Desai MM (VA Northeast Program Evaluation Center (NEPEC))
Rosenheck RA (VA Northeast Program Evaluation Center (NEPEC))
Craig TJ (VHA Office of Quality and Performance)
VA requires annual alcohol screening of medical outpatients and monitors screening as a quality measure. We set out to examine the “real-world” experience of the VA in implementing a large-scale, system-wide policy of screening. In this study, we used available data to follow the chain of events from initial screening to subsequent diagnosis of alcohol use disorder. Specifically, the objectives were to determine, in a national sample of VA medical outpatients, the rates and predictors of alcohol screening, screening positive, follow-up evaluation, and subsequently diagnosed alcohol use disorder.
Chart-abstracted quality improvement data from VA’s 2002 External Peer Review Program (EPRP) were merged with administrative database records for 15,580 medical outpatients drawn from 139 VA facilities nationwide.
Nearly three-quarters of eligible patients (N=11,553) had chart-documented alcohol screening in the past year. Of these, 4.2% (N=484) screened positive. Of those who screened positive, three-fourths (N=370) received follow-up evaluation; and, of these, 53.5% (N=198) were subsequently diagnosed with an alcohol use disorder—1.7% of the originally screened sample. Multivariate logistic regression revealed that several factors generally associated with increased risk of alcohol use disorders—including being younger, unmarried, and disabled, as well as having greater medical and psychiatric comorbidities—were actually associated with a decreased likelihood of alcohol screening. At the facility level, screening was less likely at more academically affiliated medical centers, and follow-up evaluation of a positive screen was less likely at the largest facilities.
Routine alcohol screening yielded relatively few positive cases, raising questions about its cost-effectiveness. Targeted strategies may increase the value of case-finding activities among patients at greatest risk for alcohol use disorders and at more academically affiliated facilities. Targeted efforts are also needed to ensure proper follow-up evaluation at larger medical centers where patients may experience greater system-level barriers.
By determining the extent to which patients in the VA system are screened and ultimately diagnosed with alcohol use disorders, and by identifying factors associated with steps in the pathway, the results of this study are expected to improve our understanding of the screening process and its effectiveness in actual, real-world clinical practice.