Improving recognition of alcohol use disorders in Veterans Health Administration primary care through implementation of standardized symptom assessment

About This Grant

Background: Alcohol use disorder (AUD) is the most common non-tobacco substance use disorder among Veterans. Recognizing when patients have AUD is essential to providing appropriate care. Unfortunately, AUD is substantially under-recognized and inequitably recognized across age, race, and ethnicity in VA care. VA has implemented standardized alcohol use screening in primary care. VA clinical guidelines direct primary care providers (PCPs) to determine if patients with heavy alcohol use have AUD, but there is no standardized AUD assessment process. This places burden on PCPs and results in under- and inequitable AUD recognition. Standardized symptom assessment can help PCPs efficiently, consistently, and equitably recognize AUD, may increase AUD recognition and treatment initiation, and is recommended for primary care. An efficient, VA- centered AUD assessment process is needed that uses technology for digital, pre-visit assessment integrated with VA’s electronic health record, meets Veterans’ unique needs, and fits VA-specific primary care structures. Implementation strategies suited to VA are needed to ensure clinics are supported in conducting assessment effectively and consistently. Also, many patients who have AUD identified in primary care will not be ready for treatment immediately, thus a VA-suited tool and process for proactive outreach following AUD recognition is needed to support treatment engagement. This CDA will engage VA patients and personnel to inform Veteran- centered, equitable implementation of AUD assessment in VA primary care. We will develop and pilot a user- centered assessment process and implementation strategies. We will secondarily develop a novel outreach tool/process to support treatment engagement for patients who have AUD identified in primary care. Significance: This research provides a foundation for implementing standardized AUD symptom assessment in VA primary care with the goal of increasing and improving equity in AUD recognition. This work addresses multiple VA HSR priorities: improving mental health (including AUD and associated mental health risks, such as suicide), increasing equity, innovative technology in primary care, and implementation research. Innovation and Impact: This is the first study to examine patient perspectives on AUD assessment in primary care. We will apply innovative user-centered design methods, leverage under-used VA technology for digital, pre-visit assessment, and design a novel tool/process for outreach to support treatment engagement. Specific Aims: 1) Examine patient perspectives on AUD assessment in primary care and potential differences in perspectives across patient characteristics (secondarily, examine perspectives on outreach); 2) Design a user-centered assessment process and implementation strategies (secondarily, design a novel outreach tool/process); 3) Pilot clinic-wide implementation of AUD assessment and conduct mixed-methods evaluation. Methodology: In Aim 1 we will interview ~20 national VA primary care patients with heavy alcohol use to inform a survey, then survey a random sample of ~350; both samples will be balanced on demographics to examine differences across groups. Aim 2 involves qualitative interviews with ~40 personnel from 2 VA primary care clinics, iterative co-design sessions/usability testing to develop a user-centered assessment process (and secondarily, a novel outreach tool/process), and implementation mapping to plan strategies. Aim 3 involves piloting implementation of AUD assessment in 1 clinic and evaluation through qualitative interviews with ~20 clinic personnel and ~20 patients, a brief survey of PCPs, and analysis of electronic health record data. Next Steps/Implementation: This CDA will inform 2 multi-site, hybrid trials: a hybrid type 1 to test effectiveness of the novel outreach tool/process, and a hybrid type 2 to test implementation of AUD assessment. It will provide training in survey research, user-centered design, implementation science, and addressing racial and ethnic disparities, and will support the PI in becoming an independent VA investigator focused on improving substance use-related care through user-centered innovations and implementation.