Journal of Addictive Diseases, 33:332–339, 2014 ISSN: 1055-0887 print / 1545-0848 online DOI: 10.1080/10550887.2014.969621
CARE UTILIZATION AND PATIENT CHARACTERISTICS OF VETERANS WHO MISUSE ALCOHOL Max A. Halvorson, MA1, Sharfun Ghaus, MBBS1, Michael A. Cucciare, PhD2,3,4 1 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA 2 Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA 3 Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA 4 VA South Central (VISN 16) Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
Substance abuse treatment utilization and patient characteristics of veterans (N = 167) drinking alcohol at risky levels at a Department of Veterans Affairs hospital were examined. Rates of brief intervention and specialty care were higher than those found in national samples in 2010, but fall short of recommended guidelines. Veterans receiving more care were older, lower-income, and less likely to be in a relationship. Care-receiving veterans had higher rates of mental health comorbidities and mental health treatment in the prior year for an issue other than substance use. Understanding patients’ recent care history may help primary care providers to deliver care effectively. KEYWORDS. Alcohol use disorders, patient characteristics, VA health care system, alcohol use disorders identification test-consumption, brief intervention, specialty care, veterans
Alcohol misuse is highly prevalent among veterans presenting to primary care1 and is associated with significant morbidity including cancer, cardiovascular disease, psychiatric disorders, and mortality.2 Efficacious psychosocial and pharmacological treatments exist for both mild and severe alcohol misuse. For patients with less severe alcohol misuse, brief intervention (BI)—which consists of counseling and information on recommended drinking limits— is appropriate and cost-effective and has been shown to reduce alcohol use in a wide range of individuals including college students, community samples, and U.S. active duty military personnel.3–6 For those with more severe drinking problems, a range of effective treatments such as cognitive-behavioral therapy (CBT) can
be utilized by addiction specialists to reduce consumption.7,8 Having a range of treatment options (including referral) for the spectrum of alcohol misuse is critical in primary care settings such as those within the U.S. Department of Veterans Affairs (VA), where rates of risky drinking are elevated relative to the general population.1 Over recent years, the VA has mandated a BI to improve rates of alcohol-related treatment for veterans screening positive for alcohol misuse in outpatient settings.9 In 2007, the VA implemented a national brief alcohol counseling performance measure which requires providers to counsel veterans screening positive (score ≥5) on the alcohol use disorders identification test-consumption items (AUDIT-C) for
This article is not subject to U.S. copyright law. Address correspondence to Max A. Halvorson, MA, Research Health Science Specialist, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), 795 Willow Road, Menlo Park, CA 94025. E-mail: [email protected]
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alcohol misuse.9 Veterans with a positive AUDIT-C screen are required to receive, at minimum, a BI consisting of education about safe drinking limits and the potential health related effects of alcohol misuse. Efforts to implement this performance measure, including the use of electronic clinical reminders, have significantly increased rates of documented BIs from preimplementation (34%) to post-implementation (53%);10 however, many eligible veterans still fail to receive BIs. Veterans presenting to outpatient care with more severe alcohol misuse may require treatment beyond BI.11 Accordingly, VA requires that veterans reporting an AUDIT-C score indicating probable dependence (score of 8 or greater)12 receive a referral to specialty substance use disorder (SUD) treatment. Unfortunately, few (4%) veterans reporting probable alcohol dependence utilize the VA specialty SUD care following a referral.13 Patient and clinic factors that may contribute to these low utilization rates include patients’ refusal to receive a referral or follow-up with an appointment,13 challenges in identifying patients with probable alcohol dependence,14 and provider hesitance to recommend referrals and/or discuss alcohol use with their patients. VA efforts to improve rates of alcohol-related treatment received among veterans who drink at risky levels have undoubtedly been successful as evidenced by increases in BIs among eligible veterans.10 However, continued efforts to improve rates of appropriate alcohol-related care are needed. Understanding patients’ recent history of substance use treatment and patient characteristics associated with receiving such care may improve providers’ ability to identify individuals for whom care is indicated and make treatment decisions for this population.13 Glass et al.13 examined characteristics of patients screening positive for probable dependence (AUDIT-C ≥ 8) and found that veterans receiving specialty SUD care were more likely to be in an intermediate age bracket (45–64 years old), of a minority race/ethnicity, unmarried, unemployed, and to have a lower annual household income. The authors also found higher rates of physi-
cal and mental health comorbidities amongst those treated in specialty SUD settings. However, prior work has not studied characteristics of veterans reporting alcohol consumption across a wider spectrum of alcohol misuse. Furthermore, to the author’s knowledge, no studies have examined utilization patterns of veterans with probable dependence following the implementation of the BI performance measure, which may have affected rates of BI and referral. To address this gap, the relationship between demographic and clinical characteristics and SUD care utilization (both BI and specialty care) were examined (e.g., AUDIT-C scores, physical and mental health diagnoses) in the year prior to a positive AUDIT-C screen in a sample of veterans presenting to primary care. The current study combines self-reported data collected from a sample of veterans recruited for a randomized controlled trial (RCT) to study the relative effectiveness of two methods for delivering BI with data on veterans’ utilization of alcohol-related care collected from the VA computerized patient record system (CPRS).
