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- Title
Integrating Alcohol-Related Prevention and Treatment Into Primary Care: A Cluster Randomized Implementation Trial.
- Authors
Lee, Amy K.; Bobb, Jennifer F.; Richards, Julie E.; Achtmeyer, Carol E.; Ludman, Evette; Oliver, Malia; Caldeiro, Ryan M.; Parrish, Rebecca; Lozano, Paula M.; Lapham, Gwen T.; Williams, Emily C.; Glass, Joseph E.; Bradley, Katharine A.
- Abstract
Key Points: Question: Can a multicomponent implementation intervention, including prompts in electronic health records, feedback on performance, and 6 months of practice facilitation, improve alcohol-related prevention and treatment in primary care? Findings: In this stepped-wedge cluster randomized implementation trial of 333 596 patients in primary care, the intervention increased alcohol screening, brief preventive alcohol counseling, new diagnosis of alcohol use disorders, and alcohol treatment initiation, but did not increase engagement in alcohol treatment compared with usual primary care. Meaning: Medical care often neglects unhealthy alcohol use despite its effect on morbidity and mortality; this multicomponent implementation intervention increased preventive care, diagnosis, and treatment initiation for alcohol use disorders but not treatment engagement. Importance: Unhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment. Objective: To test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration. Design, Setting, and Participants: The Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021. Interventions: The implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice's intervention period. Main Outcomes and Measures: Coprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression. Results: A total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P <.001). The proportion with AUD treatment engagement did not differ during intervention and usual care (1.4 vs 1.8 per 10 000 patients; P =.30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P <.001), new AUD diagnosis (33.8 vs 28.8 per 10 000; P =.003), and treatment initiation (7.8 vs 6.2 per 10 000; P =.04). Conclusions and Relevance: In this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation. Trial Registration: ClinicalTrials.gov Identifier: NCT02675777 This stepped-wedge cluster randomized implementation trial investigates an intervention to increase population-based alcohol-related prevention with brief interventions and treatment of alcohol use disorder in primary care.
- Publication
JAMA Internal Medicine, 2023, Vol 183, Issue 4, p319
- ISSN
2168-6106
- Publication type
Article
- DOI
10.1001/jamainternmed.2022.7083