No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
Experts have called for new models of primary care to manage alcohol use disorders (AUDs). The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for AUDs in patient-centered, alcohol-related care. Conducted at three VA primary care clinics between 10/11 and 9/14, this randomized encouragement trial enrolled 304 VA outpatients who reported heavy drinking (>4 drinks per day for women and >5 drinks per day for men) to test whether 12 months of alcohol care management – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). In the intervention group, nurse care managers (supported by an interdisciplinary team) offered outreach and engagement, repeated brief counseling, and nurse-practitioner-prescribed AUD medications (if desired). Primary outcomes included percentage of heavy drinking days (proportion of non-hospitalized days when the patient reported heavy drinking) and good drinking outcomes (abstinence or drinking below recommended limits). Secondary outcomes included engagement in alcohol-related care, such as receipt of AUD medications (i.e., naltrexone), VA addictions treatment, and/or AA attendance.
- The CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders.
- Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively.
- Secondary drinking outcomes at 3 and 12 months showed no benefit of the intervention.
- Current quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial's results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
- While the intervention was designed to address AUDs, only 73% of study participants met criteria for AUDs at baseline.
- CHOICE was an effectiveness trial and did not assess intervention fidelity because of concern that audiotapes would interfere with engagement.
- Both control and intervention subjects cut back on drinking, perhaps because the screening and enrollment process highlighted the presence of drinking problems.
Bradley K, Bobb J, Ludman E, et al. Alcohol-Related Nurse Care Management in Primary Care: A Randomized Clinical Trial. JAMA Internal Medicine. May 1, 2018;178(5):613-621.