Clinical Reminders Insufficient to Implement Alcohol Screening

Despite high rates of screening for unhealthy alcohol use in US Veterans Affairs (VA) clinics using the validated Alcohol Use Disorders Identification Test – Consumption (AUDIT-C), its sensitivity has been lower than expected. In this qualitative study, ethnographers observed participating clinical staff from 9 clinics in 7 VA sites. Of the 49 clinical staff, 31 performed alcohol screening among 72 patients. Three themes emerged from an analysis of the field transcriptions:

• The means of administration matters. Most screening was conducted verbally, guided by a clinical reminder, but some clinics used laminated paper-based means.
• Non-verbatim screening with inferences, assumptions, and suggestions as to responses contributed to low sensitivity.
• Staff changed the recommended AUDIT-C questions to reduce discomfort and stigma, including omitting the third question about the frequency of heavy episodic drinking.

Comments:

Despite the use of a clinical reminder, alcohol screening at these sites was not performed in a standardized, valid, or reliable manner; there was wide variation in how the 3 AUDIT-C questions were asked and how response sets were presented. In many cases, clinicians accepted vague replies from patients and inferred or suggested answers. Clinical reminders alone are insufficient to ensure the disciplined execution of alcohol screening. Better training might help, but patient self-administration using paper, laminated cue cards, or computerized approaches will likely do more to improve accuracy.  

Peter D. Friedmann, MD

Reference:

Williams EC, Achtmeyer CE, Thomas RM, et al. Factors underlying quality problems with alcohol screening prompted by a clinical reminder in primary care: a multi-site qualitative study. J Gen Intern Med. 2015;30(8):1125–1132.