- Email: [email protected]
Alcohol Misuse and Multiple Sclerosis
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ORIGINAL ARTICLE
Alcohol Misuse and Multiple Sclerosis Aaron P. Turner, PhD, Eric J. Hawkins, PhD, Jodie K. Haselkorn, MD, MPH, Daniel R. Kivlahan, PhD ABSTRACT. Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis. Arch Phys Med Rehabil 2009;90:842-8. Objective: To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS). Design: Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006. Setting: Veterans Health Administration (VHA). Participants: Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate). Interventions: Not applicable. Main Outcome Measures: Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcoholrelated advice from a medical professional. Results: Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5–15.2), with 11.9% (CI, 10.6 –13.2) and 2.0% (CI, 1.4 –2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (⬍50y; adjusted odds ratio [AOR]⫽1.66; CI, 1.17–2.37, and 50 –59; AOR⫽1.64; CI, 1.19 –2.27), employment (AOR⫽1.54; CI, 1.06 –2.24) and better physical health (AOR⫽1.02; CI, 1.01– 1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5–30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR⫽3.65; CI, 1.85–7.17) and less likely among those with better mental health (AOR⫽0.97; CI, 0.94 –1.00).
From the Veterans Affairs Puget Sound Health Care System (Turner, Hawkins, Haselkorn, Kivlahan), Veterans Affairs MS Center of Excellence West (Turner, Haselkorn), Veterans Affairs Center of Excellence in Substance Abuse Treatment and Education (Turner, Hawkins, Kivlahan), and the Departments of Rehabilitation Medicine (Turner, Haselkorn), Psychiatry and Behavioral Sciences (Hawkins, Kivlahan), and Epidemiology (Haselkorn), University of Washington, Seattle, WA. Supported by the Department of Veterans Affairs Rehabilitation Research and Development Service Career Development Award (grant no. B4927W), and the Veterans Affairs Center of Excellence in Substance Abuse Treatment and Education, the Veterans Affairs Multiple Sclerosis Center of Excellence West, and the Veterans Affairs Office of Quality and Performance. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Aaron P. Turner, PhD, VA Puget Sound Health Care System, Rehabilitation Care Services, S-117-RCS, 1660 S Columbian Way, Seattle, WA 98108, e-mail: [email protected]. Reprints are not available from the author. 0003-9993/09/9005-00885$36.00/0 doi:10.1016/j.apmr.2008.11.017
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Conclusions: Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care. Key Words: Alcohol; Multiple sclerosis; Rehabilitation; Screening. Published by Elsevier Inc on behalf of the American Congress of Rehabilitation Medicine. LCOHOL USE AMONG PEOPLE with MS has long been A considered a secondary clinical issue and as a result has been the subject of little scientific inquiry. There are many compelling reasons, however, why the assessment and screening of alcohol use patterns remain worthy of attention. In the general U.S. population, nearly 1 in 12 people will meet criteria for an alcohol use disorder during the past year1 and more than 1 in 4 will exceed recommended drinking guidelines.2 The health consequences associated with alcohol misuse have been widely examined and in many cases are well understood. Despite putative health benefits of moderate alcohol consumption, heavy drinking has been consistently linked to cardiovascular disease, obesity, diabetes, high blood pressure, stroke, and cirrhosis, as well as oral, GI, and breast cancer.3 Hazardous alcohol use has been shown to increase the risk of all causes of mortality,4,5 and is considered one of the leading causes of preventable death.6 In addition to physical health, alcohol misuse has also been associated with mental health difficulties as well. People with an alcohol use disorder are more likely to have a comorbid mood disorder or anxiety disorder1 and are more likely to endorse suicidal ideation and a previous suicide attempt.7 Interestingly, all 3 of these general population mental health findings have been replicated specifically in people with MS.8-10 Alcohol use may exacerbate, or add to the burden of, common MS symptoms and consequently contribute to both short term and long term disability. The acute effects of alcohol have been shown to decrease balance,11 reaction time,12 and cogniList of Abbreviations AOR AUDIT-C CI GI ICD MCS MS PCS SF-12 SHEP VA VHA
adjusted odds ratio Alcohol Use Disorders Identification TestConsumption Questions confidence interval gastrointestinal International Classification of Diseases mental component summary multiple sclerosis physical component summary Short-Form 12-Item Health Survey Survey of the Healthcare Experiences of Patients Veterans Administration Veterans Health Administration
ALCOHOL MISUSE, Turner
tive functioning.13 A history of alcohol dependence, even among those who are currently abstinent, has been associated with poorer sleep quality and greater daytime fatigue, as well as mild but persistent cognitive problems.14-16 Poor medication adherence has also been linked to alcohol misuse,17 which as a result may detract from ongoing MS disease and symptom management. Despite the general and disease-specific consequences of alcohol misuse, little is known about rates of hazardous drinking in MS. Available evidence suggests the lifetime prevalence of alcohol use disorders in MS may range from 14% to 18%,8-10,18 although these estimates are based on a small number of studies with limited sample sizes. In the only study using a large community sample, Bombardier et al8 estimated a past-month prevalence of alcohol use disorder as approximately 14%. Typical of most research on MS, the sample was composed primarily of women (77%). Several studies have shown that brief alcohol counseling delivered during a regular medical visit may lower alcohol consumption, use-related consequences, and health care costs.19,20 Effective interventions can be delivered in as little as 5 to 15 minutes.21 As a result, the U.S. Preventive Services Task Force has recommended routine assessment and intervention for alcohol misuse.22 Despite the need, most data suggest that only a minority of people with hazardous patterns of alcohol consumption receive advice from their primary care providers to consider cutting down or abstaining from alcohol.23 Little at all is known about the extent to which people with MS receive this first line of intervention. The present study was conducted to further our understanding of alcohol use patterns among people with MS in 2 primary ways. First, it examines the prevalence of, and risk factors associated with, alcohol misuse in a large national sample of veterans with MS. Second, it examines the extent to which people screening positive for alcohol misuse report receiving advice from their medical providers to cut down or refrain from drinking, and factors associated with the receipt of advice. Finally, an additional benefit of the study is that it examines these issues in a predominantly male sample, a group traditionally underrepresented in MS research. METHODS Participants First, we drew potential participants from the VA MS National Data Repository, a database containing information on all veterans receiving MS-related health care services within VHA from 1998 to 2006. The repository is updated periodically, but at the time of the data extraction for this study, it contained 34,539 unique cases. To reduce inaccurate ascertainment of MS due to coding errors, candidates were included in a final target population only if they met one or more of the following 4 criteria: (1) they had an inpatient hospitalization for MS (hospitalization was coded with the ICD-9 diagnostic code 340 for MS), (2) they had received a disease modifying agent (interferon 1a, interferon 1b, or glatiramer acetate) used only to treat MS, (3) they were VA service connected for MS (the diagnosis had been confirmed through a medical review process for purposes of VA disability pension), or (4) they had at least one outpatient encounter or inpatient stay for which the primary ICD diagnosis code was 340 during each year in which they received some VA medical service. The search algorithm for identifying a target population within the VA MS National Data Repository has been validated by chart review in previous work and has been shown to be an effective means of eliminating people who do not have MS.24 For the current study, a
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fifth criterion was added. Participants were required to have received some VHA services during the period 2004 through 2006, because only people receiving services during this time frame were eligible to receive the survey instrument described below. A total of 14,747 veterans were included in the target population. Procedures This is an observational, cross-sectional, cohort study that linked data from the VA MS National Data Repository and the VA Office of Quality and Performance Survey of the Healthcare Experiences of Patients. SHEP is a survey conducted by VHA to support national quality improvement efforts and evaluate patient satisfaction with VHA health care services across the United States.25 It is sent to approximately 50,000 people each month who (1) received provider-based outpatient or inpatient care in VHA and (2) had not been sampled in the previous 12 months. Survey methodology has been described elsewhere in greater detail.25 Information from years 2004 through 2006 was used for this study. In instances where more than 1 survey was completed, the most recent SHEP data were included in the study. All data analysis procedures were approved by the local human subjects review committee. Nationally, response rates for SHEP in 2006 were approximately 43% and 58% for inpatient and outpatient surveys respectively.26 Similarly, among people with MS in the target population, at least 1 survey was returned by 2655 of 4929 enrollees who were mailed surveys (53.9% response rate). Participants who returned the SHEP survey with a completed AUDIT-C were eligible for the present study. See figure 1 for a patient flow diagram and reasons for non-participation. Measures Alcohol misuse. We measured alcohol misuse using the AUDIT-C. The 3-item AUDIT-C was included on the SHEP survey to assess alcohol consumption patterns in the past year and has been validated as a brief alcohol screening test in VHA and non-VHA medical samples.27-29 Scores range from 0 to 12, with a cutoff of 4 or more and 3 or more identifying alcohol misuse in men and women, respectively. Higher AUDIT-C scores indicate greater alcohol misuse severity,30 and AUDIT-C scores of 8 to 12 have been associated with a higher
Fig 1. Diagram: Flow of participants and reasons for nonparticipation.