METHODS Participants Veterans (N = 167) were recruited at a VA health care facility to participate in an RCT to compare the effectiveness of two methods for delivering a BI on alcohol use.15 Though VA only mandates care for veterans with an AUDIT-C score of 5 or above, prior literature9 suggests that BIs may also be appropriate for individuals with a set of gender-matched cutoff scores indicating alcohol misuse. At their discretion, providers may deliver BIs to veterans with scores below the VA-mandated cutoff; thus these broader criteria were used to identify eligible veterans. According to these guidelines, veterans with an AUDIT-C score ≥4 for men and ≥3 for women were eligible to participate. Patients who self-reported having had any discussion with their providers regarding alcohol use were included.
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Measures A baseline self-report questionnaire was collected on 167 veterans. These data were linked to data collected through the VA’s CPRS. Data on the demographic and clinical characteristics of participants were collected from a combination of information gathered during baseline assessment interview (prior to study randomization) and from participants’ medical charts located in VA’s CPRS. Human subjects research approval for this study was granted by the Stanford University Institutional Review Board. Demographic Characteristics Demographic characteristics were self-reported and included gender, age, ethnicity, relationship status, annual household income, and employment status. Alcohol Use The AUDIT-C is a screening tool for determining whether a veteran meets criteria for alcohol misuse which is used by the VA.9 The AUDIT-C includes 3 items that assess the frequency and quantity of prior year alcohol consumption: (1) “How often did you have a drink containing alcohol in the past year?” (2) “How many standard drinks containing alcohol did you have on a typical day when you were drinking in the past year?” and (3) “How often did you have 6 or more drinks on one occasion in the past year?” Clinical Characteristics Medical charts were reviewed to identify any active mental or physical health diagnoses. A diagnosis is determined to be inactive once the condition is deemed by a provider to be no longer of clinical concern. SUDs identified in the medical record included alcohol use disorders (AUDs; abuse or dependence) and any drug use disorders (DUDs) including those associated with cocaine, cannabis, amphetamines, and use of opioids. Nicotine use disorders were excluded from the analysis. Other active mental health diagnoses identified included post-traumatic stress disorder (PTSD), anxiety disorders, depression, and bipolar disorders. Active prescriptions for psychotropic medication received any time within the year prior to the baseline assessment were also documented and included
antidepressants, benzodiazepines, and medication for the treatment of an AUD. Prior Year Utilization of Substance Use Treatment Data were collected from VA CPRS on the VA and non-VA substance use treatment utilized in the year prior to entering the RCT. Clinic notes that reported delivery of evidence-based substance use treatment including CBT, relapse prevention, motivational interviewing (MI), or components of BIs (advice or education) were counted as a treatment session. Clinic notes that described only screening or assessment of alcohol or drug use were not counted as a treatment contact. Substance use treatment was further categorized as specialty, non-specialty, or self-help. Specialty treatment included outpatient, inpatient, and residential treatment settings designed to provide intensive treatment for an AUD or DUD. Non-specialty treatment included outpatient medical settings, such as primary care, in which treatment such as components of BI may be offered. Treatment received in non-specialty care settings were further identified as being delivered by a medical (e.g., physician or nurse) or mental health provider (e.g., psychologist, psychology technician, or social worker). Non-VA substance use treatment received in the prior 6 months was identified through a self-report questionnaire completed at baseline. Analytic Plan SPSS 18 was used to conduct all statistical analyses. First, rates were described of BI and specialty SUD treatment for the full sample. Next, the rates of prior-year SUD care by AUDITC score to assess the appropriateness of treatment were examined. Finally, the rates of demographic and clinical characteristics between veterans who received no care in the prior year, those who received BI, and those who received specialty care were compared. Comparisons between these groups were conducted using analyses of variance (ANOVAs) for continuous variables (age, annual household income, AUDIT-C scores) and Chi-square analyses for dichotomously coded variables (gender, SUDs, and mental health conditions).
