Capsule Commentary on Williams et al., Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multisite Qualitative Study

One in ten deaths in working adults in the United States can be attributed to alcohol use.¹ One response to contain alcohol-related consequences is to implement population-based screening using a validated instrument of adults.² In order to ensure the same accuracy of the screening instrument, it must be used exactly as studied; for example, if done verbally, the language should be verbatim.

As noted by Williams et al., the U.S. VA has been a leader in implementation of screening for unhealthy alcohol use. In practice though, routine screening has had lower sensitivity than anticipated; this means that patients with unhealthy alcohol use are being missed.

In this qualitative study, Williams et al. ³ sought to identify factors that may explain the low sensitivity of alcohol screening. They observed 31 staff members conducting 72 instances of alcohol screening. Some notable themes that emerged that may explain the low sensitivity included non-verbatim screening, making inferences introduction and adapting questions to enhance patient comfort. These themes make clinical sense. The authors conclude that using non-verbal screening could avoid some of the issues identified in their study.

Given the significant impact that alcohol-related morbidity and mortality has in the United States, it is imperative that patients with unhealthy alcohol use are identified and counseled on reducing their use or referral to treatment when indicated. Primary care practices are a natural setting for this. However, given the constraints of busy primary care practices, we must also ensure that screening for alcohol does not become simply a check-box with no assurance of quality. The results of this work suggest that using non-verbal approaches, such as patient self-administration, can ensure fidelity to the screening instruments while identifying patients with unhealthy alcohol use. Future work is indicated to determine the effectiveness of such strategies.