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risk for subsequent hospitalizations for liver disease, GI bleeding and pancreatitis,31 mortality,32 and alcohol dependence.29 To facilitate interpretation of AUDIT-C scores, respondents were grouped into 4 categories: nondrinkers (AUDIT-C⫽0), low-level drinkers who screen negative for alcohol misuse (AUDIT-C⫽1–3 men; 1–2 women), mild-moderate alcohol misuse (AUDIT-C⫽4 –7 men; 3–7 women), and severe alcohol misuse (AUDIT-C⫽8-12).31 Demographic information. Self-reported race, education level, marital status, and employment were all obtained from SHEP. Sex and age in years at the time of the survey were obtained from the VA MS National Data Repository. Physical health. Physical health was measured using the PCS of the veteran version of the Medical Outcomes Study SF-12.33-35 Participants were asked to respond to 12 questions addressing 8 areas of health status, including items such as “In general would you say your health is . . .” with response options ranging from 1 (excellent) to 5 (poor) and “During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health: Accomplished less than you would like?” with response options ranging from 1 (all of the time) to 5 (none of the time). Items were summed and in some cases reversescored to produce subscales that were then transformed to normal scores. A final PCS score was calculated as a weighted sum of subscales according to standard scoring criteria. The final score had a potential range of 1 to 100 with higher values reflecting better physical health functioning. The SF-12 is an abbreviated version of the Medical Outcomes Study 36-Item Short Form Health Survey, which is widely used and has been validated for use with people with MS.36-38 Mental health. Mental health was measured using the MCS of the veteran version of the Medical Outcomes Study SF-12.33-35 Participants were asked to respond to 12 questions addressing 8 areas of health status, including items such as “How much of the time during the past 4 weeks have you felt calm and peaceful?” and “How much of the time during the past 4 weeks have you felt downhearted and depressed?” with response options ranging from 1 (all of the time) to 5 (none of the time). Items were summed and in some cases reversescored to produce subscales that were then transformed to normal scores. A final MCS score was calculated as a weighted sum of subscales according to standard scoring criteria. The final score had a potential range of 1 to 100 with higher values reflecting better mental health functioning. Depression. Participants were asked whether or not in the past year they had 2 or more weeks in which they felt sad, blue or depressed, or lost interest or pleasure in things that they usually cared about or enjoyed. Alcohol advice. Participants were asked “In the past 12 months has a VA doctor or other VA health care provider advised you about your drinking (to drink less or not to drink alcohol)?” Data Analysis Plan We first examined the dataset to determine the extent to which the final study sample was representative of the larger population of veterans with MS using age and sex variables available on all persons in the repository. Selection bias (whether a candidate was or was not sent a survey) and response bias (whether a candidate did or did not return a survey) were examined for these variables. We then examined the consistency of veteran characteristics over the 3 years (2004 – 2006) of survey data used in this study. The prevalence of alcohol misuse, as well as the receipt of alcohol-related advice was estimated using simple proportions Arch Phys Med Rehabil Vol 90, May 2009
and 95% CIs. Alcohol misuse was further characterized using risk zones previously established for the AUDIT-C. Chi-square tests were used to test for potential sex differences in alcohol misuse within risk zones and logistic regression was used to further test for potential sex differences in the overall prevalence of alcohol misuse after adjustment for age category. Logistic regression was used to identify correlates of alcohol misuse. First, a series of individual univariate logistic regression analyses was conducted to examine the association between alcohol misuse and each potential demographic correlate (age, sex, race, education level, marital status, employment), and health status correlate (depression, physical health, mental health). All variables that showed a relationship (defined as P⬍.10) at a univariate level were then included simultaneously in a final multivariate logistic regression model using robust SE estimates. We also used logistic regression to examine correlates of receipt of alcohol advice using an identical sequence of univariate analyses followed by the creation of a final multivariate model. In this second instance, the sample was limited to people who endorsed alcohol misuse as defined by an AUDIT-C score 4 or greater (ⱖ 3 for women). The fit of multivariate logistic regression models was assessed using the Hosmer-Lemeshow goodness-of-fit statistic. All analyses were performed using Stata version 9.2.a RESULTS Participant Characteristics Table 1 presents demographic and health characteristics of the study sample. Of eligible patients, 84.3% were men and 85.6% identified themselves as white. Approximately 61.2%
Table 1: Patient Characteristics Patient Characteristics
Sex Female Male Age ⬍50 50–59 ⱖ60 Race White Nonwhite Data missing Marital status Married Not married Data missing Education High school or less Some college College or beyond Data missing Employment Employed Not employed Data missing Depressed in last 12 months Yes No Data missing
N⫽2473
%
388 2085
15.7 84.3
607 979 887
24.6 39.6 35.8
2117 331 25
85.6 13.4 1.0
1513 905 55
61.2 36.6 2.2
824 906 706 37
33.3 36.6 28.6 1.5
231 1932 310
9.4 78.1 12.5
1116 1260 97
45.1 51.0 3.9
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were married, 78.1% were unemployed, and 65.2% reported more than high school education. The mean age ⫾ SD of the sample was 56.7⫾11.2, but men (58.1⫾10.8) were significantly older than women (49.1⫾10.2; t2471,15.2; P⬍.001). The mean mental health functioning of this sample (n⫽2434; 45.2⫾12.7) was within 1 SD of the MCS mean found in general population samples, whereas the mean physical functioning (n⫽2425; 26.3⫾10.1) was more than 2 SDs below the PCS mean found in general population samples.39 Comparability of the Study Sample Selection bias. We conducted selection bias analyses to determine if people who were mailed the SHEP survey were representative of the larger MS target population with respect to sex and age. There were no significant differences by sex among those who did and did not receive a survey and the difference in age, though statistically significant, was less than a year and is not considered clinically meaningful. Response bias. Similarly, to determine if people who returned the SHEP survey differed from those who did not, we also compared these 2 groups on sex and age. There was no significant difference in response to the SHEP survey by sex, but veterans who returned the surveys were on average older than those who did not (mean ⫾ SD, 56.8⫾11.2 vs 53.0⫾12.0, respectively; t4927,11.6; P⬍.001). Comparability of the Study Sample Across Survey Years To determine the stability of veteran characteristics across the years of the survey, we also compared the demographic and clinical characteristics of the veterans who responded to the SHEP survey. There were no differences in veteran characteristics by age, marital status (married vs not married), race, employment (employed vs not employed), or depression. However, the proportions of the sample that were women (18.3% vs 16.6% vs 12.5%, respectively; 22,2473⫽10.9, P⬍.01) varied by the year of the survey. Physical health (mean ⫾ SD, 25.6⫾10.4 vs 26.9⫾10.4 vs 26.3⫾9.4, respectively; F2,2424,3.1; P⬍.05) showed a modest but significant difference, and mental health (mean ⫾ SD, 47.0⫾12.6 vs 44.6⫾12.7 vs 44.1⫾12.6, respectively; F2,2433,11.7; P⬍.001) declined somewhat from 2004 through 2005. Prevalence of Alcohol Misuse Among survey respondents with MS, 50.9% reported no alcohol use in the past 12 months and 35.2% reported low-level drinking. Overall, the prevalence of alcohol misuse for the sample was 13.9% (CI, 12.5–15.2), with 11.9% (CI, 10.6 – 13.2) and 2.0% (CI, 1.4 –2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. No differences between sexes were noted within risk zones (mild/moderate; men 11.8% [CI, 10.4 –13.1] vs women 12.6% [CI, 9.3–15.9], 21,2473⫽0.24, P⬎.10; severe; men 2.0%
Table 2: Age-Specific Estimates of Prevalence of Alcohol Misuse by Sex
Age ⬍50 50–59 ⱖ60
n
Men Prevalence of Alcohol Misuse
n
Women Prevalence of Alcohol Misuse
391 860 834
17.4 (13.6–21.2) 15.6 (13.2–18.0) 10.2 (8.1–12.2)
216 119 53
17.6 (12.5–22.7) 13.4 (7.2–19.7) 3.8 (⫺1.5 to 9.1)
NOTE. Values are % (95% CI) or as otherwise indicated.