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RESULTS Sample Characteristics Table 1 summarizes clinical characteristics and substance use treatment utilization for the total sample. Demographic characteristics are presented elsewhere.15 Of the 167 veterans—all of whom screened positive for alcohol misuse— 45% had a documented SUD diagnosis in their medical chart, with most of these individuals being diagnosed with an AUD. The most commonly-diagnosed DUDs were cocaine and amphetamine dependence. Fortynine percent of veterans had a documented mental health diagnosis with depressive disorders being the most commonly observed. Physical health comorbidities including hypertension, obesity, and diabetes mellitus were found among 69% of veterans in the present study. Sixty-one percent of veterans had at least one documented (or self-reported) substance use treatment contact in the prior year, with 50% receiving BI and 22% receiving specialty SUD care. The majority of treatment contacts occurred in a primary care clinic and were administered by a medical care (rather than mental health) provider. Less frequent treatment types of care included self-help treatment (13%) and the use of medication (e.g., naltrexone) to manage alcohol dependence (2%). Treatment Received by AUDIT-C Score Table 2 summarizes the most intensive SUD treatment received by patients in 3 different AUDIT-C score brackets. According to VA guidelines, patients with a 3 or a 4 are to be treated at a physician’s discretion, whereas patients with a 5, 6, or 7 should receive BI and patients with a score of 8 or more should be referred to specialty SUD care. Of those with a score of 3 or 4, 80% had received no treatment in the prior year, 13% received non-specialty care, and 7% received specialty care. Of those with a score of 5,6, or 7, 53% had received at least the recommended non-specialty SUD care and 15% had received specialty SUD care, with 32% having received no care. Of those with a
335 TABLE 1. Clinical and Prior-Year Health Care Utilization Characteristics of Veterans Screening Positive for Alcohol Misuse (N = 167) Characteristics Demographics Gender (F) Age (19–44) (45–64) (65 + ) Ethnicity (minority) Relationship status (in a relationship) Annual household income ($30,000 or less) Employment (unemployed) Clinical characteristics Substance use disorders (SUDs) Alcohol use disorders (AUDs) only Drug use disorders (DUDs) only Both DUDs Cocaine use disorder Cannabis use disorder Amphetamine use disorder Opioid use disorder Mental health (MH) diagnosis PTSD Anxiety disorder Depressive disorder Bipolar disorder Physical health diagnosis Hypertension Obesity Diabetes MH-related medication Antidepressant Benzodiazepine Alcohol-related medication (e.g., naltrexone) Health care utilization Any SUD care in prior year Any non-specialty SUD care (brief intervention) Non-specialty SUD care from medical provider Non-specialty SUD care from MH provider Non-specialty care only Any specialty SUD care Specialty care only Self-help Self-help only All three care options (non-specialty, specialty, self-help) Any non-VA SUD care in past 6 months
25 83 59 52 78 75 107
15.0 49.7 35.3 31.1 46.7 44.9 64.1
75 48 4 23 27 18 8 9 6 81 31 31 42 5 115 81 54 25 35 33 3 3
44.9 28.7 2.4 13.8 16.2 10.8 4.8 5.4 3.6 48.5 18.6 18.6 25.1 3.0 68.9 51.5 32.3 15.0 20.9 19.8 1.8 1.8
62 37 15 21 2 13
37.1 22.2 9.0 12.6 1.2 13.2
score of 8 or higher, 48% had received the recommended specialty SUD care, with 44% receiving only non-specialty SUD care, and 8% having received no care.
