Kaiser Permanente researchers find modest decline in hypertension in patients who had a brief intervention talk
Patients with hypertension and unhealthy alcohol use were more likely to see a decline in their blood pressure if they were asked about their alcohol drinking habits and provided a brief intervention during a visit with their primary care team, according to new Kaiser Permanente research published in BMJ Open.
The analysis suggests that the Alcohol as a Vital Sign program at Kaiser Permanente Northern California (KPNC) benefits patients beyond simply identifying unhealthy alcohol use, said senior author Stacy Sterling, DrPH, MSW, co-director of the Center for Addiction and Mental Health Research at the Kaiser Permanente Division of Research.
“Our previous research has shown brief interventions by primary care clinicians can have an impact on patients’ problem drinking,” Sterling said. “This research takes that an important step further by showing the impact of these conversations on chronic diseases such as hypertension. This is additional confirmation that even small reductions in drinking result in important improvements in health outcomes, and on a population level that can be very powerful.”
The Alcohol as a Vital Sign initiative is a workflow introduced in 2014 in KPNC adult primary care in which medical assistants ask patients about heavy drinking in the previous 3 months and record the information in the electronic patient record. Those who screen positive for unhealthy drinking have a brief intervention (BI) with the doctor — a conversation in which the clinician uses motivational interviewing techniques to encourage a change in behavior. Brief intervention is part of a 3-part process known as SBIRT: screening, brief intervention, and referral to treatment. Patients may be referred to outpatient addiction medicine treatment if needed.
In this analysis covering 2014 to 2017, the researchers found about half of patients who screened positive received a brief intervention that was noted in the medical record.
The researchers also wanted to learn whether the initiative improved outcomes for patients with hypertension (high blood pressure) or type 2 diabetes, both conditions that can be worsened by heavy alcohol use. They identified 440,882 patients who screened positive for unhealthy drinking and focused on 72,979 patients with hypertension and 19,642 patients with type 2 diabetes. They measured drinking outcomes 12 months later, and health outcomes 18 months later, comparing the patients who received a brief intervention with those who did not.
Overall, the patients reported less drinking at 12 months whether they had had brief intervention or not. But the intervention patients had an additional reduction of .06 drinks per day or .3 drinks per week.
The analysis used recommended limits of no more than 3 drinks on any day or 7 drinks per week for women and men aged 66 and older and no more than 4 drinks on any day or 14 drinks per week for men aged 18 to 65.
The hypertension patients also had a 5% greater chance of having their diastolic blood pressure drop by up to 3 points, which is a clinically meaningful reduction that has been found to be associated with lower cardiovascular disease risk and mortality in epidemiological studies. However, no significant association was found between brief intervention and improvements in type 2 diabetes.
“The reduction in blood pressure was modest but significant,” said lead author Felicia Chi, MPH, senior data consultant at the Division of Research. “The difference is particularly important from a population perspective for health systems looking for ways to address these chronic conditions and behaviors.”
Chi said the analysis was strengthened by the large sample sizes involved, carefully formulated comparison groups whose demographics and health status are matched in a way that imitates a randomized clinical trial, and analytical methods that can adjust for potential bias due to selection and attrition.
There were some encouraging findings among specific subgroups of patients. Brief intervention was beneficial in reducing drinking for male hypertension patients, those between ages 45 and 64, and those who were exceeding daily drink limits (as opposed to those who reported exceeding weekly limits). “Knowing which patients benefit most from intervention with their doctors can inform provider training, and outreach efforts to particular groups,” Chi said.
Previous research involving KPNC adults found that those with hypertension and type 2 diabetes were more likely to exceed drinking limits, which prompted the authors to examine brief intervention’s effect on those conditions. “Our findings suggest that alcohol screening and BI in adult primary care may be an important cost-effective service for chronic disease prevention and intervention, given its brevity, low cost and potential reach,” they wrote.
For primary care practitioners, the alcohol brief intervention is one more tool they can use to address lifestyle factors in chronic illness, said Sameer Awsare, MD, associate executive director of The Permanente Medical Group. “Making lifestyle changes to control high blood pressure — such as reducing alcohol intake — is an important adjunct to the medications we can prescribe for our hypertension patients,” he said.
Sterling said the study team will continue to follow real-world use of brief intervention for additional insights. “This is a very rich data set, and we are looking at BI’s potential impact on a variety of different health conditions,” she said. “While alcohol use is the subject, we always intended for this workflow to be a tool for clinicians to address a whole range of health conditions. Brief intervention on alcohol should be part of an overall conversation about health, destigmatizing behaviors traditionally seen as ‘bad’ to focus on positive, healthy well-being.”
The study was funded by the National Institute on Alcohol Abuse and Alcoholism.
Additional co-authors were Sujaya Parthasarathy, PhD, Vanessa Palzes, MPH, Andrea Kline-Simon, MS, Constance Weisner, DrPH, MSW, Derek Satre, PhD, Richard Grant, MD, MPH, Thekla Ross, PsyD, Yun Lu, MPH, and Verena Metz, PhD, of the Division of Research; and Joseph Elson, MD, and Sameer Awsare, MD, of The Permanente Medical Group.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.