Table 3: Summary of Multivariate Logistic Regression Analysis for Demographic and Health Status Variables Associated with Alcohol Misuse (nⴝ2103) Variable
Alcohol Misuse
Demographic ⬍50 years old* 50–59 years old* Employment† Health status Better physical health (PCS)
1.66 (1.17–2.37)‡ 1.64 (1.19–2.27)§ 1.54 (1.06–2.24)‡ 1.02 (1.01–1.04)§
NOTE. Values are AOR (95% CI). *Referent is age category representing ages ⱖ60. † Referent is not employed. ‡ P⬍.05 from the Wald Statistic. § P⬍.01 from the Wald Statistic.
[CI, 1.4 –2.6] vs women 1.8% [CI, 0.5–3.1], 21,2473⫽0.07, P⬎.10). Table 2 shows age-specific prevalence of alcohol misuse and 95% confidence intervals by sex. After adjustment for age category, no difference was found in the odds of alcohol misuse for men and women (AOR⫽1.15; CI, 0.83– 1.59). To further examine for a potential sex difference, the Likelihood Ratio test was used to test for an association between alcohol misuse and a sex by age category interaction. No evidence for an interaction between sex and age category was found. Correlates of Alcohol Misuse Univariate logistic regression was used to identify individual correlates of alcohol misuse. Correlates identified in the univariate logistic regression model were then simultaneously entered in a multivariate logistic regression model to examine the association of identified correlates with the prevalence of alcohol misuse. As shown in table 3, the risk of alcohol misuse was higher among veterans younger than 60 (⬍50; AOR⫽ 1.66; CI, 1.17–2.37 and 50 –59; AOR⫽1.64; CI, 1.19 –2.27), those employed (AOR⫽1.54; CI, 1.06 –2.24) and those in better physical health (AOR⫽1.02; CI, 1.01–1.04). No difference in risk of alcohol misuse was noted between the younger than 60 age groups (⬍50 vs 50 –59; AOR⫽0.99; CI, 0.74 – 1.32). Marital status was identified during univariate analyses, but was not significantly associated with alcohol misuse in the multivariate model. The Hosmer-Lemeshow goodness-of-fit statistic for this multivariate model was not significant, suggesting little departure from perfect fit (28 ⫽1.62; P⬎.99). Prevalence of Alcohol-Related Advice Among survey respondents with MS who screened positive for alcohol misuse, 26.2% (CI, 21.5–30.9) reported receiving advice from a VA health care provider to drink less or not drink at all. Figure 2 shows the unadjusted rates of alcohol-related advice for veterans with mild/moderate (21.9%; CI, 17.1–26.7) and severe alcohol misuse (52.1%; CI, 37.4 – 66.7). Correlates of Receipt of Alcohol-Related Advice The same sequence of univariate and multivariate logistic regression models was used in analyses to identify correlates associated with subjects’ reports that they had received alcohol-related advice in the past year. As shown in table 4, severe alcohol misuse (defined as an AUDIT-C score ⱖ8) was associated with a higher likelihood of receiving advice about drinking (AOR⫽3.65; CI, 1.85–7.17), and better mental health was associated with a lower likelihood of receiving advice about drinking (AOR⫽0.97; CI, 0.94 –1.00). Although age, educaArch Phys Med Rehabil Vol 90, May 2009
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Fig 2. Rate of provider advice by mild/moderate and severe alcohol misuse zones.
tion, race, and depression were included in the multivariate regression model as a result of associations identified in univariate analyses, none of these variables was significantly associated with advice about drinking in the multivariate logistic regression model. According to the Hosmer-Lemeshow goodness-of-fit test, the fit for this multivariate model was good (26⫽2.49, P⬎.87). DISCUSSION The overall prevalence of alcohol misuse among people with MS in this study was 13.9%, a rate strikingly similar to the 14% found in previous studies using community-based and clinicbased samples that were predominantly women,8,10 but somewhat lower than the rate of 22% reported in a general outpatient veteran sample that was surveyed using a similar SHEP methodology.40 However, precise comparisons between veteran samples are difficult because of the increased risk of alcohol misuse among younger age groups and men, and the representation of these characteristics in different samples. It is important to note that this non-MS veteran sample is somewhat limited because women veterans represent a much smaller proportion of this comparison sample. Interestingly, the rates of alcohol misuse did not differ by sex in the present study, a finding that departs substantially from other general population results in which the prevalence is typically higher among men.41 It is unlikely that the mean age difference between men and women in this sample accounted for this finding because it remained in models adjusted for age and a sex by age interaction. Historically, women with hazardous alcohol use patterns have been less likely to be identified or to receive feedback in general medical settings.28,42,43 Current data underscore the need to avoid this oversight. Our findings regarding other correlates of alcohol misuse were more consistent with those reported in the alcohol misuse and MS literatures. Veterans with MS were more likely to Arch Phys Med Rehabil Vol 90, May 2009
screen positive for alcohol misuse if they were younger, employed, and in better physical health. All 3 of these findings are consistent with the only previous study of alcohol use in a broad survey of people with MS,8 even though the determination of physical health in the latter instance was more focused on disease-specific disability. Results suggest that prevention, screening, and intervention efforts might best be emphasized earlier in the course of MS (⬍60y) during the time risk for misuse is highest. Among veterans who screened positive for alcohol misuse, a relatively small minority, 26.2%, reported receiving advice to reduce or refrain from drinking from their VA health care provider. Although this rate is similar to those found in larger VA and non-VA primary care samples,23,43 it nonetheless reflects missed opportunities for intervention. Such missed opportunities are noteworthy because trials of alcohol screening and brief intervention in primary care settings have shown reductions in alcohol use in nondependent drinkers.19 Another compelling argument for the use of brief interventions among people with MS is the high percentage with potential alcohol problems who report interest in learning to reduce or stop drinking.8 Though the preferred model for treatment of chronic and severe alcohol use disorders includes more intensive treatment provided in specialty care settings, research and practice guidelines support the use of brief interventions in settings where medical care is delivered routinely.44 Many resources are available to assist clinicians less accustomed to assessing alcohol misuse. One frequently noted example is the National Institute on Alcohol Abuse and Alcoholism’s clinician guide Helping patients who drink too much.2 Providers are also uniquely positioned to identify and manage patients with alcohol misuse. Advantages include the opportunity to integrate alcohol and other health screening procedures, to initiate timely interventions, to link brief alcohol interventions to health-related concerns, and to closely monitor the drinking patterns of at risk patients during follow-up visits.2 It is also important to note that patients may perceive less discomfort45 and more privacy during alcohol-related discussions and interventions in medical settings, and also appreciate the interaction and view it as a component of high quality care.46 Brief intervention may also be particularly relevant for a patient population for whom physical and cognitive disability may serve as a barrier to receiving care. Distance to a medical center and the complexities associated with travel often represent additional burdens for people with MS that brief interventions might help to avoid. People who screened positive for more serious alcohol misuse (AUDIT-C scores ⱖ8) were more likely to report receiving advice from a provider, a result that is again consistent with previous literature in primary care.23 However, almost half (48%) of patients with scores falling within the severe misuse range reported that they did not receive any alcohol-related
Table 4: Summary of Multivariate Logistic Regression Analysis for Demographic and Health Status Variables Associated With Reporting Advice to Reduce or Abstain From Drinking (nⴝ322) Variable
Advice to Reduce or Abstain
Severe alcohol misuse (AUDIT-C Score ⱖ8)* Better mental health (MCS)
3.65 (1.85–7.17)‡ 0.97 (0.94–1.00)†
NOTE. Values are AOR (95% CI). *Referent is AUDIT-C Score⫽4 –7. † Pⱕ.05 from the Wald Statistic. ‡ P⬍.001 from the Wald Statistic.