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TABLE 2. Level of SUD Care Received by AUDIT-C Score AUDIT-C score 3 or 4 for women; 4 for men 5, 6, or 7 8 or more
No SUD care (n = 68)
Non-specialty SUD care (n = 62)
Specialty SUD care (n = 37)
44 (80.0%) 20 (32.3%) 4 (8.0%)
7 (12.7%) 33 (53.2%) 22 (44.0%)
4 (7.3%) 9 (14.5%) 24 (48.0%)
Demographic and Clinical Characteristics by Level of SUD Care Table 3 lists demographic and clinical characteristics of veterans by level of SUD care received. Veterans who received a higher level of SUD care were on average younger (F = 25.52, p < .001), had a lower mean annual household income (F = 19.61, p < .001), and were less likely to be in a relationship (χ 2 = 10.49, p < .001). Among those receiving more care, rates of diagnoses of SUDs (χ 2 = 33.65, p < .001), including both AUDs (χ 2 = 30.70, p < .001) and DUDs (χ 2 = 13.02, p < .01) were higher. Receiving care was also associated with comorbid mental health issues, including Axis I mental health disorders (χ 2 = 38.42, p < .001), such as PTSD (χ 2 = 33.91, p < .001), anxiety disorders (χ 2 = 15.57, p < .001), and depressive disorders (χ 2 = 6.19, p < .05). Veterans who had received specialty SUD care were more likely to have received mental health treatment for an issue unrelated to substance use (χ 2 = 23.73, p < .001) and were more likely to be using antidepressants (χ 2 = 29.94, p < .001), benzodiazepines (χ 2 = 10.73, p < .01), and alcohol-related medications such as naltrexone (χ 2 = 7.11, p < .05).
DISCUSSION The present study examined rates of SUD treatment utilization in the year prior to a positive AUDIT-C screen and explored the demographic and clinical characteristics of veterans receiving the spectrum of alcohol-related care. It was found that 61% of veterans in this sample received either BI or specialty SUD care in the year prior to an AUDIT-C screen of 3 or greater for women or 4 or greater for men. Half of the
total sample received BI and 22% received specialty care. Rates of demographic and clinical characteristics reaffirmed prior work suggesting that veterans who receive SUD care experience higher rates of physical and mental health comorbidities, are older, and are of lower socioeconomic status.12,16,17 The findings extend the present literature by characterizing rates of alcohol-related care and patient characteristics for a broad range of alcohol misuse. It was found that a relatively large proportion of veterans had not received the recommended level of alcohol-related care according to VA guidelines. As the sample comprised veterans who volunteered for an RCT, veterans in this study may have been more likely to be engaged with the health care system than the larger population of veterans seeking care within VA and thus, overestimate rates of alcohol-related care in this population. Despite the possibly biased sample of motivated patients, however, a large number of veterans in the sample had not received the recommended level of alcohol-related care based on their AUDIT-C scores. The sample observed non-specialty care (BI) rate of 68% for those scoring 5 or higher on the AUDIT-C was higher than the 32% found by17 and the 53% found by10 in larger national samples. Similarly, 48% of veterans in the present sample with AUDIT-C scores of 8 or greater received specialty SUD care as compared to 4–14% found in more representative samples.13 These increased rates may reflect an increase in the rate of delivery of alcohol-related care, though research utilizing larger national samples is needed to confirm these findings. Even the much higher rates of appropriate care found in the sample, however, reflect an absence of treatment for many individuals for whom it is
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TABLE 3. Patient Demographic and Clinical Characteristics by Prior Year Health Care Utilization Percent or mean (SD) Characteristic Gender (F) Age (19–44) (45–64) (65 + ) Ethnicity (minority) Relationship status (in a relationship) Annual household income ($30,000 or less) Employment (unemployed) AUDIT-C score Score ≥4 for men or ≥3 for women but >8 Score ≥8 Diagnosed SUD Diagnosed AUD Diagnosed DUD Cocaine dependence Cannabis dependence Amphetamine dependence Opioid dependence Diagnosed mental health disorder PTSD Anxiety disorders Depressive disorder Bipolar disorder (unspecified) Physical health problem Hypertension Obesity Diabetes mellitus Any mental health treatment for a non-SUD issue Antidepressant use Benzodiazepine use Naltrexone use
No SUD care (n = 68)
Non-specialty SUD care (n = 62)
Specialty SUD care (n = 37)
13.2 66.24 (13.57) 7.4 36.8 55.9 27.9 61.8 $82,474 ($73,755) 26.5 63.2 4.76 (1.48) 94.1 5.9 19.1 19.1 8.8 4.4 2.9 4.4 0.0 29.4 10.3 10.3 19.1 2.9 64.7 47.1 27.9 19.1 11.8
9.7 56.24 (15.72) 21.0 51.6 27.4 25.8 37.1 $55,475 ($52,981) 50.0 59.7 6.95 (2.07) 64.5 35.5 51.6 50.0 12.9 9.7 4.8 1.6 3.2 43.5 8.1 14.5 22.6 0.0 72.6 51.6 29.0 14.5 4.8
13.5 52.05 (11.01) 18.9 70.3 10.8 45.9 35.1 $32,376 ($33,865) 70.3 73.0 8.46 (2.67) 35.1 64.9 75.7 73.0 35.1 24.3 8.1 13.5 10.8 91.9 51.4 40.5 40.5 8.1 70.3 45.9 45.9 8.1 40.5
33.65∗∗∗ 30.70∗∗∗ 13.02∗∗ 10.00∗∗ 1.40 6.65∗ 8.12∗ 38.42∗∗∗ 33.91∗∗∗ 15.57∗∗∗ 6.19∗ 5.25 .98 .39 4.04 2.30 23.73∗∗∗
10.3 0.0 0.0
11.3 0.0 0.0
51.4 8.1 5.4
29.94∗∗∗ 10.73∗∗ 7.11∗
χ 2 or F .496 14.94∗∗∗ 25.52∗∗∗
4.93 10.49∗∗ 8.60∗∗∗ 19.61∗∗∗ 1.81 44.15∗∗∗ 41.19∗∗∗
Note. Italics indicate measures for which mean, SD, and F-statistics are reported. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.
