Predictors of Treatment Referral After AUDIT-C Screening for Heavy Drinking

Abstract

OBJECTIVES The Veterans Health Administration has implemented annual screening for heavy drinking during primary care encounters using the 3-item Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire and made specialized services available to patients with alcohol use disorders (AUDs). We sought to identify the factors that influence whether a patient who has an elevated AUDIT-C score receives appropriate care in the context of an integrated mental health services program. We focused on higher AUDIT-C scores, as these are seen in individuals who are most likely to have a moderate-to-severe AUD and more severe alcohol-related consequences. METHODS Utilizing electronic health record data, we conducted a four-year retrospective study of veterans at high-risk for an AUD, based upon an AUDIT-C score >=8 recorded during a primary care encounter at a Veterans Affairs Medical Center and its community-based outpatient clinics. RESULTS In multivariate analysis, the predictors of treatment referral were younger age, being non-white, higher AUDIT-C score, and main campus location. Among patients referred for treatment, younger age and being white were associated with an increased likelihood of completing a pre-treatment assessment. CONCLUSIONS Efforts to increase the consistency of treatment referrals, according to established clinical guidelines, could enhance the effectiveness of AUDIT-C screening during primary care visits. Subgroups of patients who may benefit from such efforts include individuals with high-risk but sub-maximal AUDIT-C scores, older patients, and patients who are seen at community-based outpatient clinics.

Racial Inequalities in Alcohol Use Disorder Diagnosis in a Sample of 700,000 Veterans

“…It is unclear whether the difference is due to an overdiagnosis of Black Veterans, underdiagnosis of White Veterans, or a combination of the two, both of which are harmful, as overdiagnosis can be stigmatizing and underdiagnosis can delay treatment. The inequitable diagnostic process occurs in the context of Black Veterans being referred and receiving alcohol treatment at higher rates than White or Hispanic Veterans, 12,13 though it is unclear whether this results in better outcomes or what the potential impact is of receiving an AUD diagnosis.…”

“…6 The race or ethnicity of a patient and patient-provider racial/ethnic discordance, can also influence diagnostic decisions through implicit bias, 4,7,8 i.e., healthcare providers' unconscious prejudices or stereotypes that impacts clinical judgment or treatment. 9,10 Studies in the Veterans Health Administration of the Department of Veterans Affairs (VA) have shown that, compared to White Veterans, Black and Hispanic Veterans have a higher rate of clinically recognized alcohol use disorder (AUD) 11 and Black Veterans are more likely to be identified as needing an intervention 12,13 and to receive psychosocial interventions, 12,14 but less likely to receive pharmacotherapy for AUD. 15 One potential explanation for the observed disparities is that the groups have different alcohol consumption patterns.…”