Alcohol-Related Discussions in Primary Care

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Original Research

Alcohol-Related Discussions in Primary Care

J Fam Pract. 2000 January;49(1):28-33

References

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In Phase 2, 70% of the screening was done by office assistants, compared with 57% in Phase 3 (P = .03). However, the screener did not significantly affect the characteristics of alcohol-related discussions, such as duration and intensity. Although 2 of the participating clinicians reported missing the screening of some patients, the clinicians reported only one patient who refused screening of the 3391 patients seen during these 2 phases of our study. Data were recorded on the pocket-sized card after each visit in approximately 40%, at the end of each day in another 40%, and at the end of the week in about 20% in both Phase 1 and 2; data were recorded somewhat closer to the visit in Phase 3 (60% after each visit, 33% each day).

Discussion

In all phases of this study, the primary care clinicians discussed alcohol with approximately 10% of their patients, usually at their own initiation. Relatively few discussions (approximately 1 out of 5) were prompted by the clinician’s concern about a possible alcohol problem, and even fewer were initiated by a patient or concerned family member. Unlike the successful 5- to 15-minute interventions published in the literature, these alcohol-related discussions were remarkably short. In Phase 1, considering only the 19 clinicians who also participated in Phase 2, 93% of the alcohol-related discussions were shorter than 4 minutes, even when they were prompted by the clinician’s concern.

We thought routine screening would increase the frequency of alcohol-related discussions, shift the focus from clinicians doing their own screening to intervening with identified problem drinkers, and make the discussions longer and more uncomfortable. But routine screening made almost no difference in alcohol-related discussions. Clinicians reported shifts in the triggers for alcohol-related discussions and the types of patient visits during which alcohol was discussed, but we found no significant changes in the duration or intensity of alcohol-related discussions.

In Phase 3, after the physicians received training in identifying and intervening with problem drinkers, alcohol-related discussions were significantly longer. When initiated in response to a positive screening result, most discussions were longer than 2 minutes, but only 26% lasted longer than 4 minutes, still shorter than effective brief interventions.^1,2

Our findings are, in some respects, generalizable to other primary care clinicians. The proportion of visits in which alcohol was discussed in our study was similar to the 9% reported by the Direct Observation of Primary Care study.²⁰ This was the first study of problem drinking by ASPN, and the patients were comparable with those seen in the National Ambulatory Medical Care Survey.¹⁵

The reasons for the lack of change with the addition of routine screening remain unclear; we suggest 3 possibilities. First, these clinicians may have already known their patients well; adding routine screening gave them little additional information. However, the most commonly cited reason for not discussing alcohol with patients who had a positive screening result was a lack of time. Second, most clinicians had their office assistant screen patients, and more discussions might have taken place had the clinicians done the screening and used a positive response as an opportunity to engage the patient in a conversation about drinking. The duration of discussions prompted by clinician concern, however, was similar across all 3 phases of our study. Third, time constraints may have limited clinicians’ ability to respond to an unexpectedly positive screening result. A lack of time was given as a reason for not discussing a positive screening result with 22 of 61 patients in Phase 2, 17 of 30 in Phase 3. Notably and also contrary to our expectations, clinician discomfort with screening-prompted discussions was no greater than with those in Phase 1, suggesting that adding routine screening seldom creates an awkward situation for the clinician.

Although training was associated with longer discussions, the changes from Phase 2 (before training) to Phase 3 (after training) were smaller than we anticipated. Further exploration is warranted, but as documented by Stange and colleagues,²⁰ an ordinary office visit deals with a multitude of issues. The lack of substantial change in alcohol-related discussions may simply be because of the crowded agenda of the primary care office visit.

We do not know the content or outcome of the alcohol-related discussions during the 3 phases of data collection or how many of those who screened positive actually had at-risk drinking, an alcohol-use disorder, both, or neither. Of those who had a negative screening result yet had an alcohol-related discussion, 5 of the 34 discussions in Phase 2 and 15 of the 44 in Phase 3 were prompted by clinician concern. We suspect some of these patients had false-negative screening results, and we do not know how many other problem drinkers were missed by the screening question.