title: Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff.
abstract: OBJECTIVE
  Population-based alcohol screening, followed by brief intervention for patients who screen positive for unhealthy alcohol use, is widely recommended for primary care settings and considered a top prevention priority, but is challenging to implement. However, new policy initiatives in the U.S., including the Affordable Care Act, may help launch widespread implementation. While the nationwide Veterans Health Administration (VA) has achieved high rates of documented alcohol screening and brief intervention, research has identified quality problems with both. We conducted a qualitative key informant study to describe local implementation of alcohol screening and brief intervention from the perspectives of frontline adopters in VA primary care in order to understand the process of implementation and factors underlying quality problems.
  
  
  METHODS
  A purposive snowball sampling method was used to identify and recruit key informants from 5 VA primary care clinics in the northwestern U.S. Key informants completed 20-30 minute semi-structured interviews, which were recorded, transcribed, and qualitatively analyzed using template analysis.
  
  
  RESULTS
  Key informants (N=32) included: clinical staff (n=14), providers (n=14), and administrative informants (n=4) with varying participation in implementation of and responsibility for alcohol screening and brief intervention at the medical center. Ten inter-related themes (5 a priori and 5 emergent) were identified and grouped into 3 applicable domains of Greenhalgh's conceptual framework for dissemination of innovations, including values of adopters (theme 1), processes of implementation (themes 2 and 3), and post-implementation consequences in care processes (themes 4-10). While key informants believed alcohol use was relevant to health and important to address, the process of implementation (in which no training was provided and electronic clinical reminders "just showed up") did not address critical training and infrastructure needs. Key informants lacked understanding of the goals of screening and brief intervention, believed referral to specialty addictions treatment (as opposed to offering brief intervention) was the only option for following up on a positive screen, reported concern regarding limited availability of treatment resources, and lacked optimism regarding patients' interest in seeking help.
  
  
  CONCLUSIONS
  Findings suggest that the local process of implementing alcohol screening and brief intervention may have inadequately addressed important adopter needs and thus may have ultimately undermined, instead of capitalized on, staff and providers' belief in the importance of addressing alcohol use as part of primary care. Additional implementation strategies, such as training or academic detailing, may address some unmet needs and help improve the quality of both screening and brief intervention. However, these strategies may be resource-intensive and insufficient for comprehensively addressing implementation barriers.
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Department of Health Services, University of Washington, Box 357660; 1959 NE Pacific St, Seattle, WA 98195, USA; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA. Electronic address: Emily.Williams3@va.gov.
authors: Emily C
authors: EC
authors: Williams
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Primary and Specialty Medical Care Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, 1660S. Columbian Way, Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, 1660S. Columbian Way, Seattle, WA 98108, USA. Electronic address: Carol.Achtmeyer@va.gov.
authors: Carol E
authors: CE
authors: Achtmeyer
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA. Electronic address: Jessica.Young@va.gov.
authors: Jessica P
authors: JP
authors: Young
authors: Pacific Northwest University of Sciences College of Osteopathic Medicine, 111 University Parkway, Yakima, WA 98901, USA. Electronic address: stacey.ritt@gmail.com.
authors: Stacey E
authors: SE
authors: Rittmueller
authors: Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, 1959 NE Pacific St, Seattle, WA 98195, USA; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA. Electronic address: ludman.e@ghc.org.
authors: Evette J
authors: EJ
authors: Ludman
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, 1660S. Columbian Way, Seattle, WA 98108, USA; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA. Electronic address: lapham.g@ghc.org.
authors: Gwen T
authors: GT
authors: Lapham
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA. Electronic address: Amy.Lee6@va.gov.
authors: Amy K
authors: AK
authors: Lee
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Department of Health Services, University of Washington, Box 357660; 1959 NE Pacific St, Seattle, WA 98195, USA. Electronic address: Laura.Chavez2@va.gov.
authors: Laura J
authors: LJ
authors: Chavez
authors: Primary and Specialty Medical Care Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, 1660S. Columbian Way, Seattle, WA 98108, USA; Department of Medicine, University of Washington, Box 356420; 1959 NE Pacific St, Seattle, WA 98195, USA. Electronic address: Douglas.Berger@va.gov.
authors: Douglas
authors: D
authors: Berger
authors: Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System; 1660S. Columbian Way (S-152), Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, 1660S. Columbian Way, Seattle, WA 98108, USA; Department of Medicine, University of Washington, Box 356420; 1959 NE Pacific St, Seattle, WA 98195, USA; Department of Health Services, University of Washington, Box 357660; 1959 NE Pacific St, Seattle, WA 98195, USA; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA. Electronic address: bradley.k@ghc.org.
authors: Katharine A
authors: KA
authors: Bradley
mesh_terms: D019973:Alcohol-Related Disorders / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy*; D001291:Attitude of Health Personnel; D006801:Humans; D011320:Primary Health Care; D015397:Program Evaluation; D036301:Qualitative Research; D014481:United States; D014493:United States Department of Veterans Affairs
keywords: Alcohol; Brief intervention; Implementation; Qualitative; Screening