Screening for alcohol use disorders among medical outpatients: The influence of individual and facility characteristics

Objective: Screening of adults in primary care has been recommended to reduce alcohol misuse. This study determined the rates and predictors of alcohol screening, screening positive, follow-up evaluation, and subsequently diagnosed alcohol use disorder in a national sample of Department of Veterans Affairs (VA) medical outpatients. Method: Chart-abstracted quality improvement data from the VA's 2002 External Peer Review Program were merged with records for 15,580 medical outpatients drawn from 139 VA facilities nationwide. Results: Nearly three-quarters of eligible patients (N=11,553) had chart-documented alcohol screening in the past year. Of these, 4.2% (N=484) screened positive. Of those who screened positive, three-fourths (N=370) received follow-up evaluation, and of these, 53.5% (N=198) were subsequently diagnosed with an alcohol use disorder -1.7% of the originally screened sample. Multivariate logistic regression revealed that several factors generally associated with increased risk of alcohol use disorders - including being younger, unmarried, and disabled, as well as having greater medical and psychiatric comorbidities - were actually associated with a decreased likelihood of alcohol screening. At the facility level, screening was less likely at more academically affiliated centers, and follow-up evaluation of a positive screening was less likely at the largest facilities. Conclusions: Routine alcohol screening yielded relatively few positive cases, raising questions about its cost-effectiveness. Targeted strategies may increase the value of case-finding activities among patients at greatest risk for alcohol use disorders and at more academically affiliated facilities. Targeted efforts are also needed to ensure proper follow-up evaluation at larger medical centers where patients may experience greater system-level barriers.