Screening for Unhealthy Alcohol Use Does Not Ensure Appropriate Intervention

Although primary-care based screening, brief intervention, and referral for treatment for unhealthy alcohol use has increased, questions remain about effectiveness in implementation. In this retrospective study, Veterans Affairs care providers were prompted electronically to refer patients to a behavioral health program, addiction service, or emergency care if they screened positive on the AUDIT-C* for unhealthy alcohol use (score ≥5), the PHQ-2** for depression (score ≥3), or the PC-PTSD† for post-traumatic stress disorder (score ≥3). Patient visits over 2 years to 77 primary care physicians, nurse practitioners, and physician assistants were included in the study.
 

• Screening identified 4690 patients with positive AUDIT-C scores, 2772 patients with positive PHQ-2 scores, and 1590 patients with positive PC-PTSD scores.

• Referral rates were 15% for unhealthy alcohol use, 61% for depression, and 74% for PTSD.

• After adjustment for clinician, patients with a positive PHQ-2 or PC-PTSD screen were 10 and 19 times more likely, respectively, to be referred to treatment than patients with a positive AUDIT-C screen.

Comments:

This study did not assess whether providers conducted brief interventions for patients who screened positive for unhealthy alcohol use. Because there is no “brief intervention” for depression or PTSD, the study may have differentially underestimated clinician response to a positive screen for alcohol. Nonetheless, the large difference in referral rates suggests that, unfortunately, performing screening for unhealthy alcohol use does not necessarily lead to optimal intervention.

Hillary Kunins, MD, MPH, MS

Reference:

Maust DT, Mavandadi S, Klaus J, et al. Missed opportunities: fewer service referrals after positive alcohol misuse screens in VA primary care. Psychiatr Serv. 2011;62(3):310–312.