Training hepatologists in alcohol use disorder management: a pilot study

Abstract

Background and Aims

Alcohol use disorder (AUD) and alcohol associated liver disease (ALD) commonly co-occur, and integrated approaches to treatment are associated with better outcomes. This study aimed to develop an online module, the Program for Advanced Training of Hepatologists in Alcohol Use Disorder Management (PRATHAM), to enroll and train hepatologists, and to evaluate changes in participants’ knowledge, attitudes, practices, and self-perceived competence pre- and post-training.

Methods

This included identification of specific needs, establishing learning objectives, designing a curriculum, and developing didactic presentations for hepatologists. Interested participants were enrolled in the online module and were asked to submit pre-tests, clinical cases, and a post-test, which included an evaluation of knowledge, attitudes, practice, and self-perceived competence. Descriptive statistics and the Wilcoxon signed-rank test were used to analyze the data. An intention-to-treat analysis was used to address missing data.

Results

An 8-week curriculum was developed for 18 hepatologists from five different countries. Of these, 17 completed the pre-test, and 11 filled out the post-test proforma. Eleven complex clinical cases were discussed. There was a significant improvement in the participants’ knowledge, practice, and self-perceived competence pre- and post-training. However, no significant change in attitudes was noted.

Conclusions

This study underscores the importance of tailored educational interventions in medical specialties such as hepatology, where practitioners frequently encounter patients with AUD. The significant improvements in practice, self-efficacy, and knowledge highlight the potential of targeted training programs to enhance patient care. Future studies could engage a more diverse group of hepatologists and evaluate patient outcomes.

Introduction

Alcohol consumption accounted for 2.6 million deaths, representing 4.7% of all fatalities globally in 2019, making it a significant public health problem (World Health Organization 2024). Alcohol associated liver disease (ALD) is one of the major causes of alcohol attributable deaths and disability. The prevalence of ALD is 4.6% globally (Niu et al. 2023) and 4.81% in the Asian region (Xu et al. 2022). It was also the cause of cirrhosis in 12.6% and hepatocellular carcinoma in 8.30% of cases in Asia (Xu et al. 2022). India contributes 18.3% of global liver disease-related deaths (Mokdad et al. 2014), with alcohol use emerging as an important cause of chronic liver disease (Mondal et al. 2022). Studies have shown that the amount and duration of alcohol use are strongly related to the development and progression of ALD (Singal and Mathurin 2021).

The escalating prevalence of alcohol use disorder (AUD) and its direct impact on liver health necessitate a specialized approach toward its management. An integrated or multidisciplinary approach to managing the dual pathology of AUD and liver disease has been shown to be effective (Addolorato et al. 2013, Mellinger et al. 2021, Fomin et al. 2023). Several guidelines from scientific organizations have recommended integrated care in the management of patients with ALD (European Association for the Study of the Liver 2012, Singal et al. 2018).

However, limitations such as a lack of trained professionals and funding, among others, are barriers to the integration of care for AUD in physical health care settings (Deenik et al. 2019, Osborne et al. 2021). The rates of treatment of AUD in cases with ALD remain low. From the patient’s perspective, barriers include lack of awareness of treatment options, low felt need for treatment, affordability and logistic concerns, and stigma (Mellinger et al. 2018, Sedarous and Flemming 2023). From a clinician’s perspective, the barriers reported are a lack of clarity on roles, decreased confidence in prescribing medications for AUD to patients with ALD, stigma and negative perceptions about patients with AUD, lack of time to provide behavioral interventions, and lack of integration and liaison between specialist services (Watkins et al. 2017, Johnson et al. 2022). A report from the USA highlighted that only 25% of hepatologists felt confident prescribing medications for AUD while managing ALD patients due to a lack of training in the field (Cotter et al. 2020).

One solution to the problems highlighted above is to conduct training programs for practicing medical specialists who frequently encounter patients with ALD. This is supported by several reports that highlight the need for additional training for physicians who are involved in managing ALD patients (Das and Roberts 2016, Cotter et al. 2020, Johnson et al. 2022). The Extension for Community Healthcare Outcomes (ECHO) program is one such model that has been used extensively for training healthcare providers in the management of complex mental health conditions (Bairy et al. 2021) and addiction (Mahadevan et al. 2020). Project ECHO is an innovative telementoring model that uses real-time video conferencing to connect frontline health providers (“spokes”) with multidisciplinary teams of specialists (“hubs”). Through case-based learning and brief didactics, the program creates an "all-teach, all-learn" community that empowers clinicians to manage complex conditions and deliver expert-level care directly within their own communities (Arora et al. 2014).

