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Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care.

ABSTRACT: INTRODUCTION:Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs). STUDY DESIGN:RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016. SETTING/PARTICIPANTS:Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers. INTERVENTION:Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources. MAIN OUTCOME MEASURES:Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up. RESULTS:In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI=-0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI=-0.019, -0.521). CONCLUSIONS:CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern. TRIAL REGISTRATION:This study is registered at clinicaltrials.gov NCT01032772.

SUBMITTER: Velasquez MM

PROVIDER: S-EPMC6590512 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care.

Velasquez Mary M MM von Sternberg Kirk L KL Floyd R Louise RL Parrish Danielle D Kowalchuk Alicia A Stephens Nanette S NS Ostermeyer Britta B Green Charles C Seale J Paul JP Mullen Patricia Dolan PD

American journal of preventive medicine 20170417 1

<h4>Introduction</h4>Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception interventi ...[more]

PMID: 28427955

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Project description:BackgroundIt remains unclear whether the racial-ethnic composition or the socioeconomic profiles of eligible primary care practices better explain practice participation in the Centers for Medicare and Medicaid Services' (CMS) Comprehensive Primary Care Plus (CPC+) program.ObjectiveTo examine whether practices serving high proportions of Black or Latino Medicare fee-for-service (FFS) beneficiaries were less likely to participate in CPC+ in 2021 compared to practices serving lower proportions of these populations.Design2019 IQVIA OneKey data on practice characteristics was linked with 2018 CMS claims data and 2021 CMS CPC+ participation data. Medicare FFS beneficiaries were attributed to practices using CMS's primary care attribution method.Participants11,718 primary care practices and 7,264,812 attributed Medicare FFS beneficiaries across 18 eligible regions.MethodsMultivariable logistic regression models examined whether eligible practices with relatively high shares of Black or Latino Medicare FFS beneficiaries were less likely to participate in CPC+ in 2021, controlling for the clinical and socioeconomic profiles of practices.Main measuresProportion of Medicare FFS beneficiaries attributed to each practice that are (1) Latino and (2) Black.Key resultsOf the eligible practices, 26.9% were CPC+ participants. In adjusted analyses, practices with relatively high shares of Black (adjusted odds ratio, aOR = 0.62, p < 0.05) and Latino (aOR = 0.32, p < 0.01) beneficiaries were less likely to participate in CPC+ compared to practices with lower shares of these beneficiary groups. State differences in CPC+ participation rates partially explained participation disparities for practices with relatively high shares of Black beneficiaries, but did not explain participation disparities for practices with relatively high shares of Latino beneficiaries.ConclusionsThe racial-ethnic composition of eligible primary care practices is more strongly associated with CPC+ participation than census tract-level poverty. Practice eligibility requirements for CMS-sponsored initiatives should be reconsidered so that Black and Latino beneficiaries are not left out of the benefits of practice transformation.

Project description:Substance use, a leading cause of illness and death, is underidentified in medical practice.The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool was developed to address the need for a brief screening and assessment instrument that includes all commonly used substances and fits into clinical workflows. The goal of this study was to assess the performance of the TAPS tool in primary care patients.Multisite study, conducted within the National Drug Abuse Treatment Clinical Trials Network, comparing the TAPS tool with a reference standard measure. (ClinicalTrials.gov: NCT02110693).5 adult primary care clinics.2000 adult patients consecutively recruited from clinic waiting areas.Interviewer- and self-administered versions of the TAPS tool were compared with a reference standard, the modified World Mental Health Composite International Diagnostic Interview (CIDI), which measures problem use and substance use disorder (SUD).Interviewer- and self-administered versions of the TAPS tool had similar diagnostic characteristics. For identifying problem use (at a cutoff of 1+), the TAPS tool had a sensitivity of 0.93 (95% CI, 0.90 to 0.95) and specificity of 0.87 (CI, 0.85 to 0.89) for tobacco and a sensitivity of 0.74 (CI, 0.70 to 0.78) and specificity of 0.79 (CI, 0.76 to 0.81) for alcohol. For problem use of illicit and prescription drugs, sensitivity ranged from 0.82 (CI, 0.76 to 0.87) for marijuana to 0.63 (CI, 0.47 to 0.78) for sedatives; specificity was 0.93 or higher. For identifying any SUD (at a cutoff of 2+), sensitivity was lower.The low prevalence of some drug classes led to poor precision in some estimates. Research assistants were not blinded to participants' TAPS tool responses when they administered the CIDI.In a diverse population of adult primary care patients, the TAPS tool detected clinically relevant problem substance use. Although it also may detect tobacco, alcohol, and marijuana use disorders, further refinement is needed before it can be recommended broadly for SUD screening.National Institute on Drug Abuse.

