TY - JOUR
KW - Adult
KW - Aged
KW - Alcoholism/diagnosis
KW - Boston
KW - Female
KW - Humans
KW - Male
KW - Mass Screening/methods/standards
KW - Middle Aged
KW - New York City
KW - Practice Guidelines as Topic
KW - Primary Health Care/methods/standards
KW - Substance-Related Disorders/diagnosis
AU - J. McNeely
AU - A. Adam
AU - J. Rotrosen
AU - S. E. Wakeman
AU - T. E. Wilens
AU - J. Kannry
AU - R. N. Rosenthal
AU - A. Wahle
AU - S. Pitts
AU - S. Farkas
AU - C. Rosa
AU - L. Peccoralo
AU - E. Waite
AU - A. Vega
AU - J. Kent
AU - C. K. Craven
AU - T. A. Kaminski
AU - E. Firmin
AU - B. Isenberg
AU - M. Harris
AU - A. Kushniruk
AU - L. Hamilton
A1 - 
AB - IMPORTANCE: Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. OBJECTIVE: To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. DESIGN, SETTING, AND PARTICIPANTS: This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. INTERVENTIONS: Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. MAIN OUTCOMES AND MEASURES: Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. RESULTS: Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). CONCLUSIONS AND RELEVANCE: In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02963948.
AD - Department of Population Health, New York University Grossman School of Medicine, New York.; Department of Medicine, Division of General Internal Medicine, New York University Grossman School of Medicine, New York.; Department of Psychiatry, University Hospital Lausanne, Lausanne, Switzerland.; Department of Psychiatry, New York University Grossman School of Medicine, New York.; Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston.; Department of Psychiatry, Massachusetts General Hospital, Boston.; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.; Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.; The Emmes Company, Rockville, Maryland.; The Emmes Company, Rockville, Maryland.; Department of Psychiatry, New York University Grossman School of Medicine, New York.; National Institute on Drug Abuse, Bethesda, Maryland.; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.; Department of Psychiatry, Massachusetts General Hospital, Boston.; Department of Psychiatry, Massachusetts General Hospital, Boston.; Department of Psychiatry, Massachusetts General Hospital, Boston.; Department of Population Health, New York University Grossman School of Medicine, New York.; School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada.; Department of Population Health, New York University Grossman School of Medicine, New York.
BT - JAMA network open
C5 - HIT & Telehealth; Opioids & Substance Use
CP - 5
DO - 10.1001/jamanetworkopen.2021.10721
IS - 5
JF - JAMA network open
LA - eng
M1 - Journal Article
N2 - IMPORTANCE: Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. OBJECTIVE: To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. DESIGN, SETTING, AND PARTICIPANTS: This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. INTERVENTIONS: Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. MAIN OUTCOMES AND MEASURES: Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. RESULTS: Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). CONCLUSIONS AND RELEVANCE: In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02963948.
PY - 2021
SN - 2574-3805; 2574-3805
T1 - Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics
T2 - JAMA network open
TI - Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics
U1 - HIT & Telehealth; Opioids & Substance Use
U2 - 34014326
U3 - 10.1001/jamanetworkopen.2021.10721
VL - 4
VO - 2574-3805; 2574-3805
Y1 - 2021
Y2 - May 3
ER -