The current study was undertaken with the hypothesis that a structured educational intervention delivered by addiction psychiatrists will aid in enhancing attitude, practice, self-perceived competence, and knowledge of hepatologists in managing AUD in ALD patients. With the above considerations in mind, this article provides an overview of the development, implementation, and outcomes of a program to train hepatologists across five countries in the management of patients affected by AUD and ALD.

Materials and methods

Module development

The first step was the development of the online module “Program for Advanced Training of Hepatologists in Alcohol Use Disorder Management (PRATHAM).” The development stage consisted of:

1. Identifying the needs of the hepatologists in managing patients with AUD and ALD,

2. Transcribing the needs into clear learning objectives,

3. Designing a curriculum that aligns with the learning objectives, and

4. Developing didactic presentations for the topics included in the curriculum.

The systematic organization of tasks into steps enabled a structured approach to curriculum development, ensuring alignment with the identified learning objectives. A meticulously crafted curriculum spanning over eight weeks was thoroughly reviewed by the study team at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru. The final curriculum (Table 1), with a focus on didactic presentation and comprehensive discussion of ALD patients managed by the participants in their respective practices, was then distributed to participants.

Table 1.

Details of the curriculum developed for PRATHAM.

Session number	Case discussion	Didactic
1	Introductory session
2	2 cases	Screening for AUD–Patient barriers in reporting alcohol use and accepting treatment
3	2 cases	Alcohol Use Disorder: DSM 5 Criteria
4	2 cases	Assessment and Management of Alcohol Withdrawal
5	2 cases	Brief interventions and counseling techniques
6	2 cases	FDA-approved medications for AUD: Disulfiram, Acamprosate, and Naltrexone
7	2 cases	Non-FDA approved medications for AUD: Baclofen, Gabapentin, Topiramate
8	2 cases	Pharmacotherapy of concomitant comorbidities

The didactic sessions were structured to impart a comprehensive understanding of AUD, encompassing its pathophysiology, diagnosis, management strategies, and the psychosocial aspects influencing patient outcomes. Further, engaging participants in case discussions enabled exploration of practical approaches to managing AUD in clinical practice and the integration of theoretical knowledge with real-life clinical scenarios. We ensured that patient names were not disclosed or recorded on any platform to protect patient confidentiality.

Program implementation

Twenty-eight practicing hepatologists from the USA, India, Chile, France, and Spain who were part of the ALD Special Interest Group of the American Association for the Study of Liver Diseases were approached to gauge their interest in AUD management training provided by addiction specialists. Of these, 18 showed interest in participating in this training course and were included in this study. The faculty consisted of six addiction specialists from NIMHANS.

The program included a synchronous component of weekly online sessions conducted via the ECHO platform, with each participant’s attendance recorded and stored on the platform. With a total course duration of 8 weeks, each live tele-ECHO session enabled direct interaction among participants and the hub team, with both theoretical and practical discussions conducted through didactic lectures and case discussions. This allowed the team to blend the theoretical aspects of AUD with the practical application of these concepts in real-life scenarios. The duration of the sessions was 90 min, with 30 min for didactic sessions and 60 min for case discussions and a Q&A session. All 18 hepatologists were asked to submit a complex case they had seen in their clinical practice for presentation and discussion during the live tele-ECHO session.

At the end of every session, an online link was sent to participants to request anonymous feedback on the session. This allowed us to continually improve the session’s conduct throughout the course. At the end of 8 weeks, feedback was again sought from the participants completing the course. Such insights were useful in encouraging the hub team and enabling us to improve the quality of the content and delivery methods.

The program also had an asynchronous component, with self-learning materials shared by email every week, which participants could access easily, and doubts related to the same were cleared during the sessions. Given the trained nature of hepatologists, the short duration of the program, and the time constraints faced by participants, the Moodle-based asynchronous Learning Management System (LMS) platform, which has been used in other ECHO programs, was not used.