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advice. Despite growing evidence regarding the efficacy of brief alcohol interventions in primary care settings, and greater advocacy to deliver alcohol counseling to patients with hazardous drinking patterns, most patients who screen positive for alcohol misuse do not report receiving alcohol-related advice. A number of barriers such as inadequate training in the identification and treatment of hazardous drinking,47 provider discomfort with alcohol-related discussions,48,49 or time constraints associated with growing demands on primary care visits50 may have contributed to these missed intervention opportunities. Among people with MS who also screened positive for alcohol misuse, the odds of receiving alcohol-related advice were also lower for those who endorsed better mental health. A similar finding has been found in other studies identifying patient correlates of brief intervention23,51 and may reflect the willingness of providers to intervene when the potential consequences of excessive alcohol use are more salient. Interestingly, poor physical functioning—a factor typically found associated with a greater likelihood of counseling in the alcohol misuse literature—was not associated with receipt of advice about alcohol use in this sample. However, it is possible that the relatively poor physical health of this patient sample and limited statistical power explain this discrepant result. Study Limitations This study has several limitations. Study data were obtained from 2 large national VA databases. Overall, the survey response rate was 54% and respondents were a little older than nonrespondents, although other differences on nonassessed demographic or clinical factors may have confounded our findings. Additionally, though no meaningful sex or age differences were noted in those who were sent a survey, it is possible that other important differences were not detected. The study may have been underpowered to detect sex differences in the receipt of alcohol-related advice among those with severe misuse. AUDIT-C and alcohol-related advice data were obtained from mailed surveys and thus may be subject to the biases of the self-report method. Without a criterion standard for assessing alcohol consumption, it is not clear if these biases have under- or over-estimated the true patterns of alcohol use. However, there is evidence to suggest that self-report is considered a reliable and valid approach for measurement of alcohol consumption.52,53 Poor recall, social desirability, or patient misunderstanding of alcohol-related discussions may underestimate the true rate of advice patients received in this study. Results also may not generalize to persons with MS who are not veterans or who do not receive care in the VA health care system. Additional research would be helpful to elucidate the natural history of alcohol misuse over time, as well as the longitudinal impact of misuse on physical functioning and mental health controlling for initial status. CONCLUSIONS Alcohol misuse represents an important health risk among veterans with MS. Risk for misuse is most prominent earlier in the disease course when people are younger and in better physical health. Unlike non-MS samples, prevalence rates for men and women are highly similar. Fewer than one third of persons with alcohol misuse reported they had received advice from a medical provider in the past year to reduce or refrain from drinking. Advice was more common when misuse was more severe and people reported poorer mental health. Brief screening and intervention in the form of advice or referral can be conducted in as little as 5 minutes in the course of a routine medical visit.
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References 1. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64:830-42. 2. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Washington (DC): US Department of Health and Human Services; 2005. 3. National Institute on Alcohol Abuse and Alcoholism. State of the science report on the effects of moderate drinking. US Department of Health and Human Services, 2003. Available at: http:// pubs.niaaa.nih.gov/publications/ModerateDrinking-03.htm. Accessed August 20, 2008. 4. Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med 1997;337:1705-14. 5. Rehm J, Greenfield TK, Rogers JD. Average volume of alcohol consumption, patterns of drinking, and all-cause mortality: results from the US National Alcohol Survey. Am J Epidemiol 2001;153: 64-71. 6. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-45. 7. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999;56:617-26. 8. Bombardier CH, Blake KD, Ehde DM, Gibbons LE, Moore D, Kraft GH. Alcohol and drug abuse among persons with multiple sclerosis. Mult Scler 2004;10:35-40. 9. Feinstein A. An examination of suicidal intent in patients with multiple sclerosis. Neurology 2002;59:674-8. 10. Quesnel S, Feinstein A. Multiple sclerosis and alcohol: a study of problem drinking. Mult Scler 2004;10:197-201. 11. Mangold S, Laubli T, Krueger H. Effects of a low alcohol dose on static balance, fine motor activity, and mental performance. Neurotoxicol Teratol 1996;18:547-54. 12. Wang MQ, Taylor-Nicholson ME, Airhihenbuwa CO, Mahoney BS, Fitzhugh EC, Christina R. Psychomotor and visual performance under the time-course effect of alcohol. Percept Mot Skills 1992;75(3 Pt 2):1095-106. 13. Schweizer TA, Vogel-Sprott M, Danckert J, Roy EA, Skakum A, Broderick CE. Neuropsychological profile of acute alcohol intoxication during ascending and descending blood alcohol concentrations. Neuropsychopharmacology 2006;31:1301-9. 14. Vik PW, Cellucci T, Jarchow A, Hedt J. Cognitive impairment in substance abuse. Psychiatr Clin North Am 2004;27:97-109, ix. 15. Davies SJ, Pandit SA, Feeney A, et al. Is there cognitive impairment in clinically ‘healthy’ abstinent alcohol dependence? Alcohol Alcohol 2005;40:498-503. 16. Parsons OA, Nixon SJ. Cognitive functioning in sober social drinkers: a review of the research since 1986. J Stud Alcohol 1998;59:180-90. 17. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication non-adherence. Ann Intern Med 2008;149:795-804. 18. Patten SB, Metz LM, Reimer MA. Biopsychosocial correlates of lifetime major depression in a multiple sclerosis population. Mult Scler 2000;6:115-20. 19. Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007 Apr 18;(2):CD004148. 20. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36-43. Arch Phys Med Rehabil Vol 90, May 2009
848
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21. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997;12:274-83. 22. US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med 2004;140:554-6. 23. Burman ML, Kivlahan D, Buchbinder M, et al. Alcohol-related advice for Veterans Affairs primary care patients: who gets it? Who gives it? J Stud Alcohol 2004;65:621-30. 24. Culpepper W, Ehrmantrout M, Wallin M, Flannery K, Bradham D. Identification of the VHA MS Surveillance Registry. The problem of case finding from administrative databases. J Rehabil Res Dev 2006;43:17-24. 25. Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med 2006;(21 Suppl 3):S26-32. 26. Wright SM, Elter JR. SHEP: Overview and transition to CAHPS. 2008; Washington (DC): Department of Veterans Affairs. Available at: http://vaww.oqp.med.va.gov/oqp_services/veterans_satisfaction/ uploads/SHEP_Quality_Kickoff%20fnl2.ppt. Accessed September 29, 2008. 27. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res 2007;31:1208-17. 28. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcoholscreening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 2003;163:821-9. 29. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158:1789-95. 30. Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res 2004;28:448-55. 31. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcohol Clin Exp Res 2007;31:443-51. 32. Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001; 62:826-33. 33. Jones D, Kazis L, Lee A, et al. Health status assessments using the Veterans SF-12 and SF-36: methods for evaluating outcomes in the Veterans Health Administration. J Ambul Care Manage 2001; 24:68-86. 34. Kazis LE, Ren XS, Lee A, et al. Health status in VA patients: results from the Veterans Health Study. Am J Med Qual 1999; 14:28-38. 35. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33. 36. Hobart JC, Freeman JA, Lamping D, Fitzpatrick R, Thompson AJ. The SF-36 in multiple sclerosis: why basic assumptions must be tested. J Neurol Neurosurg Psychiatry 2001;71:363-70. 37. Freeman J, Hobart JC, Langdon DW, Thompson AJ. Clinical appropriateness: a key factor in outcome measure selection: the 36
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38. 39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
item short form health survey in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000;68:150-6. Ware JE, Kosinski M, Dewey JE. How to score version 2 of the SF-36 Health Survey. Lincoln: QualityMetric Inc; 2000. Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. How to score version 2 of the SF-12 Health Survey. Lincoln: QualityMetric Inc; 2002. Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care 2006;12:597-606. Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res 2005;29:844-54. Buchsbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ. Physician detection of drinking problems in patients attending a general medicine practice. J Gen Intern Med 1992;7:517-21. Volk RJ, Steinbauer JR, Cantor SB. Patient factors influencing variation in the use of preventive interventions for alcohol abuse by primary care physicians. J Stud Alcohol 1996;57:203-9. Maciosek MV, Edwards NM, Coffield AB, et al. Priorities among effective clinical preventive services: methods. Am J Prev Med 2006;31:90-6. Curry SJ, Ludman E, Grothaus L, Donovan D, Kim E, Fishman P. At-risk drinking among patients making routine primary care visits. Prev Med 2000;31:595-602. Saitz R, Horton NJ, Cheng DM, Samet JH. Alcohol counseling reflects higher quality of primary care. J Gen Intern Med 2008; 23:1482-6. Kaner EF, Wutzke S, Saunders JB, Powell A, Morawski J, Bouix JC. Impact of alcohol education and training on general practitioners’ diagnostic and management skills: findings from a World Health Organization collaborative study. J Stud Alcohol 2001;62: 621-7. Bradley KA, Epler AJ, Bush KR, et al. Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking. J Gen Intern Med 2002; 17:315-26. McCormick KA, Cochran NE, Back AL, Merrill JO, Williams EC, Bradley KA. How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med 2006;21: 966-72. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41. D’Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care 2005;43:229-36. Babor TF, Steinberg K, Anton R, Del Boca F. Talk is cheap: measuring drinking outcomes in clinical trials. J Stud Alcohol 2000;61:55-63. Del Boca FK, Noll JA. Truth or consequences: the validity of self-report data in health services research on addictions. Addiction 2000;95(Suppl 3):S347-60.
Supplier a. StataCorp LP, 4905 Lakeway Dr, College Station, TX 77845.
