-related quality of life, utilization of medical and addiction services and HIV risk behaviors. Findings: Of the 470 subjects enrolled, 235 were randomized to the HELP clinic intervention. Linkage to primary medical care occurred in 69% of the interven-tion group compared to 53% in the control group (P = 0.0003). The clinic was similarly effective for subjects with alcohol and illicit drug problems. Randomization to the HELP clinic resulted in no significant differences in secondary outcomes. Conclusions: The HELP clinic, a multi-disciplinary clinic located in a detoxification unit, effectively linked alcohol- and drug-dependent individuals to primary medical care. This intervention utilized a 'reachable moment', the period of addiction care, as a window of opportunity for linking substance abusers to medical care.

Establishing the feasibility of performance measures for alcohol and other drugs.

Garnick DW; Lee MT; Chalk M; Gastfriend D; Horgan CM; McCorry F et al. Journal of Substance Abuse Treatment 23(4): 375-386, 2002. (29 refs.)
Performance measures estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality. Development of performance measures for alcohol and other drug services has lagged behind development of such measures for many other chronic medical conditions, probably because of the unique social role of alcohol and drug use. The Washington Circle (a multiple-disciplinary group of providers, researchers, managed care representatives, and public policy represent-atives) examined three performance measures for alcohol and other drug (AOD) services. These measures, which were developed and applied to managed care organizations' administrative data for their commercial enrollees, are: (1) identification, the percent of adult enrollees with AOD diagnoses; (2) initiation, the percent of adults with an inpatient AOD admission or with an index outpatient visit for AOD abuse or dependence and any additional AOD services within 14 days of identification; and (3) engagement, the percent of adults diagnosed with AOD disorders that receives two additional AOD services within 30 days of the initiation of care. Results indicated that using administrative databases to compare managed care organizations' performance is feasible, meaningful and informative. This article discusses issues in interpreting performance measures in several areas: organizational structure of alcohol and other drug services, information available for measurement, and computational issues.