Program evaluation

A questionnaire was developed and reviewed by the team to gather data on participants’ attitudes, practices, self-perceived competence, and knowledge. Data collection throughout the course was comprehensive, encompassing pre- and post-test questionnaires to assess attitudes, practice, self-perceived competence, and knowledge among participants. Pre- and post-tests included scales for attitude (regard for medical conditions, attribution of health professionals, emotional responses toward health professionals), practice, and self-perceived competence. Two sets of questions, rated by reviewers as of similar difficulty, were used to assess knowledge pre- and post-training to avoid learning biases.

The data were collected and stored in a HIPAA-compliant database, JotForm. Case submissions from each participant were also stored in the same database. The data from the pre- and post-tests were anonymized and analyzed to support further interpretation.

Statistical analysis

R version 4.0.5 was utilized to analyze and visualize the data (R: The R Project for Statistical Computing n.d.). Descriptive statistics were used to describe the demographics and profile of cases discussed. Wilcoxon sign rank test (for paired data), a non-parametric test, was used for statistical analysis (Wilcoxon Signed Rank Test for Paired Comparisons of Clustered Data 2006). Missing data were dealt with using intention-to-treat analysis (Intention-to-Treat Principle 2001). The study was reviewed and approved by the IRB at the NIMHANS.

Results

Study population

A total of 18 hepatologists from five countries were enrolled in the study. Of these, 17 participants completed the pre-test questionnaire, and 11 participants completed the post-test questionnaire. Of the six participants who did not complete the post-test, two did not attend any sessions, while the remaining four attended between three and four sessions. The participants’ details are presented in Table 2.

Table 2.

Demographic details of the participants (N = 18).

Variable	Number
Age band (in years)
31–40	8
41–50	6
51–60	4
Sex
Male	13
Female	5
Years of practice
1–5	2
6–10	4
10–20	9
>20	4
Highest degree
Gastroenterology	3
Hepatology	15

Clinical cases

A total of 11 ALD clinical cases (mean age 50 years, six males) were submitted by participants and discussed over eight weeks across different sessions. Of these, seven patients had cirrhosis (decompensated in five), three presented with severe alcohol-associated hepatitis and acute on chronic liver failure, and one patient had post-transplant allograft steatohepatitis. All had AUD, and four reported concomitant nicotine use disorder. A more detailed account of each case is provided in Supplementary Table S1.

Analysis of pre- and post-test data

Tables 3–7 describe data on attitude, practices, and self-perceived competence of hepatologists pre- and post-training. There was a significant improvement in self-perceived competence (W = 158, P = .002) (Fig. 1) and knowledge (W = 164.5, P < .001) (Fig. 2) regarding AUD management after completion of the module. There was also a trend toward enhancement in practice (W = 132, P = .070) on AUD (Fig. 3). However, there was no change in the attitude of participants (W = 119, P = .237), nor in attribution (W = 63.5, P = .161) and emotional responses of health professionals (W = 71.5, P = .302), data not shown.

Table 3.

Measuring attitude: Medical condition regard scale.

Item number	Scale item	Pre-test (median) (n = 17)	Post-test (median) (n = 17)
1	I prefer not to work with patients having AUD.	1	1
2	Patients with AUD make me feel uncomfortable.	2	1
3	I enjoy giving extra time to patients like this.	5	5
4	Working with patients like this is satisfying.	5	5
5	I feel especially compassionate toward patients like this.	5	5
6	Treating patients like this is a waste of medical dollars.	1	1

The answers are to be provided on a six-point Likert scale scored as follows: 1 = strongly disagree, 2 = disagree, 3 = not sure but probably disagree, 4 = not sure but probably agree, 5 = agree, and 6 = strongly agree.

Table 7.

Self-perceived competence in managing cases of AUD.

Item number	Scale item	Pre-test (median) (n = 17)	Post-test (median) (n = 17)
1	Discussing about alcohol use with patients.	4	4
2	Conducting an addiction-focused assessment.	3	3
3	Identifying alcohol withdrawal states.	3	3
4	Identifying neuropsychiatric complications of alcohol use.	3	3
5	Differentiating between alcohol use and alcohol use disorder (AUD)/dependence	3	4
6	Prescribing benzodiazepines for alcohol withdrawal states.	3	3
7	Prescribing long-term pharmacotherapy (Naltrexone, Acamprosate, Disulfiram, Others).	2	3
8	Conducting brief interventions for patients with AUD.	2	3
9	Using motivational interviewing for patients with AUD.	2	3
10	Discussing relapse prevention in patients with AUD.	2	3

1 = No skill, 2 = Slight skill, 3 = Average skill, 4 = Competent, 5 = Expert (Can train others).

