Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care

Bobb, Jennifer F.; Lee, Amy K.; Lapham, Gwen T.; Oliver, Malia; Ludman, Evette; Achtmeyer, Carol E.; Parrish, Rebecca; Caldeiro, Ryan M.; Lozano, Paula; Richards, Julie; Bradley, Katharine A.

doi:10.3390/ijerph14091030

Cited by 52 publications

(70 citation statements)

References 69 publications

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“…Thus, our finding that homelessness was positively associated with treatment initiation for AUD is likely not generalizable. Several studies are testing whether integrating AUD treatment into primary care can overcome barriers to AUD treatment . Integrated care has been successfully trialed for patients with mental health and SUDs attending HCV clinics and has been shown to increase rates of HCV treatment .…”

Section: Discussionmentioning

confidence: 99%

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

et al. 2020

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BaCKgRoUND aND aIMS:Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. appRoaCH aND ReSUltS: This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96).CoNClUSIoNS: Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

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Section: Discussionmentioning

confidence: 99%

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

et al. 2020

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“…1). Of these, 24 reports were randomized controlled trials (RCTs) , 12 were controlled designs [47][48][49][50][51][52][53][54][55][56][57][58] and 20 were before/after and other designs [59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78]. Thirty-five were alcohol-specific, while 21 focused on broader prevention ( Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…For example, asking about alcohol consumption, eliciting alcohol history, 'assessment' of alcohol consumption or similar was used for screening; 'brief advice', 'brief counselling', and discussing alcohol was used for BI. Only six reports addressed improvement in rates of pharmacotherapy uptake for relapse prevention [31,42,43,49,61,75]. None included implementation of psychosocial therapies, though referral to such therapies was mentioned as a treatment option.…”

Section: Targeted Clinical Actionsmentioning

confidence: 99%

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

et al. 2020

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Background: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. Methods: We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. Results: Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements.

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“…Avoiding identification bias by restricting the analysis to patients diagnosed before randomization was not appealing because of the nature of the stepped wedge design, whereby patients seen in the clinic before randomization may not have follow-up visits to the clinic during the time period after the clinic crossed over to the intervention group (up to 2-3 years later). Consequently, investigators favored a primary analysis approach that used as its study population all patients who visited the clinic (including patients with a first visit after randomization), because the intervention was not expected to affect this population [40,46,47]. Another example is a cluster-randomized, parallel group trial to test the effectiveness of an intervention to improve colorectal cancer screening rates [41,42].…”

Section: Discussionmentioning

confidence: 99%

Addressing identification bias in the design and analysis of cluster-randomized pragmatic trials: a case study

Bobb

Qiu

Matthews

et al. 2020

Trials

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Background: Pragmatic trials provide the opportunity to study the effectiveness of health interventions to improve care in real-world settings. However, use of open-cohort designs with patients becoming eligible after randomization and reliance on electronic health records (EHRs) to identify participants may lead to a form of selection bias referred to as identification bias. This bias can occur when individuals identified as a result of the treatment group assignment are included in analyses. Methods: To demonstrate the importance of identification bias and how it can be addressed, we consider a motivating case study, the PRimary care Opioid Use Disorders treatment (PROUD) Trial. PROUD is an ongoing pragmatic, cluster-randomized implementation trial in six health systems to evaluate a program for increasing medication treatment of opioid use disorders (OUDs). A main study objective is to evaluate whether the PROUD intervention decreases acute care utilization among patients with OUD (effectiveness aim). Identification bias is a particular concern, because OUD is underdiagnosed in the EHR at baseline, and because the intervention is expected to increase OUD diagnosis among current patients and attract new patients with OUD to the intervention site. We propose a framework for addressing this source of bias in the statistical design and analysis. Results: The statistical design sought to balance the competing goals of fully capturing intervention effects and mitigating identification bias, while maximizing power. For the primary analysis of the effectiveness aim, identification bias was avoided by defining the study sample using pre-randomization data (pre-trial modeling demonstrated that the optimal approach was to use individuals with a prior OUD diagnosis). To expand generalizability of study findings, secondary analyses were planned that also included patients newly diagnosed post-randomization, with analytic methods to account for identification bias. Conclusion: As more studies seek to leverage existing data sources, such as EHRs, to make clinical trials more affordable and generalizable and to apply novel open-cohort study designs, the potential for identification bias is likely to become increasingly common. This case study highlights how this bias can be addressed in the statistical study design and analysis.

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Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care

Cited by 52 publications

References 69 publications

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

Addressing identification bias in the design and analysis of cluster-randomized pragmatic trials: a case study

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