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

Kaiser Foundation Research Institute, Oakland CA

Investigators

Abstract

Enter the text here that is the new abstract information for your application. This section must be no longer than 30 lines of text. 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 are at high-risk for moderate-severe AUD based on 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.