Patient‐ and provider‐level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis

Abstract

Background Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration. Methods Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1‐year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ‐2) from the electronic health record. Results The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co‐occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ‐2 depression score (2.85, p = 0.004). Conclusions We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

All perspectives need to be accounted for when determining the effectiveness of therapies for alcohol use disorder

“…We found that many times patients declined offers for AUD treatment in a chart review study. 6 Likewise, our non-VA study found strong evidence of provider stigma in these conversations and their notes, which may translate into patient decline. 5 These findings emphasize the need for future work toward increasing AUD-related care, which starts with capturing data from all ends of the patient, caregiver, system, and societal spectrum.…”

Inpatient Screening, Brief Intervention, and Referral to Treatment for Alcohol Use Disorder in Patients Admitted with Alcohol-associated Liver Disease Is Not Universally Implemented in Practice, But Can Reduce Readmissions for Alcohol-associated Hepatitis

“… 25 Another retrospective review also found that only 64% of cirrhosis patients were offered outpatient AUD treatment. 26 Factors that impede the implementation of SBIRT include gaps in knowledge or comfort about aspects of managing AUD, such as pharmacotherapy, as well as insufficient healthcare resources and system limitations. 24 , 26 , 27 Most of the SBIRT in our study was started by social workers and addictions counsellors, which further highlights the importance of a multidisciplinary approach to AUD and ALD.…”