Figure 1.

Statistically significant improvement in self-perceived competence in AUD management before (26.0 ± 6.0, mean ± SD) and after (35.3 ± 6.0, mean ± SD) the program (W = 158, P = .002), with the lowest possible score being 10 and the highest possible score being 50.

Figure 2.

A significant increase was noted in knowledge before (67.97 ± 14.63, mean ± SD) and after (89.90 ± 11.60, mean ± SD) the program (W = 164.5, P < .001). Scores were out of 100.

Figure 3.

A trend toward improvement in practices in AUD management before (55.0 ± 6.5, mean ± SD) and after (59.2 ± 7.0, mean ± SD) the program (W = 132, P = .070), the lowest possible score is 14, and the highest possible score is 70.

Table 4.

Measuring attitude: Attribution of health professionals.

Item number	Scale item	Pre-test (median) (n = 17)	Post-test (median) (n = 17)
1	Someone with an addiction is responsible for this.	2	2
2	Someone with an addiction is in control of this addiction.	1	2
3	Someone with an addiction can be treated successfully.	4	4
4	Addiction is a disease.	5	5
5	Addiction is the consequence of weakness.	1	1

The answers are to be provided on a five-point Likert scale scored as follows: 1 = totally disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree and 5 = totally agree.

Table 5.

Measuring attitude: emotional responses of health professionals.

Item number	Scale item	Pre-test (median) (n = 17)	Post-test (median) (n = 17)
1	I feel anger for people with an addiction.	2	2
2	I feel fear for people with an addiction.	3	2
3	I feel pity for people with an addiction.	3	4

The answers are to be provided on a five-point Likert scale scored as follows: 1 = never, 2 = rarely, 3 = sometimes, 4 = often and 5 = always.

Table 6.

Practices in AUD management.

Item number	Scale item	Pre-test (median) (n = 17)	Post-test (median) (n = 17)
1	I ask my patients whether they use alcohol.	5	5
2	I ask about the amount, duration of use, frequency and reason for using alcohol.	5	5
3	I ask about the knowledge of alcohol-related harm.	4	4
4	I assess the user’s willingness to quit alcohol.	4	5
5	I advise to quit (or reduce) alcohol.	5	5
6	I discuss the risks of alcohol use.	4	5
7	I highlight the benefits of quitting alcohol.	5	5
8	I counsel about the harmful effects of alcohol use.	5	5
9	I discuss about why quitting alcohol is relevant.	4	4
10	I order liver tests in cases of heavy alcohol use.	5	5
11	I assist by prescribing detoxification.	2	3
12	I assist by prescribing long-term medications for AUD.	2	3
13	I assist by identifying and handling triggers and high-risk situations that are associated with alcohol use.	2	3
14	I arrange follow-up and ask about alcohol use.	4	4

1 = Never, 2 = Less than half of the time, 3 = Half of the time, 4 = Usually, 5 = Always.

Qualitative feedback

At the end of every session, an online link was sent to participants to describe their experience. We received constructive feedback from the participants after completion of the 8-week module. It has been organized based on Moore’s Expanded Outcomes Framework for Assessing Learners and Evaluating Instructional Activities (Table 8).

Table 8.

Qualitative feedback aligned to Moore’s expanded CME evaluation format.

