Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics.
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ABSTRACT:
SUBMITTER: McNeely J
PROVIDER: S-EPMC8138691 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectiveTo examine the influence of Oregon's coordinated care organizations (CCOs) and pay-for-performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services.Data sources/study settingSecondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs.Study designLongitudinal mixed-methods design with simultaneous data collection with equal importance.Data collection/extraction methodsQualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6-month transition period, and 30 months following CCO implementation. Data were aggregated by half-year with analyses restricted to Medicaid recipients 18-64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion.Principal findingsQuantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI.ConclusionsResults provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment.
| S-EPMC5980159 | biostudies-literature
Project description:Colorectal cancer (CRC) screening is underutilized. To effect change, we must understand reasons for underuse at multiple levels of the health-care system. We evaluated patient, provider, and clinic factors that predict variation in CRC screening among primary-care clinics and primary-care providers (PCPs).We analyzed electronic medical record (EMR) data for 34,319 adults eligible for CRC screening, 19 clinics, and 97 PCPs in a large, academic physician group. Detailed data on potential patient, provider, and clinic predictors of CRC screening were obtained from the EMR. PCP perceptions of CRC screening barriers were measured via survey. The outcome was completion of CRC screening at the patient level. Multivariate logistic regression with clustering on clinics obtained adjusted odds ratios and 95% confidence intervals for potential predictors of CRC screening at each level.Seventy-one percentage of patients completed CRC screening. Variation in screening rates was seen among clinics (51-80%) and among PCPs (51-82%). Significant predictors of completing CRC screening were identified at all levels: patient (older age, white race, being married, primarily English-speaking, having commercial insurance plans vs. Medicare or Medicaid, and higher health-care resource utilization), provider (larger panel size of patients eligible for CRC screening), and clinic (hospital-owned, shorter distance to nearest optical colonoscopy center).Variation in CRC screening exists among primary-care clinics and providers within a single clinic. Predictors of variation can be identified at patient, provider, and clinic levels. Quality improvement interventions addressing CRC screening need to be directed at multiple levels of the health-care system.
| S-EPMC3741068 | biostudies-literature
Project description:BackgroundThe successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care.MethodsA retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR <60 ml/min per 1.73 m2 and/or urine albumin-creatinine ratio (uACR) >30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal prudent medications and nonsteroidal anti-inflammatory drugs (NSAIDs) were assessed.ResultsOverall, 254,831 (94%) patients had either eGFR, urine protein/albumin, or both. However, screening for protein/albuminuria was low (56%), particularly in patients with isolated HTN (35%). Of 254,831 patients, 92,900 (36%) had laboratory evidence of CKD and, of these, 40,586 (44%) were recognized to have CKD by ICD code and/or nephrology referral. CKD due to presence of uACR criteria alone had the lowest recognition (19%) as compared with CKD due to eGFR criteria (44%) or both (67%). Frequency of emergency room visits, hospitalization, and cardiac and endovascular procedures requiring contrast had the highest odds and races other than white had the lower odds of screening. In contrast, CKD recognition was high in races other than white and increased with worsening eGFR and increasing uACR. In screened and recognized CKD, prescription was higher for angiotensin inhibitors, statins, and diuretics, and was lower for NSAIDs.ConclusionsAlthough overall CKD screening rate was high, screening of protein/albuminuria in isolated HTN and overall recognition of CKD was low in at-risk veterans. Increased recognition was associated with a favorable prescription rate for renal prudent medications.
