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• W2040551275 abstract "Alcohol-related discussions between patients and their health-care providers are essential to high-quality health care. Such discussions include screening and brief interventions (SBI) [1–3], as well as management of alcohol dependence. Nevertheless, only a minority of patients report such discussions. Even after a multi-year campaign to implement SBI in medical settings in Sweden, Nilsen et al. found that only 19% of patients who screened positive for hazardous drinking on mailed surveys reported having discussed alcohol use with a health-care provider [4]. Moreover, alcohol-related discussions were very brief [4]. Surveys in other countries over the past two decades have had similarly disappointing results with only a minority of patients reporting having been advised or even asked about alcohol use (Table S1; see supporting information details at the end). Further, alcohol-related discussions that do occur last a few minutes or less [5–7]. Performance measurement—and specifically accountability measures—may be required to implement SBI in medical settings. Accountability measures refer to quality measures which are publically reported, linked to financial incentives and/or used for accreditation [8]. The US Veterans Affairs (VA) health-care system has used accountability measures combined with tools in an electronic medical record to implement alcohol screening [9] and brief interventions (BI) [10]. National rates of documented screening and BI in the VA were 97% and 76%, respectively, in the first half of fiscal year 2011 (personal communication). VA's experience, as well as the demonstrated value of accountability measures for improving other aspects of health care, suggests that other health-care systems may need to use such measures to implement SBI. Most accountability measures for SBI used to date have been based on medical record documentation by health-care providers [9,10]. However, linking incentives for SBI to medical record documentation has important limitations. First, accountability measures based on rates of documented screening do not encourage high-quality screening [11]. Further, variation in the prevalence of positive screens that results from variable quality of screening could undermine the validity of measures that evaluate rates of BI among patients with documented positive screens. Sites that identify fewer patients with hazardous drinking could more easily achieve high rates of BI, creating a potential incentive for identifying fewer patients with hazardous drinking. Accountability measures based on survey questions such as the one used by Nilsen et al. could have several advantages over those based on medical record documentation. Patient report on satisfaction surveys has been used successfully for accountability measures for smoking cessation counseling [12]. Accountability measures for BI based on patient report would create incentives for health-care systems to identify patients with hazardous drinking so that BI could be provided. Such measures might also motivate providers to have longer alcohol-related discussions, as the duration of medical counseling is a strong predictor of patient recall [13]. Questions about BI would need to be preceded with an agreed-upon validated alcohol screen, such as the consumption questions of the Alcohol Use Disorders Identification Test (AUDIT) used by Nilsen et al. [4] to allow comparisons across health-care systems. Survey assessment of BI could also be used to study the comparative effectiveness of various approaches to BI implementation. A consensus on core BI questions for inclusion on surveys would facilitate comparative effectiveness research. Both advice [9,10,14–16] and feedback linking drinking to health [4,10] are central components of evidence-based BI [2] that can be measured by surveys. We favor an adaptation of a carefully validated question about advice used as an accountability measure for smoking cessation counseling [17]: ‘In the last 12 months, how often were you advised to . . . [decrease drinking or abstain] by a doctor or other health provider?’[18]. Research comparing patient-report measures of BI to measures based on provider documentation will be essential. Further, Nilsen et al.'s innovative question regarding whether an alcohol-related discussion had ‘led to reduction of . . . drinking’ should be evaluated further. However, because measures of the severity of hazardous drinking are strong predictors of both alcohol-related discussions and decreased drinking [19], studies of the association of patient report of BI with changes in drinking should adjust for drinking severity. This adjustment appears not to have been possible in analyses of factors associated with patient report of reductions in drinking in the study by Nilsen et al. As a result, those findings should be interpreted cautiously. To conclude, the study by Nilsen et al. is important, in that it both reminds us of the challenges of SBI implementation and the value of asking patients about their alcohol-related discussions with health-care providers. Asking patients whether they have been advised about their drinking may be a useful accountability measure for SBI. Standard questions, included as accountability measures on mailed patient satisfaction surveys, could encourage high-quality alcohol screening and BI and could also be used for comparative effectiveness research. In this way, patient surveys could provide a foundation for the next stage of SBI implementation. The authors greatly appreciate the support of the Veterans Affairs Office of Quality and Performance (OQP), which shared quality improvement data for this report. We would also like to acknowledge Gwen Lapham, Carol Achtmeyer, Anna Rubinsky, Eric Hawkins, Richard Saitz and Daniel Kivlahan, who have collaborated on evaluations of SBI in the VA health-care systems and thereby contributed to the development of some of the ideas in this editorial. The research reported here was supported by Group Health Research Institute; the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Health Services Research and Development and the Veterans Affairs Substance Use Disorders Quality Enhancement Research Initiative (SUB 98-000). Dr Bradley is a senior investigator at GHRI and an associate investigator at the VA Northwest HSR&D Center of Excellence VA Puget Sound Health Care System, Seattle, WA. Dr Williams is an investigator at the VA Northwest HSR&D Center of Excellence VA Puget Sound Health Care System, Seattle, WA and an Assistant Professor in the Department of Health Services at the University of Washington. Some of the concepts in this commentary were presented at the 2009 Addiction Health Services Research meeting; the 2010 International Society for Biomedical Research on Alcoholism meetings; and the VA HSR&D Annual meeting 2011. The views expressed in this paper are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, Group Health Cooperative or the University of Washington. None. Table S1 Population-based surveys assessing alcohol-related discussions (ARD) among patients with hazardous drinking*. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article." @default.
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• W2040551275 title "Commentary on Nilsen et al. (2011): The importance of asking patients-the potential value of patient report of brief interventions" @default.
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