A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment
Abstract: Background: Alcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment. Objective: The principal aims of this study were to test the effectiveness of a primary care-based Alcohol Care Management (ACM) program for alcohol use disorder and treatment engagement in veterans. Design: The design of the study was a 26-week single-blind randomized clinical trial. The study was conducted in the primary care practices at three VA medical centers. Participants were randomly assigned to treatment in ACM or standard treatment in a specialty outpatient addiction treatment program. Participants: One hundred and sixty-three alcohol-dependent veterans were randomized. Intervention: ACM focused on the use of pharmacotherapy and psychosocial support. ACM was delivered in-person or by telephone within the primary care clinic. Main measurements: Engagement in treatment and heavy alcohol consumption. Key results: The ACM condition had a significantly higher proportion of participants engaged in treatment over the 26 weeks [OR=5.36, 95 % CI = (2.99, 9.59)]. The percentage of heavy drinking days were significantly lower in the ACM condition [OR=2.16, 95 % CI= (1.27, 3.66)], while overall abstinence did not differ between groups. Conclusion: Results demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.
Abstract: Introduction: Persistent inequities exist in obstetric and neonatal outcomes in military families despite universal health care coverage. Though the exact underlying cause has not been identified, social determinants of health may uniquely impact military families. The purpose of this study was to qualitatively investigate the potential impact of social determinants of health and the lived experiences of military individuals seeking maternity care in the Military Health System. Materials and methods: This was an Institutional Review Board-approved protocol. Nine providers conducted 31 semi-structured interviews with individuals who delivered within the last 5 years in the direct or purchased care market. Participants were recruited through social media blasts and clinic flyers with both maximum variation and homogenous sampling to ensure participation of diverse individuals. Data were coded and themes were identified using inductive qualitative research methods. Results: Three main themes were identified: Requirements of Military Life (with subthemes of pregnancy notification and privacy during care, role of pregnancy instructions and policies, and role of command support), Sociocultural Aspects of the Military Experience (with subthemes of pregnancy as a burden on colleagues and a career detractor, postpartum adjustment, balancing personal and professional requirements, pregnancy timing and parenting challenges, and importance of friendship and camaraderie in pregnancy), and Navigating the Healthcare Experience (including subthemes of transfer between military and civilian care and TRICARE challenges, perception of military care as inferior to civilian, and remote duty stations and international care). Conclusions: The unique stressors of military life act synergistically with the existing health care challenges, presenting opportunities for improvements in care. Such opportunities may include increased consistency of policies across services and commands. Increased access to group prenatal care and support groups, and increased assistance with navigating the health care system to improve care transitions were frequently requested changes by participants.