Are people who consume alcohol—but who aren’t dependent on it—drinking to levels that can harm their health? Could the risk be effectively detected and addressed in primary care? Kathy Bradley has been exploring these questions since the late 1980s, when researchers recognized that risky drinking accounts for more illness and death than alcohol addiction, which is much less common.
A general internist, Dr. Bradley concentrates on identifying and addressing unhealthy alcohol use in primary care. Research shows that even a short discussion with a health care provider can help patients reduce risky drinking. In 5 to 15 minutes, a counseling intervention typically advises drinking below recommended limits or abstaining, connects drinking to the patient’s health concerns, and helps the patient set change goals. The recent National Commission on Prevention Priorities ranked alcohol screening and brief alcohol counseling the third-highest priority among prevention recommendations for adults.
While at the Veterans Affairs (VA) Puget Sound Health Care System, Dr. Bradley discovered ways to more efficiently identify unhealthy alcohol use. Her team validated the “AUDIT-C” three-item alcohol screen and a single-question screen in VA patients as well as non-VA patient populations. They also linked high AUDIT-C scores with adverse health outcomes, including decreased medication adherence and increases in fractures and trauma; hospitalizations for liver disease, gastrointestinal bleeding and pancreatitis; surgical complications and post-op health care utilization; and mortality. An ongoing VA study is evaluating whether changes in AUDIT-C scores are associated with changes in health outcomes. If so, AUDIT-C scores could be used as a “vital sign” to monitor drinking.
Dr. Bradley was instrumental in helping implement alcohol screening and brief alcohol counseling at more than 900 VA sites—and in developing the VA's national performance measures. Using performance measures and decision support in an electronic health record (EHR), yearly alcohol screening rates in the VA have been high since 2007. Her team also developed and tested an EHR-based clinical reminder that provides decision support for brief alcohol counseling, as well as performance measures for counseling. Together, the EHR tools and the performance measures recently resulted in high rates of alcohol counseling.
Currently, Dr. Bradley is evaluating performance measures of brief alcohol counseling. She recently turned her attention to management of alcohol use disorders in primary care settings, as well as identifying and addressing drug use disorders with proactive outreach. She is leading the National Institute of Health's National Institute on Alcohol Abuse and Alcoholism Study on Collaborative Care for Primary Care Patients with unhealthy drinking: "Considering Healthier Drinking Options in Collaborative Care" (CHOICE) trial, which has finished enrollment and will be completed in October 2015. She and her clinical partners are also funded by the Agency for Health Research and Quality to implement alcohol screening, brief alcohol counseling, and shared decision-making for alcohol use disorders in a sustainable manner at all 25 primary care clinics within Group Health. In addition, she has ongoing research developing a patient decision aid for shared decision-making for alcohol use disorders, and with her clinical partners, has obtained a Group Health Partnership for Innovation grant to test proactive outreach from primary care teams to patients with alcohol or drug use disorders.
Alcohol and drug misuse
Alcohol and drug use disorders
Physician decision support; eHealth
Implementation research; quality measurement
Alcohol and drug screening; brief alcohol interventions
Screening and brief intervention; mental health quality measurement
Primary care management of alcohol misuse
Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Chavez LJ, Ludman EJ, Berger D, Bradley KA.Factors underlying quality problems with alcohol screening prompted by a clinical reminder in primary care: a multi-site qualitative study.
J Gen Intern Med. 2015 Mar 3. [Epub ahead of print]. PubMed
Bradley K, Kivlahan D.Medications for alcohol use disorder--reply.
JAMA. 2014 Oct 1;312(13):1352. doi: 10.1001/jama.2014.10167. PubMed
Rittmueller SE, Frey MS, Williams EC, Sun H, Bryson CL, Bradley KA.Association between alcohol use and cardiovascular self-care behaviors among male hypertensive VA outpatients: a cross-sectional study.
Subst Abus. 2014 Jun 25:0 [Epub ahead of print]. PubMed
Lapham GT, Rubinsky AD, Williams EC, Hawkins EJ, Grossbard J, Chavez LJ, Kivlahan DR, Bradley KA.Decreasing sensitivity of clinical alcohol screening with the AUDIT-C after repeated negative screens in VA clinics.
Drug Alcohol Depend. 2014 Jun 23. pii: S0376-8716(14)00939-9. doi: 10.1016/j.drugalcdep.2014.06.017 [Epub ahead of print] PubMed
New York Times, May 14, 2014