Systematic Implementation of Patient-centered Care for Alcohol Use Trial: Beyond Referral to Treatment

Kaiser Foundation Research Institute, Oakland CA

Investigators

Abstract

SUMMARY. About 14% of US adults have an active alcohol use disorder (AUD) and most never receive treatment. Experts agree primary care should play a major role in identifying AUD and engaging patients in treatment. However, screening, brief intervention and referral to treatment (SBIRT) alone has not been found to increase AUD treatment. High-quality patient-centered primary care usually relies on shared decision- making, which can help motivate patients and support them in finding treatments that are aligned with their preferences. While patients likely prefer shared decision-making with their primary care providers, time pressures and other barriers in primary care may limit the reach of shared decision-making in primary care; centralized approaches with systematic outreach could decrease the burden on primary care and have greater reach, but it is unknown whether shared decision-making for AUD will be effective in the absence of an established clinical relationship. SPECIFIC AIMS: The Systematic Implementation of Patient-centered Care for Alcohol Use Trial is a pragmatic, cluster-randomized, effectiveness-implementation trial testing two interventions to systematically implement shared decision-making with primary care patients with AUD: a primary care intervention and a centralized intervention. The specific aims of the trial are to test whether each intervention—compared to usual care alone—(1) increases the proportion of primary care patients engaged in AUD treatment over a year follow-up or (2) decreases alcohol use over 2 years follow-up. METHODS: The proposed trial is conducted in 30 primary care clinics in which usual care includes SBIRT. The trial randomizes the 30 clinics to one of three approaches to managing AUD: (1) usual care; (2) a primary care intervention added to usual care that uses state-of-the-art implementation interventions to systematically encourage primary care providers to offer routine shared decision-making for AUD; and (3) a centralized intervention added to usual care that systematically offers outreach and shared decision-making for AUD by a social worker. The trial sample includes 1,500 adult primary care patients who have ≥4 self-reported DSM-5 AUD symptoms documented in their medical records. Primary outcomes are: 1) the prevalence of documented AUD treatment engagement during 12 months of follow-up per National Committee for Quality Assurance (NCQA) definitions (2 visits for AUD treatment in the 34 days after initiation), and 2) changes in alcohol use at follow-up screening based on changes in the AUDIT-C score from baseline to follow-up 9-24 months later (irrespective of treatment engagement). Intent to treat analyses include all eligible patients regardless of whether they receive shared decision-making and compare patients in each intervention arm to those in the usual care arm. IMPACT: Over 32 million US adults have active AUD. Many are identified in primary care but few engage in referrals to treatment. This trial will test two practical population-based interventions to increase treatment engagement in patients who report AUD symptoms.