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Alcohol as a Vital Sign: We Ask Everyone

By Ann Wallace, Senior Communications Specialist, Kaiser Permanente Division of Research

If you’ve paid a visit to your primary care physician in the last 18 months, it’s highly likely that the Medical Assistant (MA) who accompanies you to the exam room has asked two brief questions about your alcohol consumption.

Those questions are the threshold for Alcohol as a Vital Sign (AlcVS), a systematic screening process for unhealthy drinking that was introduced into the MA Rooming Tool in 2013. Since then, well over 2 million members of Kaiser Permanente Northern California (KPNC) have been screened.

The New Normal

That volume normalizes what can be a sensitive subject. The credit belongs in large measure to the region’s MAs, who “have done a fantastic job,” according to Stacy Sterling, MSW, MPH, and Thekla Ross, PsyD, of the Behavioral Health Research Initiative at the Division of Research, where the screening tool originated as a study. “The MAs’ screening rates for alcohol consumption are 85 percent, which is on par with exercise and smoking.”

If the patient’s answers indicate an unhealthy level of consumption, the process moves to the primary care physician through a Best Practice Advisory. Two more questions are asked to assess the risk of alcohol dependency. If there is no risk, the physician has a conversation — a brief intervention — with the patient about the health consequences of excessive drinking and the benefits of cutting back. If the patient is at risk, the doctor offers a referral to Chemical Dependency Services for further assessment.

Making the Connection

Joseph Elson, MD, assistant chief of medicine at San Francisco Medical Center, notes that the well-documented connection between excess alcohol consumption and negative health outcomes — hypertension, falls, gastrointestinal bleeding, sleep disorders and depression — frequently provides the entrée for the brief intervention.

“My experience is that often when a patient has triggered positive for unhealthy drinking, the complaint that brought them in for a visit is related to it,” he says. “That allows me to say ‘I suspect that if you drank less, that condition might improve or resolve itself.’

“Quantifying things is important for people. We can point to our ‘We Ask Everyone’ posters and show what low risk limits and standard drink sizes look like. We’re providing knowledge they may not have had. That’s a win-win. We’ve reduced unhealthy drinking and resolved a health issue. Alcohol as a Vital Sign delivers a big bang for your buck.”

A Recognized Leader

Barry Levine, MD, chair of addiction medicine chiefs, is a “passionate advocate” for bringing chemical dependency into primary care, not just in Kaiser Permanente but nationwide. He notes that “alcohol consumption is becoming more commonplace in the doctor-patient dialogue, and that’s going to have a beneficial impact on our patients’ health.”

While acknowledging that “it’s hard to expand what happens in primary care,” Levine believes that “it’s effective to bring behavioral health interventions into this setting. What we are doing with Alcohol as a Vital Sign is the first step in the big picture of placing services where the patients are. Kaiser Permanente should be in the lead on this.”

The Centers for Disease Control has cited Kaiser Permanente Northern California as the first private U.S. health care system to roll out a systematic alcohol screening and intervention tool. They meet periodically with the program’s leadership team, and are encouraging them to bring the learnings from their experience to a broader audience of health plan leaders across the country. And that, Levine notes, “is a quite a feather in our cap.”

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