KA Bradley MD MPH, Northwest Health Services Research and Development Center of Excellence; Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine and Health Services, University of Washington; A Epler BA, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; KR Bush MPH, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; JL Sporleder BS, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; C Dunn PhD, Department of Psychiatry and Behavioral Sciences, University of Washington; N Cochran MD, VA White River Junction; Department of Medicine and Community and Family Medicine, Dartmouth Medical School; CH Braddock III MD MPH, Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine and Health Services, University of Washington; MB McDonell MS, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; SD Fihn MD MPH, Northwest Health Services Research and Development Center of Excellence; Primary and Specialty Medical Care Service, VA Puget Sound Health Care System; Departments of Medicine and Health Services, University of Washington.

Objectives: No published study has directly evaluated the nature of discussions that primary care providers have with patients regarding alcohol use. The objective of this study was to determine the content and style of discussions that primary care providers have with at-risk drinkers during scheduled appointments. A secondary objective was to compare the rate and content of alcohol-related discussions in clinics with and without a provider prompting intervention.

Methods: As a sub-study of the ACQUIP trial, male patients and their providers in two firms of a Veterans Affairs (VA) General Internal Medicine Clinic were invited to participate in an audio-tape study of patient-provider communication. Patients were eligible if they indicated on a questionnaire that they were willing to consider having their clinic appointments taped, if they reported past-year at-risk drinking, and if their provider consented. Patients and providers were blinded to the focus of this sub-study on alcohol. At-risk drinking was defined as a score of >= 1 point on a previously validated augmented CAGE questionnaire, or report of drinking 5 or more drinks on an occasion in the past year. All utterances from alcohol-related discussions were coded into Motivational Interviewing Skills Code categories. Intervention: At scheduled primary care visits, providers in the Intervention firm received tailored ACQUIP Drinking Practices Reports summarizing participating patients' responses to mailed alcohol-screening questionnaires. Drinking Practices Reports included information about patients’ drinking pattern, alcohol-related problems, previous alcohol treatment, and readiness-to-change drinking. Providers in both firms were offered alcohol-related continuing medical education (one 45 minute conference).

Results: Of 68 taped visits of at-risk drinkers with their providers, 39 (57.4%) included any discussion of alcohol, 17/41 (41.5%) in the Control firm and 22/27 (81.5%) in the Intervention firm (P<0.01). Providers contributed 58% of utterances during alcohol-related discussions, including primarily questions (24%), information giving (23%) and facilitation (34%). Advice, reflective listening, and supportive or affirming statements were less common, 5%, 4%, and 5% of utterances respectively. Only 21% of all taped visits included alcohol-related advice, 33% and 12% in the Intervention and Control firms, respectively (p=0.035). Compared to Controls, Intervention providers’ appointments included more questions (mean number of utterances per visit 2.9 versus 1.1), information giving (3.0 versus 0.9), and affirming or supportive statements (0.7 versus 0.2), but similar amounts of advice (0.4 versus 0.3). Intervention patients made more statements reflecting motivation to change drinking (1.2 versus 0.3).

Conclusions: Alcohol-related primary care discussions mainly involved assessment and information giving. A minority of taped at-risk drinkers in this study received explicit alcohol-related advice. Prompting providers about at-risk drinking was associated with a greater likelihood that alcohol-related discussions occurred, and that patients received alcohol-related advice.

Impact: The VA requires annual alcohol screening for primary care patients, but little is known about the counseling that providers offer patients who report at-risk drinking. This study suggests that general medical providers may need additional education regarding advising at-risk drinkers. Alcohol screening programs that prompt providers with detailed information regarding patients’ past-year symptoms, may increase rates of alcohol counseling.