Expanded framework levels	Description
Level 1: Participation	Attendance, participant demographics, and the reach of the program. "It has been a great honor to participate in this inaugural AUD training program for hepatologists." "I would strongly recommend my colleagues to participate in future similar programs."
Level 2: Satisfaction	Learners’ perspectives regarding the quality, design, pacing, and delivery of the curriculum. General Praise & Organization: "Very well organized program... Will look forward more such opportunities and will spread the word to all my colleagues." "It was an excellent and well-designed curriculum." "It is a fantastic program and it is a great way to learn. The quality, experience and passion of the team for teaching is remarkable." "Excellent course, I would recommend it to every hepatologist!" Feedback on Pacing & Structure: "Great program, but many of the sessions were very packed." Suggestions for Future Program Design: "Should include more patients with alcoholic liver disease." "More practical focused case based sessions." "It may be helpful to invite case submissions before starting the program." "I would also recommend follow-up maintenance sessions for the current group of attendees..."
Level 3A: Declarative Knowledge Level 3B: Procedural Knowledge	Acquisition of knowledge, skills, or attitudes "Learnt so much in last 8 weeks through the didactics and case presentations and lively discussions." "Some of the later cases presented during the program were challenging and very educational to discuss." "...the motivation that you left behind is great and the learning will surely continue..."
Level 4: Competence	Learner’s ability to demonstrate the technical skills or strategies in an educational setting Desire for Competence-Building/Demonstration: "I would like more examples of applying different techniques through role playing or skits so we can see how these skills are used in action." Gaps in Subjective Competence/Confidence: "I think that for those of us who are not used to doing brief interventions and motivational interviewing, the time was insufficient. I would have liked to participate with you in more brief interventions and feel more secure in this matter."
Level 5: Performance	How the learners actually apply their newly acquired knowledge and skills in real-world clinical practice Direct Application & Reference Tools: "It would be wonderful to have the PowerPoints so that I can make a quick reference guide for myself and to share with my colleagues." "...and the learning will surely continue in clinical practice." Knowledge Translation / Peer Sharing: "I will try to share what I have learned in the meantime."
Level 6: Patient Health	Not undertaken by the current design of the study
Level 7: Community Health

Discussion

General physicians and hepatologists frequently encounter patients with co-occurring AUD and ALD in clinical practice. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is the current standard of care followed by providers managing these patients (Thoele et al. 2021). A comprehensive approach where both diseases are managed concurrently may improve short-term outcomes, although the long-term outcomes of these integrated interventions have not been definitively studied (Jophlin et al. 2024, Singal et al. 2024). However, specialty mental health and general medical systems have traditionally operated in silos due to several barriers leading to fragmented patient care (Druss 2002).

The lack of adequate training in addiction treatment is an important barrier to providing comprehensive care to patients with ALD (DiMartini et al. 2022). Awareness building, sensitization, and training may be stepping stones in promoting collaborative models required to best deliver service package interventions to patients with ALD. A survey of hepatologists found that only one-fourth of the participants were comfortable prescribing medications to manage AUD (Cotter et al. 2020). Another recent survey of 408 gastroenterologists and hepatologists found that only 29% ever prescribed medications for AUD. A total of 84% of non-prescribers cited a lack of comfort as the reason. Further, 77% perceived low education on addiction, and 90% desired addiction training during their gastroenterology or hepatology fellowship (Im et al. 2021). These observations are relevant given that dedicated AUD-related training to hepatologists leads to improvement in AUD screening and use of treatment interventions (Saraireh et al. 2020).

The findings of our study, that practice, self-perceived competence, and knowledge on AUD among hepatologists improved after their focused training by addiction specialists, are encouraging. The training module was successful in equipping participants with practical tools that boosted their confidence and comfort in addressing and managing the AUD component in patients with ALD. The increase in knowledge underscores the module’s role in filling the informational gaps that hepatologists may have regarding AUD, which is pivotal for making informed clinical decisions.

The lack of significant change in attitudes toward AUD, including participants’ attribution and emotional responses, may be due to relatively high scores in these attitudinal domains at baseline in the pre-test analysis. Future studies need to explore alternative, more sensitive measures that can overcome this ceiling effect to accurately assess the impact of interventions across the various domains of attitude assessment. A relatively short study duration of eight weeks may also explain this finding. Attitude changes often require sufficient time for individuals to process new information, reflect on their beliefs, and internalize any behavioral adjustments. Thus, future research aimed at investigating attitude changes may benefit from extending follow-up periods to better capture the nuanced evolution of participants’ attitudes over time.

Our study findings have important clinical implications. The feedback received from the hepatologists suggests they desire to engage in and learn about AUD management. However, given that a small number of highly interested hepatologists agreed to be a part of this program, the results may not be generalizable. In this regard, future strategies would be needed to engage a diverse group of physicians and hepatologists, especially those who might be initially indifferent or hold negative attitudes toward AUD. Encouraging participation from a wider audience may require addressing barriers to engagement, such as perceived irrelevance, time constraints, or preconceived notions about the effectiveness of such training.