ORIGINAL ARTICLE
Alcohol Misuse and Multiple Sclerosis Aaron P. Turner, PhD, Eric J. Hawkins, PhD, Jodie K. Haselkorn, MD, MPH, Daniel R. Kivlahan, PhD ABSTRACT. Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis. Arch Phys Med Rehabil 2009;90:842-8. Objective: To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS). Design: Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006. Setting: Veterans Health Administration (VHA). Participants: Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate). Interventions: Not applicable. Main Outcome Measures: Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcoholrelated advice from a medical professional. Results: Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5–15.2), with 11.9% (CI, 10.6 –13.2) and 2.0% (CI, 1.4 –2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (⬍50y; adjusted odds ratio [AOR]⫽1.66; CI, 1.17–2.37, and 50 –59; AOR⫽1.64; CI, 1.19 –2.27), employment (AOR⫽1.54; CI, 1.06 –2.24) and better physical health (AOR⫽1.02; CI, 1.01– 1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5–30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR⫽3.65; CI, 1.85–7.17) and less likely among those with better mental health (AOR⫽0.97; CI, 0.94 –1.00).
From the Veterans Affairs Puget Sound Health Care System (Turner, Hawkins, Haselkorn, Kivlahan), Veterans Affairs MS Center of Excellence West (Turner, Haselkorn), Veterans Affairs Center of Excellence in Substance Abuse Treatment and Education (Turner, Hawkins, Kivlahan), and the Departments of Rehabilitation Medicine (Turner, Haselkorn), Psychiatry and Behavioral Sciences (Hawkins, Kivlahan), and Epidemiology (Haselkorn), University of Washington, Seattle, WA. Supported by the Department of Veterans Affairs Rehabilitation Research and Development Service Career Development Award (grant no. B4927W), and the Veterans Affairs Center of Excellence in Substance Abuse Treatment and Education, the Veterans Affairs Multiple Sclerosis Center of Excellence West, and the Veterans Affairs Office of Quality and Performance. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Aaron P. Turner, PhD, VA Puget Sound Health Care System, Rehabilitation Care Services, S-117-RCS, 1660 S Columbian Way, Seattle, WA 98108, e-mail: [email protected]. Reprints are not available from the author. 0003-9993/09/9005-00885$36.00/0 doi:10.1016/j.apmr.2008.11.017
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Conclusions: Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care. Key Words: Alcohol; Multiple sclerosis; Rehabilitation; Screening. Published by Elsevier Inc on behalf of the American Congress of Rehabilitation Medicine. LCOHOL USE AMONG PEOPLE with MS has long been A considered a secondary clinical issue and as a result has been the subject of little scientific inquiry. There are many compelling reasons, however, why the assessment and screening of alcohol use patterns remain worthy of attention. In the general U.S. population, nearly 1 in 12 people will meet criteria for an alcohol use disorder during the past year1 and more than 1 in 4 will exceed recommended drinking guidelines.2 The health consequences associated with alcohol misuse have been widely examined and in many cases are well understood. Despite putative health benefits of moderate alcohol consumption, heavy drinking has been consistently linked to cardiovascular disease, obesity, diabetes, high blood pressure, stroke, and cirrhosis, as well as oral, GI, and breast cancer.3 Hazardous alcohol use has been shown to increase the risk of all causes of mortality,4,5 and is considered one of the leading causes of preventable death.6 In addition to physical health, alcohol misuse has also been associated with mental health difficulties as well. People with an alcohol use disorder are more likely to have a comorbid mood disorder or anxiety disorder1 and are more likely to endorse suicidal ideation and a previous suicide attempt.7 Interestingly, all 3 of these general population mental health findings have been replicated specifically in people with MS.8-10 Alcohol use may exacerbate, or add to the burden of, common MS symptoms and consequently contribute to both short term and long term disability. The acute effects of alcohol have been shown to decrease balance,11 reaction time,12 and cogniList of Abbreviations AOR AUDIT-C CI GI ICD MCS MS PCS SF-12 SHEP VA VHA
adjusted odds ratio Alcohol Use Disorders Identification TestConsumption Questions confidence interval gastrointestinal International Classification of Diseases mental component summary multiple sclerosis physical component summary Short-Form 12-Item Health Survey Survey of the Healthcare Experiences of Patients Veterans Administration Veterans Health Administration
ALCOHOL MISUSE, Turner
tive functioning.13 A history of alcohol dependence, even among those who are currently abstinent, has been associated with poorer sleep quality and greater daytime fatigue, as well as mild but persistent cognitive problems.14-16 Poor medication adherence has also been linked to alcohol misuse,17 which as a result may detract from ongoing MS disease and symptom management. Despite the general and disease-specific consequences of alcohol misuse, little is known about rates of hazardous drinking in MS. Available evidence suggests the lifetime prevalence of alcohol use disorders in MS may range from 14% to 18%,8-10,18 although these estimates are based on a small number of studies with limited sample sizes. In the only study using a large community sample, Bombardier et al8 estimated a past-month prevalence of alcohol use disorder as approximately 14%. Typical of most research on MS, the sample was composed primarily of women (77%). Several studies have shown that brief alcohol counseling delivered during a regular medical visit may lower alcohol consumption, use-related consequences, and health care costs.19,20 Effective interventions can be delivered in as little as 5 to 15 minutes.21 As a result, the U.S. Preventive Services Task Force has recommended routine assessment and intervention for alcohol misuse.22 Despite the need, most data suggest that only a minority of people with hazardous patterns of alcohol consumption receive advice from their primary care providers to consider cutting down or abstaining from alcohol.23 Little at all is known about the extent to which people with MS receive this first line of intervention. The present study was conducted to further our understanding of alcohol use patterns among people with MS in 2 primary ways. First, it examines the prevalence of, and risk factors associated with, alcohol misuse in a large national sample of veterans with MS. Second, it examines the extent to which people screening positive for alcohol misuse report receiving advice from their medical providers to cut down or refrain from drinking, and factors associated with the receipt of advice. Finally, an additional benefit of the study is that it examines these issues in a predominantly male sample, a group traditionally underrepresented in MS research. METHODS Participants First, we drew potential participants from the VA MS National Data Repository, a database containing information on all veterans receiving MS-related health care services within VHA from 1998 to 2006. The repository is updated periodically, but at the time of the data extraction for this study, it contained 34,539 unique cases. To reduce inaccurate ascertainment of MS due to coding errors, candidates were included in a final target population only if they met one or more of the following 4 criteria: (1) they had an inpatient hospitalization for MS (hospitalization was coded with the ICD-9 diagnostic code 340 for MS), (2) they had received a disease modifying agent (interferon 1a, interferon 1b, or glatiramer acetate) used only to treat MS, (3) they were VA service connected for MS (the diagnosis had been confirmed through a medical review process for purposes of VA disability pension), or (4) they had at least one outpatient encounter or inpatient stay for which the primary ICD diagnosis code was 340 during each year in which they received some VA medical service. The search algorithm for identifying a target population within the VA MS National Data Repository has been validated by chart review in previous work and has been shown to be an effective means of eliminating people who do not have MS.24 For the current study, a
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fifth criterion was added. Participants were required to have received some VHA services during the period 2004 through 2006, because only people receiving services during this time frame were eligible to receive the survey instrument described below. A total of 14,747 veterans were included in the target population. Procedures This is an observational, cross-sectional, cohort study that linked data from the VA MS National Data Repository and the VA Office of Quality and Performance Survey of the Healthcare Experiences of Patients. SHEP is a survey conducted by VHA to support national quality improvement efforts and evaluate patient satisfaction with VHA health care services across the United States.25 It is sent to approximately 50,000 people each month who (1) received provider-based outpatient or inpatient care in VHA and (2) had not been sampled in the previous 12 months. Survey methodology has been described elsewhere in greater detail.25 Information from years 2004 through 2006 was used for this study. In instances where more than 1 survey was completed, the most recent SHEP data were included in the study. All data analysis procedures were approved by the local human subjects review committee. Nationally, response rates for SHEP in 2006 were approximately 43% and 58% for inpatient and outpatient surveys respectively.26 Similarly, among people with MS in the target population, at least 1 survey was returned by 2655 of 4929 enrollees who were mailed surveys (53.9% response rate). Participants who returned the SHEP survey with a completed AUDIT-C were eligible for the present study. See figure 1 for a patient flow diagram and reasons for non-participation. Measures Alcohol misuse. We measured alcohol misuse using the AUDIT-C. The 3-item AUDIT-C was included on the SHEP survey to assess alcohol consumption patterns in the past year and has been validated as a brief alcohol screening test in VHA and non-VHA medical samples.27-29 Scores range from 0 to 12, with a cutoff of 4 or more and 3 or more identifying alcohol misuse in men and women, respectively. Higher AUDIT-C scores indicate greater alcohol misuse severity,30 and AUDIT-C scores of 8 to 12 have been associated with a higher
Fig 1. Diagram: Flow of participants and reasons for nonparticipation.