| S-EPMC8815593 | biostudies-literature
Project description:Alcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment.The principal aims of this study were to test the effectiveness of a primary care-based Alcohol Care Management (ACM) program for alcohol use disorder and treatment engagement in veterans.The design of the study was a 26-week single-blind randomized clinical trial. The study was conducted in the primary care practices at three VA medical centers. Participants were randomly assigned to treatment in ACM or standard treatment in a specialty outpatient addiction treatment program.One hundred and sixty-three alcohol-dependent veterans were randomized.ACM focused on the use of pharmacotherapy and psychosocial support. ACM was delivered in-person or by telephone within the primary care clinic.Engagement in treatment and heavy alcohol consumption.The ACM condition had a significantly higher proportion of participants engaged in treatment over the 26 weeks [OR?=?5.36, 95 % CI = (2.99, 9.59)]. The percentage of heavy drinking days were significantly lower in the ACM condition [OR?=?2.16, 95 % CI?= (1.27, 3.66)], while overall abstinence did not differ between groups.Results demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.
| S-EPMC3889933 | biostudies-literature
Project description:BACKGROUND:Despite evidence supporting the effectiveness of alcohol screening and brief advice to reduce heavy drinking, implementation in primary healthcare remains limited. The challenges that clinicians experience when delivering such interventions are well-known, but we have little understanding of the patient perspective. We used Normalization Process Theory (NPT) informed interviews to explore patients' views on alcohol screening and brief advice in routine primary healthcare. METHODS:Semi-structured qualitative interviews with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice were analysed thematically, informed by Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflexive monitoring). RESULTS:We found mixed understanding of the adverse health consequences of heavy drinking, particularly longer-term risks. There was some awareness of current alcohol guidelines but these were viewed flexibly, depending on the individual drinker and drinking context. Most described alcohol screening as routine, with clinicians viewed as trustworthy and objective. Patients enacted a range of self-regulatory techniques to limit their drinking but perceived such strategies as learned through experience rather than based on clinical advice. However, most saw alcohol advice as a valuable component of preventative healthcare, especially those experiencing co-occurring health conditions. CONCLUSIONS:Despite strong acceptance of the screening role played by primary care clinicians, patients have less confidence in the effectiveness of alcohol advice. Primary care-based alcohol brief advice needs to reflect how individuals actually drink, and harness strategies that patients already commonly employ, such as self-regulation, to boost its relevance.
| S-EPMC7178930 | biostudies-literature
Project description:BackgroundEfforts to integrate substance use disorder treatment into primary care settings are growing. Little is known about how well primary care settings can sustain treatment delivery to address substance use following the end of implementation support.MethodsData from two clinics operated by one multi-site federally qualified health center (FQHC) in the US, including administrative data, staff surveys, interviews, and focus groups, were used to gather information about changes in organizational capacity related to alcohol and opioid use disorder (AOUD) treatment delivery during and after a multi-year implementation intervention was executed. Treatment practices from the intervention period were compared to practices after the intervention period to examine whether the practices were sustained. Data from staff surveys and interviews were used to examine the factors related to sustainment.ResultsThe two clinics sustained multiple components of AOUD care 1 year following the end of implementation support, including care coordination, psychotherapy, and medication-assisted treatment. Some of the practices were modified over time, for example, screening became less frequent by design, while use of care coordination and psychotherapy for AOUDs expanded. Participants identified staff training and funding for medications as key challenges to sustaining treatment.ConclusionsFollowing a multi-year implementation intervention, a large FQHC continued to deliver AOUD treatment. Access to external funding and staff support appeared to be critical elements for sustaining care over time.Trial registrationclinicaltrials.gov identifier: NCT01810159.