To our knowledge, this is one of the few studies to demonstrate the benefits of a short duration of focused training on addiction for hepatologists who are managing patients with ALD. It mirrors the findings of a previous study, which developed and tested a brief three session curriculum for AUD management for hepatologists (Johnson et al. 2023). However, our intervention which is based on the ECHO model also involved real life case-based discussions which are more likely to lead to changes in practice. Hence, this initiative fills a crucial gap in the existing literature, where the focus on interdisciplinary approaches to AUD management has been notably scarce. Although not an objective, the use of assessment processes in our study (Table 9) that follow the Moore’s framework to evaluate continued medical education is a strength of our study (Moore Jr et al. 2009).

Table 9.

Evaluation of PRATHAM based on Moore’s expanded CME framework.

Expanded framework levels	Description
Level 1: Participation	The number of Case Discussions carried out during the course. (n = 11)
Level 2: Satisfaction	Post-completion test was sent to the participants which included a part on feedback about the course to collect the impressions of participants. No objective scale was used to measure this criterion.
Level 3A: Declarative Knowledge	Pre- and post-test knowledge questionnaires were used for an objective assessment.
Level 3B: Procedural Knowledge
Level 4: Competence	Self-report of competence was taken in pre-and post-tests. Analysis showed a significant increase in ratings in the post-test questionnaire compared to the pre-test questionnaire.
Level 5: Performance	Pre- and post-assessments included self-reported scales to measure the differences in attitude in three domains: medical condition regard, attribution of health professionals, emotional responses of health professionals, and practices of the participants. There was no significant change found in any of the three domains of attitude, while there was a significant change in the practices of the participants in pre- and post-assessment.
Level 6: Patient Health	Not undertaken by the current design of the study.
Level 7: Community Health

However, we do recognize certain limitations of this study, including the short duration limiting capturing the ability to capture the full spectrum of potential outcomes, the smaller sample size reducing the study power and generalizability of the findings, selection bias with selection of interested hepatologists potentially impacting the study’s representativeness, self-reported subjective changes without using any objective measures introducing a potential bias, and the outcomes being assessed immediately after the course ended, limiting the study’s ability to comment on the continued or long-term effects of the training module. These limitations should be considered when interpreting the results.

In conclusion, our study findings underscore the importance of tailored educational interventions in hepatology to comprehensively manage AUD in the setting of ALD. The significant improvements in practice, self-perceived competence, and knowledge highlight the potential of targeted training programs to enhance patient care. However, the findings also call for a more nuanced approach to changing attitudes, perhaps through longitudinal engagement or incorporating elements that challenge existing biases more directly. The significance of this study extends beyond its findings; it sets a precedent for future research in this area and opens avenues for further investigation into similar models across different medical specialties. Longitudinal studies could offer insights into the durability of these educational interventions’ effects, providing a roadmap for sustaining and expanding the gains observed in this study. The findings also encourage planning more extensive and detailed studies to evaluate the impact of behavior change in real-world practice, patient- and community-level outcomes.

Abbreviations

AUD: alcohol use disorder

ALD: alcohol associated liver disease

SBIRT: Screening, Brief Intervention, and Referral to Treatment.

Author contributions

Udit Panda (Project administration [equal], Writing—review & editing [equal]), Abhishek Sharma (Writing—review & editing [equal]), Daniel Kavati (Writing—review & editing [equal]), Likhita C (Project administration [equal]), N Kubenthiran (Project administration [equal], Writing—review & editing [equal]), Sanjeev Arora (Conceptualization [equal], Funding acquisition [equal], Investigation [equal], Resources [equal], Supervision [equal], Writing—review & editing [equal])

Conflicts of interest

A.K.S. serves as a consultant on the SBIR grant for Pleiogenix pharma; served as DSMB member for phase-2b DUR-928 trial for Durect pharma; serves on advisory board for Orphalan and Disc Medicine; Speaks and writes for Medscape, CLD Foundation, Expert Perspectives, Gastro Endo News, Dynamed, Medical Education Speakers Network, Up-to-Date, Madrigal Pharma, Practice Point.

Funding

Kentucky Medicaid (SUP26-C5531) and NIAAA (U01 AA026980-06) to A.K.S.

Data availability

Data are with J.M. and P.K.C. and will be made available if needed.