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risk for subsequent hospitalizations for liver disease, GI bleeding and pancreatitis,31 mortality,32 and alcohol dependence.29 To facilitate interpretation of AUDIT-C scores, respondents were grouped into 4 categories: nondrinkers (AUDIT-C⫽0), low-level drinkers who screen negative for alcohol misuse (AUDIT-C⫽1–3 men; 1–2 women), mild-moderate alcohol misuse (AUDIT-C⫽4 –7 men; 3–7 women), and severe alcohol misuse (AUDIT-C⫽8-12).31 Demographic information. Self-reported race, education level, marital status, and employment were all obtained from SHEP. Sex and age in years at the time of the survey were obtained from the VA MS National Data Repository. Physical health. Physical health was measured using the PCS of the veteran version of the Medical Outcomes Study SF-12.33-35 Participants were asked to respond to 12 questions addressing 8 areas of health status, including items such as “In general would you say your health is . . .” with response options ranging from 1 (excellent) to 5 (poor) and “During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health: Accomplished less than you would like?” with response options ranging from 1 (all of the time) to 5 (none of the time). Items were summed and in some cases reversescored to produce subscales that were then transformed to normal scores. A final PCS score was calculated as a weighted sum of subscales according to standard scoring criteria. The final score had a potential range of 1 to 100 with higher values reflecting better physical health functioning. The SF-12 is an abbreviated version of the Medical Outcomes Study 36-Item Short Form Health Survey, which is widely used and has been validated for use with people with MS.36-38 Mental health. Mental health was measured using the MCS of the veteran version of the Medical Outcomes Study SF-12.33-35 Participants were asked to respond to 12 questions addressing 8 areas of health status, including items such as “How much of the time during the past 4 weeks have you felt calm and peaceful?” and “How much of the time during the past 4 weeks have you felt downhearted and depressed?” with response options ranging from 1 (all of the time) to 5 (none of the time). Items were summed and in some cases reversescored to produce subscales that were then transformed to normal scores. A final MCS score was calculated as a weighted sum of subscales according to standard scoring criteria. The final score had a potential range of 1 to 100 with higher values reflecting better mental health functioning. Depression. Participants were asked whether or not in the past year they had 2 or more weeks in which they felt sad, blue or depressed, or lost interest or pleasure in things that they usually cared about or enjoyed. Alcohol advice. Participants were asked “In the past 12 months has a VA doctor or other VA health care provider advised you about your drinking (to drink less or not to drink alcohol)?” Data Analysis Plan We first examined the dataset to determine the extent to which the final study sample was representative of the larger population of veterans with MS using age and sex variables available on all persons in the repository. Selection bias (whether a candidate was or was not sent a survey) and response bias (whether a candidate did or did not return a survey) were examined for these variables. We then examined the consistency of veteran characteristics over the 3 years (2004 – 2006) of survey data used in this study. The prevalence of alcohol misuse, as well as the receipt of alcohol-related advice was estimated using simple proportions Arch Phys Med Rehabil Vol 90, May 2009
and 95% CIs. Alcohol misuse was further characterized using risk zones previously established for the AUDIT-C. Chi-square tests were used to test for potential sex differences in alcohol misuse within risk zones and logistic regression was used to further test for potential sex differences in the overall prevalence of alcohol misuse after adjustment for age category. Logistic regression was used to identify correlates of alcohol misuse. First, a series of individual univariate logistic regression analyses was conducted to examine the association between alcohol misuse and each potential demographic correlate (age, sex, race, education level, marital status, employment), and health status correlate (depression, physical health, mental health). All variables that showed a relationship (defined as P⬍.10) at a univariate level were then included simultaneously in a final multivariate logistic regression model using robust SE estimates. We also used logistic regression to examine correlates of receipt of alcohol advice using an identical sequence of univariate analyses followed by the creation of a final multivariate model. In this second instance, the sample was limited to people who endorsed alcohol misuse as defined by an AUDIT-C score 4 or greater (ⱖ 3 for women). The fit of multivariate logistic regression models was assessed using the Hosmer-Lemeshow goodness-of-fit statistic. All analyses were performed using Stata version 9.2.a RESULTS Participant Characteristics Table 1 presents demographic and health characteristics of the study sample. Of eligible patients, 84.3% were men and 85.6% identified themselves as white. Approximately 61.2%
Table 1: Patient Characteristics Patient Characteristics
Sex Female Male Age ⬍50 50–59 ⱖ60 Race White Nonwhite Data missing Marital status Married Not married Data missing Education High school or less Some college College or beyond Data missing Employment Employed Not employed Data missing Depressed in last 12 months Yes No Data missing
N⫽2473
%
388 2085
15.7 84.3
607 979 887
24.6 39.6 35.8
2117 331 25
85.6 13.4 1.0
1513 905 55
61.2 36.6 2.2
824 906 706 37
33.3 36.6 28.6 1.5
231 1932 310
9.4 78.1 12.5
1116 1260 97
45.1 51.0 3.9
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were married, 78.1% were unemployed, and 65.2% reported more than high school education. The mean age ⫾ SD of the sample was 56.7⫾11.2, but men (58.1⫾10.8) were significantly older than women (49.1⫾10.2; t2471,15.2; P⬍.001). The mean mental health functioning of this sample (n⫽2434; 45.2⫾12.7) was within 1 SD of the MCS mean found in general population samples, whereas the mean physical functioning (n⫽2425; 26.3⫾10.1) was more than 2 SDs below the PCS mean found in general population samples.39 Comparability of the Study Sample Selection bias. We conducted selection bias analyses to determine if people who were mailed the SHEP survey were representative of the larger MS target population with respect to sex and age. There were no significant differences by sex among those who did and did not receive a survey and the difference in age, though statistically significant, was less than a year and is not considered clinically meaningful. Response bias. Similarly, to determine if people who returned the SHEP survey differed from those who did not, we also compared these 2 groups on sex and age. There was no significant difference in response to the SHEP survey by sex, but veterans who returned the surveys were on average older than those who did not (mean ⫾ SD, 56.8⫾11.2 vs 53.0⫾12.0, respectively; t4927,11.6; P⬍.001). Comparability of the Study Sample Across Survey Years To determine the stability of veteran characteristics across the years of the survey, we also compared the demographic and clinical characteristics of the veterans who responded to the SHEP survey. There were no differences in veteran characteristics by age, marital status (married vs not married), race, employment (employed vs not employed), or depression. However, the proportions of the sample that were women (18.3% vs 16.6% vs 12.5%, respectively; 22,2473⫽10.9, P⬍.01) varied by the year of the survey. Physical health (mean ⫾ SD, 25.6⫾10.4 vs 26.9⫾10.4 vs 26.3⫾9.4, respectively; F2,2424,3.1; P⬍.05) showed a modest but significant difference, and mental health (mean ⫾ SD, 47.0⫾12.6 vs 44.6⫾12.7 vs 44.1⫾12.6, respectively; F2,2433,11.7; P⬍.001) declined somewhat from 2004 through 2005. Prevalence of Alcohol Misuse Among survey respondents with MS, 50.9% reported no alcohol use in the past 12 months and 35.2% reported low-level drinking. Overall, the prevalence of alcohol misuse for the sample was 13.9% (CI, 12.5–15.2), with 11.9% (CI, 10.6 – 13.2) and 2.0% (CI, 1.4 –2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. No differences between sexes were noted within risk zones (mild/moderate; men 11.8% [CI, 10.4 –13.1] vs women 12.6% [CI, 9.3–15.9], 21,2473⫽0.24, P⬎.10; severe; men 2.0%
Table 2: Age-Specific Estimates of Prevalence of Alcohol Misuse by Sex
Age ⬍50 50–59 ⱖ60
n
Men Prevalence of Alcohol Misuse
n
Women Prevalence of Alcohol Misuse
391 860 834
17.4 (13.6–21.2) 15.6 (13.2–18.0) 10.2 (8.1–12.2)
216 119 53
17.6 (12.5–22.7) 13.4 (7.2–19.7) 3.8 (⫺1.5 to 9.1)
NOTE. Values are % (95% CI) or as otherwise indicated.