recommended and, within the VA, mandated. Future research should explore factors that contribute to non-treatment and methods (e.g., improving care transitions from primary to specialty SUD care settings) that may improve rates of both BI and specialty care delivered to veterans with alcohol misuse. Understanding the milieu of care that patients who present to primary care with alcohol use issues may already be receiving and the characteristics of patients who receive said care (whether it be BI or specialty care) may help providers to identify patients for whom
care is warranted and deliver the appropriate level of SUD care. Though AUDIT-C scores are valid overall for predicting alcohol misuse,12 they are imperfect predictors of alcohol-related problems.14 A fuller view of patients’ clinical characteristics (e.g., presence of mental health comorbidities) and the care they are already receiving may help primary care providers to decide whether BI or referral to specialty SUD care is most appropriate. Veterans who received SUD care tended to be younger, to not be in a relationship, and to have lower annual household income; these findings are consistent with
prior literature.13,17 Rates of PTSD, anxiety disorders, depressive disorders, and of receiving treatment for these disorders were also much higher among veterans who received SUD care. These findings reiterate general trends in substance abuse comorbidity16 as well as more recent findings highlighting the increased mental health burden on veterans with probable alcohol dependence.13 Furthermore, patients who received either BI or specialty SUD care were more likely to have had a non-SUD mental health treatment contact in the prior year. These prominent mental health comorbidities and the high prevalence of non-SUD mental health treatment suggest that mental health specialists and primary care providers seeing patients with non-SUD mental health issues may be in a privileged position to identify and address problematic drinking patterns. An awareness of patterns of comorbidities and patient characteristics associated with SUD issues may also help providers embedded in care teams such as VA’s patient-aligned care teams (PACTs) to coordinate and manage other types of medical care for their patients. In particular, collocation of mental health services with primary care along with enhanced provider communication could improve coordination of care and outcomes.19 The study has several noteworthy limitations. Selection bias may have been a factor in that participants in the present study represent a population of veterans who are motivated to discuss their alcohol use and/or are engaged in the health care system. This may have biased the results toward an inflated estimate of treatment utilization. Results are from a single-site study, limiting the generalizability of findings to the larger cohort of alcohol-misusing veterans or other geographical locations of VA medical facilities. In addition, veterans may have been hesitant to self-report past self-help or non-VA care, leading to underestimates of these types of care. Despite these limitations, the current study adds to the current literature by describing prior SUD treatment and associated patient characteristics for patients presenting to primary care with the spectrum of alcohol misuse.
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Primary care providers experience pressure to provide care that is effective, expedient, and comprehensive. Though established guidelines outline appropriate screening and treatment procedures for alcohol misuse, primary care providers are forced to prioritize certain presenting problems and to triage patients quickly and effectively. A better understanding of patients’ prior care history and associated clinical and personal characteristics may supply providers with added information to make decisions of what type of care (BI or referral) to provide to their patients. Mental health issues, for example, may trigger providers to ask about substance abuse problems or recent treatment history. By better understanding the patient as a whole, the providers’ ability to make effective treatment decisions can be enhanced. ACKNOWLEDGMENTS The views expressed are the authors’ and do not necessarily reflect those of the VA. FUNDING This research was supported by a Career Development Award-2 (CDA 08-004) to Dr. Cucciare by the VA Health Services Research and Development (HSR&D) Service. REFERENCES 1. Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med 2000; 160(13):1977–89. 2. Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005; 365(9458):519–30. doi: 10.1016/S01406736(05)17870-2. 3. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Benefitcost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 2000; 38(1):7–18. 4. Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in pri-
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