Few people in the US talk about alcohol use with a health professional in a primary care setting. A new study showed that providers’ use of evidence-based screening and counseling for unhealthy alcohol use more than tripled after a quality improvement strategy was introduced.

The Stop Unhealthy Alcohol Use Now (STUN) study, led by Daniel E. Jonas, MD, MPH, with the Division of General Internal Medicine at The Ohio State University College of Medicine in Columbus, Ohio, enrolled 21 small-to-medium primary care practices (with 54,294 adult patients) across North Carolina into a 1-year practice facilitation intervention that created workflows for each practice and tools to address unhealthy alcohol use.

Practices received 1 year of facilitation program training, which included quality improvement coaching, electronic health record support, and clinician training on screening and counseling.

Screening, using the recommended Alcohol Use Disorders Identification Test-Consumption, was the primary outcome, and it increased dramatically from 17.4% (95% CI, 6.0%-28.9%) per practice to 57.6% (95% CI, 29.1%-86.1%) by the end of the second quarter of intervention (P < .001). Among the patients screened, a weighted 13.9% (95% CI, 6.8%-21.1%) screened positive for unhealthy alcohol use.

Results May Underrepresent Potential Gains

The authors pointed out that their research was done between February 1, 2020, and September 1, 2023, overlapping both the height of the COVID pandemic and North Carolina’s historic shift to Medicaid Managed Care, which strained administrative resources of primary care practices.

“We theorize that the increases in rates of screening and counseling found in STUN would have been larger without these barriers,” the authors wrote.

Tailored Approach Boosts Results

Editorialists Alison N. Huffstetler, MD, with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, DC, and Alex H. Krist, MD, MPH, with the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, wrote in an invited commentary that the power of the intervention may lie in its ability to be tailored to each practice instead of having rigid rules and protocols.

“[The facilitators] meet with clinical leadership and practice representatives, offer tools and resources to help practices identify and define the roles of clinicians and staff members for screening and counseling, and share best practices and lessons learned from other practices. Counseling interventions are offered as options, but no single approach is required,” the editorialists noted. Practices can change their intervention to integrate with their workflow and better serve patients.

They pointed out, however, that despite the increase in screening, the increase in counseling rates was lower than hoped. According to the study, “[T]he number of opportunities to provide counseling was fairly low in some practices.”

The editorialists wrote that the intervention needs a wider introduction. Teaching the intervention in residency, they said, could help broadly disseminate the information.

Approach Has Shortcomings

Emily C. Williams, PhD, MPH, professor of Health Systems and Population Health at the University of Washington School of Public Health in Seattle, Washington, said this study adds further evidence that practice intervention is a promising path for addressing unhealthy alcohol use but needs more work.

Previous work, including research she coauthored, also found promising results for practice facilitation, but she says her qualitative analysis of clinicians implementing the intervention highlighted some limitations.

Williams, who is coeditor-in-chief of Addiction Science & Clinical Practice, found clinicians were often not doing high-quality screening. “They were not asking the questions verbatim. They were really nervous about asking the questions. Providers were scared that screening positive would result in a lot of care they didn’t have the capacity to provide. Clinical reminders showed up, and they didn’t know how to use them. It’s a culture-change intervention,” she said, adding that the age-old stigma that comes with talking about unhealthy alcohol use is not easily overcome. 

Practice facilitation is also resource-intensive, and sites such as federally qualified health centers often don’t have the resources, Williams added. 

However, she said, “I think this is an extremely promising path. When we’re getting triple the amount of screens done, that’s a strong foundation to build on.”

The work was supported by the Agency for Healthcare Research and Quality. The authors, editorialists, and Williams reported having no relevant financial relationships. 

Marcia Frellick is an independent, Chicago-based healthcare journalist and a regular contributor to Medscape Medical News.