| S-EPMC6006923 | biostudies-literature
Project description:BackgroundAlcohol screening and brief intervention (BI) is an effective primary care preventive service, but implementation rates are low. Automating BI using interactive voice response (IVR) may be an efficient way to expand patient access to needed information and advice.ObjectiveTo develop IVR-based BI and pilot test it for feasibility and acceptability.DesignSingle-group pre-post feasibility study.ParticipantsPrimary care patients presenting for an office visit.InterventionsIVR-BI structured to correspond to the provider BI method recommended by NIAAA: (1) Ask about use; (2) Assess problems; (3) Advise and Assist for change, and (4) Follow up for continued support. Advice was tailored to patient readiness and preferences.MeasurementsUtilization rate, call duration, and patients' subjective reports of usefulness, comfort and honesty with the IVR-BI. Pre-post evaluation of motivation to change and change in alcohol consumption as measured by Timeline Follow Back.ResultsCall duration ranged from 3-7 minutes. Subjective reactions were generally positive or neutral. About 40% of subjects indicated IVR-BI had motivated them to change. About half of the patients had discussed drinking with their provider at the visit. These tended to be heavier drinkers with greater concerns about drinking. Patients who reported a provider-delivered BI and called the IVR-BI endorsed greater comfort and honesty with the IVR-BI. On average, a 25% reduction in alcohol use was reported two weeks after the clinic visit.ConclusionsUsing IVR technology to deliver BI in a primary care setting is feasible and data suggest potential for efficacy in a larger trial.
| S-EPMC2842550 | biostudies-literature
Project description:BackgroundThe U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face.ObjectiveAs part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences.DesignQualitative formative evaluation.ApproachFormative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies.Key resultsWhile all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings.ConclusionsIntegrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.
| S-EPMC9132563 | biostudies-literature
Project description:Functional precision medicine (FPM) aims to optimize patient-specific drug selection based on the unique characteristics of their cancer cells. Recent advancements in high throughput ex vivo drug profiling have accelerated interest in FPM. Here, we present a proof-of-concept study for an integrated experimental system that incorporates ex vivo treatment response with a single-cell gene expression output enabling barcoding of several drug conditions in one single-cell sequencing experiment. We demonstrate this through a proof-of-concept investigation focusing on the glucocorticoid-resistant acute lymphoblastic leukemia (ALL) E/R+ Reh cell line. Three different single-cell transcriptome sequencing (scRNA-seq) approaches were evaluated, each exhibiting high cell recovery and accurate tagging of distinct drug conditions. Notably, our comprehensive analysis revealed variations in library complexity, sensitivity (gene detection), and differential gene expression detection across the methods. Despite these differences, we identified a substantial transcriptional response to fludarabine, a highly relevant drug for treating high-risk ALL, which was consistently recapitulated by all three methods. These findings highlight the potential of our integrated approach for studying drug responses at the single-cell level and emphasize the importance of method selection in scRNA-seq studies. Finally, our data encompassing 27 327 cells are freely available to extend to future scRNA-seq methodological comparisons.
| S-EPMC10823582 | biostudies-literature
Project description:BackgroundThis study examines the use of career ladders for medical assistants (MAs) in primary care practices as a mechanism for increasing wages and career opportunity for MAs. A growing body of research on primary care suggests that successful expansion of support staff roles such as MAs may have positive organizational and quality of care outcomes, but little is known about worker outcomes.ObjectiveEvaluate the effectiveness of career ladders in improving wages and career opportunity among MAs.DesignWe use a mixed-methods design to evaluate the impact of career ladders on MA job quality.ParticipantsWe draw on interview data collected from 115 key informants at four large health systems (ranging from 24 to 29 clinics each), and we analyze wage and employment data for MAs from primary care clinics in the four health systems in the sample.ApproachWe describe the MA career ladder context and infrastructure within primary care clinics and evaluate the rewards to MAs for participation in the career ladder programs.Key resultsThe expanded roles within career ladders for MAs focused on the following four clinical and educational areas: panel management and care coordination, EHR documentation support, supporting delivery of person-centered care, and supervision and training. The three primary components of the career ladder infrastructure were training and education for MAs and providers, credentialing and certification for MAs, and differentiated job levels for MAs. The use of career ladders in the four large health systems in our case study sample resulted in yearly income increases ranging from $3000 to $10,000 annually.ConclusionInvesting in career ladders in primary care clinics can improve MA job quality while also potentially addressing issues of equity, efficiency, and quality in the health care sector.
| S-EPMC8606365 | biostudies-literature