Table 3: Summary of Multivariate Logistic Regression Analysis for Demographic and Health Status Variables Associated with Alcohol Misuse (nⴝ2103) Variable
Alcohol Misuse
Demographic ⬍50 years old* 50–59 years old* Employment† Health status Better physical health (PCS)
1.66 (1.17–2.37)‡ 1.64 (1.19–2.27)§ 1.54 (1.06–2.24)‡ 1.02 (1.01–1.04)§
NOTE. Values are AOR (95% CI). *Referent is age category representing ages ⱖ60. † Referent is not employed. ‡ P⬍.05 from the Wald Statistic. § P⬍.01 from the Wald Statistic.
[CI, 1.4 –2.6] vs women 1.8% [CI, 0.5–3.1], 21,2473⫽0.07, P⬎.10). Table 2 shows age-specific prevalence of alcohol misuse and 95% confidence intervals by sex. After adjustment for age category, no difference was found in the odds of alcohol misuse for men and women (AOR⫽1.15; CI, 0.83– 1.59). To further examine for a potential sex difference, the Likelihood Ratio test was used to test for an association between alcohol misuse and a sex by age category interaction. No evidence for an interaction between sex and age category was found. Correlates of Alcohol Misuse Univariate logistic regression was used to identify individual correlates of alcohol misuse. Correlates identified in the univariate logistic regression model were then simultaneously entered in a multivariate logistic regression model to examine the association of identified correlates with the prevalence of alcohol misuse. As shown in table 3, the risk of alcohol misuse was higher among veterans younger than 60 (⬍50; AOR⫽ 1.66; CI, 1.17–2.37 and 50 –59; AOR⫽1.64; CI, 1.19 –2.27), those employed (AOR⫽1.54; CI, 1.06 –2.24) and those in better physical health (AOR⫽1.02; CI, 1.01–1.04). No difference in risk of alcohol misuse was noted between the younger than 60 age groups (⬍50 vs 50 –59; AOR⫽0.99; CI, 0.74 – 1.32). Marital status was identified during univariate analyses, but was not significantly associated with alcohol misuse in the multivariate model. The Hosmer-Lemeshow goodness-of-fit statistic for this multivariate model was not significant, suggesting little departure from perfect fit (28 ⫽1.62; P⬎.99). Prevalence of Alcohol-Related Advice Among survey respondents with MS who screened positive for alcohol misuse, 26.2% (CI, 21.5–30.9) reported receiving advice from a VA health care provider to drink less or not drink at all. Figure 2 shows the unadjusted rates of alcohol-related advice for veterans with mild/moderate (21.9%; CI, 17.1–26.7) and severe alcohol misuse (52.1%; CI, 37.4 – 66.7). Correlates of Receipt of Alcohol-Related Advice The same sequence of univariate and multivariate logistic regression models was used in analyses to identify correlates associated with subjects’ reports that they had received alcohol-related advice in the past year. As shown in table 4, severe alcohol misuse (defined as an AUDIT-C score ⱖ8) was associated with a higher likelihood of receiving advice about drinking (AOR⫽3.65; CI, 1.85–7.17), and better mental health was associated with a lower likelihood of receiving advice about drinking (AOR⫽0.97; CI, 0.94 –1.00). Although age, educaArch Phys Med Rehabil Vol 90, May 2009
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ALCOHOL MISUSE, Turner
Fig 2. Rate of provider advice by mild/moderate and severe alcohol misuse zones.
tion, race, and depression were included in the multivariate regression model as a result of associations identified in univariate analyses, none of these variables was significantly associated with advice about drinking in the multivariate logistic regression model. According to the Hosmer-Lemeshow goodness-of-fit test, the fit for this multivariate model was good (26⫽2.49, P⬎.87). DISCUSSION The overall prevalence of alcohol misuse among people with MS in this study was 13.9%, a rate strikingly similar to the 14% found in previous studies using community-based and clinicbased samples that were predominantly women,8,10 but somewhat lower than the rate of 22% reported in a general outpatient veteran sample that was surveyed using a similar SHEP methodology.40 However, precise comparisons between veteran samples are difficult because of the increased risk of alcohol misuse among younger age groups and men, and the representation of these characteristics in different samples. It is important to note that this non-MS veteran sample is somewhat limited because women veterans represent a much smaller proportion of this comparison sample. Interestingly, the rates of alcohol misuse did not differ by sex in the present study, a finding that departs substantially from other general population results in which the prevalence is typically higher among men.41 It is unlikely that the mean age difference between men and women in this sample accounted for this finding because it remained in models adjusted for age and a sex by age interaction. Historically, women with hazardous alcohol use patterns have been less likely to be identified or to receive feedback in general medical settings.28,42,43 Current data underscore the need to avoid this oversight. Our findings regarding other correlates of alcohol misuse were more consistent with those reported in the alcohol misuse and MS literatures. Veterans with MS were more likely to Arch Phys Med Rehabil Vol 90, May 2009
screen positive for alcohol misuse if they were younger, employed, and in better physical health. All 3 of these findings are consistent with the only previous study of alcohol use in a broad survey of people with MS,8 even though the determination of physical health in the latter instance was more focused on disease-specific disability. Results suggest that prevention, screening, and intervention efforts might best be emphasized earlier in the course of MS (⬍60y) during the time risk for misuse is highest. Among veterans who screened positive for alcohol misuse, a relatively small minority, 26.2%, reported receiving advice to reduce or refrain from drinking from their VA health care provider. Although this rate is similar to those found in larger VA and non-VA primary care samples,23,43 it nonetheless reflects missed opportunities for intervention. Such missed opportunities are noteworthy because trials of alcohol screening and brief intervention in primary care settings have shown reductions in alcohol use in nondependent drinkers.19 Another compelling argument for the use of brief interventions among people with MS is the high percentage with potential alcohol problems who report interest in learning to reduce or stop drinking.8 Though the preferred model for treatment of chronic and severe alcohol use disorders includes more intensive treatment provided in specialty care settings, research and practice guidelines support the use of brief interventions in settings where medical care is delivered routinely.44 Many resources are available to assist clinicians less accustomed to assessing alcohol misuse. One frequently noted example is the National Institute on Alcohol Abuse and Alcoholism’s clinician guide Helping patients who drink too much.2 Providers are also uniquely positioned to identify and manage patients with alcohol misuse. Advantages include the opportunity to integrate alcohol and other health screening procedures, to initiate timely interventions, to link brief alcohol interventions to health-related concerns, and to closely monitor the drinking patterns of at risk patients during follow-up visits.2 It is also important to note that patients may perceive less discomfort45 and more privacy during alcohol-related discussions and interventions in medical settings, and also appreciate the interaction and view it as a component of high quality care.46 Brief intervention may also be particularly relevant for a patient population for whom physical and cognitive disability may serve as a barrier to receiving care. Distance to a medical center and the complexities associated with travel often represent additional burdens for people with MS that brief interventions might help to avoid. People who screened positive for more serious alcohol misuse (AUDIT-C scores ⱖ8) were more likely to report receiving advice from a provider, a result that is again consistent with previous literature in primary care.23 However, almost half (48%) of patients with scores falling within the severe misuse range reported that they did not receive any alcohol-related
Table 4: Summary of Multivariate Logistic Regression Analysis for Demographic and Health Status Variables Associated With Reporting Advice to Reduce or Abstain From Drinking (nⴝ322) Variable
Advice to Reduce or Abstain
Severe alcohol misuse (AUDIT-C Score ⱖ8)* Better mental health (MCS)
3.65 (1.85–7.17)‡ 0.97 (0.94–1.00)†
NOTE. Values are AOR (95% CI). *Referent is AUDIT-C Score⫽4 –7. † Pⱕ.05 from the Wald Statistic. ‡ P⬍.001 from the Wald Statistic.