Project description:BACKGROUND:Primary care settings are uniquely positioned to reach individuals at risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches. OBJECTIVE:The aim of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization or target of the intervention, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy. METHODS:We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to December 2018 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 2307 initial records, 42 were included and coded independently by 2 investigators. RESULTS:Compared with the years of 2000 to 2009, published studies on technology-based alcohol interventions in primary care nearly tripled during the years of 2010 to 2018. Of the 42 included studies, 28 (64%) were randomized controlled trials. Furthermore, studies were rated on risk of bias and found to be predominantly low risk (n=18), followed by moderate risk (n=16), and high risk (n=8). Of the 24 studies with primary or secondary efficacy outcomes related to drinking and drinking-related harms, 17 (71%) reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, of the 31 studies with direct comparisons with treatment as usual (TAU), 13 (42%) reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to TAU. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention. CONCLUSIONS:Our systematic review has highlighted a pattern of growth in the number of studies evaluating technology-based alcohol interventions in primary care. Although these interventions appear to be largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings.

Project description:Importance:Experts recommend that alcohol use disorders (AUDs) be managed in primary care, but effective approaches are unclear. Objective:To test whether 12 months of alcohol care management, compared with usual care, improved drinking outcomes among patients with or at high risk for AUDs. Design, Setting, and Participants:This randomized clinical trial was conducted at 3 Veterans Affairs (VA) primary care clinics. Between October 11, 2011, and September 30, 2014, the study enrolled 304 outpatients who reported heavy drinking (?4 drinks per day for women and ?5 drinks per day for men). Interventions:Nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner-prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The comparison was usual primary care. Main Outcomes and Measures:Primary outcomes, assessed by blinded telephone interviewers at 12 months, were percentage of heavy drinking days in the prior 28 days measured by timeline follow-back interviews and a binary good drinking outcome, defined as abstinence or drinking below recommended limits in the prior 28 days (according to timeline follow-back interviews) and no alcohol-related symptoms in the past 3 months as measured by the Short Inventory of Problems. Results:Of 304 participants, 275 (90%) were male, 206 (68%) were white, and the mean (SD) age was 51.4 (13.8) years. At baseline, both the CHOICE intervention (n?=?150) and usual care (n?=?154) groups reported heavy drinking on 61% of days (95% CI, 56%-66%). During the 12-month intervention, 137 of 150 patients in the intervention group (91%) had at least 1 nurse visit, and 77 of 150 (51%) had at least 6 nurse visits. A greater proportion of patients in the intervention group than in the usual care group received alcohol-related care: 42% (95% CI, 35%-49%; 63 of 150 patients) vs 26% (95% CI, 19%-35%; 40 of 154 patients). Alcohol-related care included more AUD medication use: 32% (95% CI, 26%-39%; 48 of 150 patients in the intervention group) vs 8% (95% CI, 5%-13%; 13 of 154 patients in the usual care group). No significant differences in primary outcomes were observed at 12 months between patients in both groups. The percentages of heavy drinking days were 39% (95% CI, 32%-47%) and 35% (95% CI, 28%-42%), and the percentages of patients with a good drinking outcome were 15% (95% CI, 9%-22%; 18 of 124 patients) and 20% (95 % CI, 14%-28%; 27 of 134 patients), in the intervention and usual care groups, respectively (P?=?.32-.44). Findings at 3 months were similar. Conclusions and Relevance:The CHOICE intervention did not decrease heavy drinking or related problems despite increased engagement in alcohol-related care. Trial Registration:clinicaltrials.gov Identifier: NCT01400581.

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Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care.

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Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care.

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