Practice Facilitation to Improve Screening for Unhealthy Alcohol Use in Virginia: Outcomes of AHRQ’s EvidenceNow Initiative

Context: Unhealthy alcohol use (UAU) is the third leading cause of preventable death. While several screening tools with reliable sensitivity and specificity are recommended for screening, they are not routinely used. As a result, UAU is often missed and interventions such as brief counseling, motivational interviewing, medication treatment, and referrals are infrequently provided.

Objective: This four-year AHRQ-funded study aimed to enroll practices to evaluate the effect of practice facilitation to promote use of recommended screening instruments (AUDIT-C or SASQ), identify risky drinking, and follow up and treat positive screens. Practice facilitation included identification of a practice champion, workflow assessment, and assistance with practice protocols and resources.

Population studied: Primary care practices across Virginia. Enrolled practices were randomized to immediate practice facilitation or time-delayed facilitation to serve as a control.

Data set and analysis: We conducted three cross-sectional analyses of patients using a chart review at 0, 3, and 6 months of the study.

Outcome measures: Chart documented screening for UAU, brief counseling, referral for support, and medication use for risky drinking.

Results: 76 practices were enrolled; 11,306 patient charts were reviewed. While many practices documented alcohol use (76.5%intervention, 70.9% delayed intervention, p<0.005), practice facilitation resulted in a statistically significant increase in use of the recommended screening instrument (p<0.005). Patients from practices that received practice facilitation were not more likely to have documentation of a diagnosis of risky drinking (p=0.60), brief counseling interventions (p=0.34), referral to programs (8.3%vs 9.8%, p=0.60), or medication treatment (p=0.92).

Discussion: Practice facilitation resulted in a large increase in UAU screening, but there was not an increase in documentation of identification or treatment of risky drinking. Qualitative assessments of practice meetings and post-intervention interviews suggest that clinicians believed they identified more risky drinking, provided more brief counseling, and even had practice cultural changes in approach to risky drinking. The limited effect identified by chart review may partly be a documentation issue, but it also highlights the need for greater practice support to deal with this challenging preventive service.