ALCOHOL MISUSE, Turner
advice. Despite growing evidence regarding the efficacy of brief alcohol interventions in primary care settings, and greater advocacy to deliver alcohol counseling to patients with hazardous drinking patterns, most patients who screen positive for alcohol misuse do not report receiving alcohol-related advice. A number of barriers such as inadequate training in the identification and treatment of hazardous drinking,47 provider discomfort with alcohol-related discussions,48,49 or time constraints associated with growing demands on primary care visits50 may have contributed to these missed intervention opportunities. Among people with MS who also screened positive for alcohol misuse, the odds of receiving alcohol-related advice were also lower for those who endorsed better mental health. A similar finding has been found in other studies identifying patient correlates of brief intervention23,51 and may reflect the willingness of providers to intervene when the potential consequences of excessive alcohol use are more salient. Interestingly, poor physical functioning—a factor typically found associated with a greater likelihood of counseling in the alcohol misuse literature—was not associated with receipt of advice about alcohol use in this sample. However, it is possible that the relatively poor physical health of this patient sample and limited statistical power explain this discrepant result. Study Limitations This study has several limitations. Study data were obtained from 2 large national VA databases. Overall, the survey response rate was 54% and respondents were a little older than nonrespondents, although other differences on nonassessed demographic or clinical factors may have confounded our findings. Additionally, though no meaningful sex or age differences were noted in those who were sent a survey, it is possible that other important differences were not detected. The study may have been underpowered to detect sex differences in the receipt of alcohol-related advice among those with severe misuse. AUDIT-C and alcohol-related advice data were obtained from mailed surveys and thus may be subject to the biases of the self-report method. Without a criterion standard for assessing alcohol consumption, it is not clear if these biases have under- or over-estimated the true patterns of alcohol use. However, there is evidence to suggest that self-report is considered a reliable and valid approach for measurement of alcohol consumption.52,53 Poor recall, social desirability, or patient misunderstanding of alcohol-related discussions may underestimate the true rate of advice patients received in this study. Results also may not generalize to persons with MS who are not veterans or who do not receive care in the VA health care system. Additional research would be helpful to elucidate the natural history of alcohol misuse over time, as well as the longitudinal impact of misuse on physical functioning and mental health controlling for initial status. CONCLUSIONS Alcohol misuse represents an important health risk among veterans with MS. Risk for misuse is most prominent earlier in the disease course when people are younger and in better physical health. Unlike non-MS samples, prevalence rates for men and women are highly similar. Fewer than one third of persons with alcohol misuse reported they had received advice from a medical provider in the past year to reduce or refrain from drinking. Advice was more common when misuse was more severe and people reported poorer mental health. Brief screening and intervention in the form of advice or referral can be conducted in as little as 5 minutes in the course of a routine medical visit.
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References 1. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64:830-42. 2. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Washington (DC): US Department of Health and Human Services; 2005. 3. National Institute on Alcohol Abuse and Alcoholism. State of the science report on the effects of moderate drinking. US Department of Health and Human Services, 2003. Available at: http:// pubs.niaaa.nih.gov/publications/ModerateDrinking-03.htm. Accessed August 20, 2008. 4. Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med 1997;337:1705-14. 5. Rehm J, Greenfield TK, Rogers JD. Average volume of alcohol consumption, patterns of drinking, and all-cause mortality: results from the US National Alcohol Survey. Am J Epidemiol 2001;153: 64-71. 6. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-45. 7. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999;56:617-26. 8. Bombardier CH, Blake KD, Ehde DM, Gibbons LE, Moore D, Kraft GH. Alcohol and drug abuse among persons with multiple sclerosis. Mult Scler 2004;10:35-40. 9. Feinstein A. An examination of suicidal intent in patients with multiple sclerosis. Neurology 2002;59:674-8. 10. Quesnel S, Feinstein A. Multiple sclerosis and alcohol: a study of problem drinking. Mult Scler 2004;10:197-201. 11. Mangold S, Laubli T, Krueger H. Effects of a low alcohol dose on static balance, fine motor activity, and mental performance. Neurotoxicol Teratol 1996;18:547-54. 12. Wang MQ, Taylor-Nicholson ME, Airhihenbuwa CO, Mahoney BS, Fitzhugh EC, Christina R. Psychomotor and visual performance under the time-course effect of alcohol. Percept Mot Skills 1992;75(3 Pt 2):1095-106. 13. Schweizer TA, Vogel-Sprott M, Danckert J, Roy EA, Skakum A, Broderick CE. Neuropsychological profile of acute alcohol intoxication during ascending and descending blood alcohol concentrations. Neuropsychopharmacology 2006;31:1301-9. 14. Vik PW, Cellucci T, Jarchow A, Hedt J. Cognitive impairment in substance abuse. Psychiatr Clin North Am 2004;27:97-109, ix. 15. Davies SJ, Pandit SA, Feeney A, et al. Is there cognitive impairment in clinically ‘healthy’ abstinent alcohol dependence? Alcohol Alcohol 2005;40:498-503. 16. Parsons OA, Nixon SJ. Cognitive functioning in sober social drinkers: a review of the research since 1986. J Stud Alcohol 1998;59:180-90. 17. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication non-adherence. Ann Intern Med 2008;149:795-804. 18. Patten SB, Metz LM, Reimer MA. Biopsychosocial correlates of lifetime major depression in a multiple sclerosis population. Mult Scler 2000;6:115-20. 19. Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007 Apr 18;(2):CD004148. 20. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36-43. Arch Phys Med Rehabil Vol 90, May 2009
848
ALCOHOL MISUSE, Turner
21. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997;12:274-83. 22. US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med 2004;140:554-6. 23. Burman ML, Kivlahan D, Buchbinder M, et al. Alcohol-related advice for Veterans Affairs primary care patients: who gets it? Who gives it? J Stud Alcohol 2004;65:621-30. 24. Culpepper W, Ehrmantrout M, Wallin M, Flannery K, Bradham D. Identification of the VHA MS Surveillance Registry. The problem of case finding from administrative databases. J Rehabil Res Dev 2006;43:17-24. 25. Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med 2006;(21 Suppl 3):S26-32. 26. Wright SM, Elter JR. SHEP: Overview and transition to CAHPS. 2008; Washington (DC): Department of Veterans Affairs. Available at: http://vaww.oqp.med.va.gov/oqp_services/veterans_satisfaction/ uploads/SHEP_Quality_Kickoff%20fnl2.ppt. Accessed September 29, 2008. 27. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res 2007;31:1208-17. 28. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcoholscreening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 2003;163:821-9. 29. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158:1789-95. 30. Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res 2004;28:448-55. 31. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcohol Clin Exp Res 2007;31:443-51. 32. Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001; 62:826-33. 33. Jones D, Kazis L, Lee A, et al. Health status assessments using the Veterans SF-12 and SF-36: methods for evaluating outcomes in the Veterans Health Administration. J Ambul Care Manage 2001; 24:68-86. 34. Kazis LE, Ren XS, Lee A, et al. Health status in VA patients: results from the Veterans Health Study. Am J Med Qual 1999; 14:28-38. 35. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33. 36. Hobart JC, Freeman JA, Lamping D, Fitzpatrick R, Thompson AJ. The SF-36 in multiple sclerosis: why basic assumptions must be tested. J Neurol Neurosurg Psychiatry 2001;71:363-70. 37. Freeman J, Hobart JC, Langdon DW, Thompson AJ. Clinical appropriateness: a key factor in outcome measure selection: the 36
Arch Phys Med Rehabil Vol 90, May 2009
38. 39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
item short form health survey in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000;68:150-6. Ware JE, Kosinski M, Dewey JE. How to score version 2 of the SF-36 Health Survey. Lincoln: QualityMetric Inc; 2000. Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. How to score version 2 of the SF-12 Health Survey. Lincoln: QualityMetric Inc; 2002. Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care 2006;12:597-606. Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res 2005;29:844-54. Buchsbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ. Physician detection of drinking problems in patients attending a general medicine practice. J Gen Intern Med 1992;7:517-21. Volk RJ, Steinbauer JR, Cantor SB. Patient factors influencing variation in the use of preventive interventions for alcohol abuse by primary care physicians. J Stud Alcohol 1996;57:203-9. Maciosek MV, Edwards NM, Coffield AB, et al. Priorities among effective clinical preventive services: methods. Am J Prev Med 2006;31:90-6. Curry SJ, Ludman E, Grothaus L, Donovan D, Kim E, Fishman P. At-risk drinking among patients making routine primary care visits. Prev Med 2000;31:595-602. Saitz R, Horton NJ, Cheng DM, Samet JH. Alcohol counseling reflects higher quality of primary care. J Gen Intern Med 2008; 23:1482-6. Kaner EF, Wutzke S, Saunders JB, Powell A, Morawski J, Bouix JC. Impact of alcohol education and training on general practitioners’ diagnostic and management skills: findings from a World Health Organization collaborative study. J Stud Alcohol 2001;62: 621-7. Bradley KA, Epler AJ, Bush KR, et al. Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking. J Gen Intern Med 2002; 17:315-26. McCormick KA, Cochran NE, Back AL, Merrill JO, Williams EC, Bradley KA. How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med 2006;21: 966-72. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41. D’Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care 2005;43:229-36. Babor TF, Steinberg K, Anton R, Del Boca F. Talk is cheap: measuring drinking outcomes in clinical trials. J Stud Alcohol 2000;61:55-63. Del Boca FK, Noll JA. Truth or consequences: the validity of self-report data in health services research on addictions. Addiction 2000;95(Suppl 3):S347-60.
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