Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study.
BACKGROUND
Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics.


OBJECTIVE
We aimed to understand factors that might contribute to low sensitivity of alcohol screening.


METHODS
This was an observational, qualitative study.


METHODS
Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S.


METHODS
Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes.


RESULTS
We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort.


CONCLUSIONS
This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.
Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA, emily.williams3@va.gov.
Emily C
EC
Williams
Carol E
CE
Achtmeyer
Rachel M
RM
Thomas
Joel R
JR
Grossbard
Gwen T
GT
Lapham
Laura J
LJ
Chavez
Evette J
EJ
Ludman
Douglas
D
Berger
Katharine A
KA
Bradley
D000437:Alcoholism / Q000175:diagnosis*; D000488:Allied Health Personnel; D006284:Health Plan Implementation; D006801:Humans; D008403:Mass Screening; D009726:Nurses; D036301:Qualitative Research; D011787:Quality of Health Care; D017010:Reminder Systems; D015813:Substance Abuse Detection / Q000379:methods*; D014728:Veterans / Q000523:psychology; D058014:Veterans Health / Q000592:standards