OHSU-PSU School of Public Health & OHSU School of Medicine, Oregon Health & Science University, Portland.
Stony Brook University School of Social Welfare, Stony Brook, New York.
JAMA Netw Open. 2023 Oct 2;6(10):e2338224. doi: 10.1001/jamanetworkopen.2023.38224.
Rates of alcohol-associated deaths increased over the past 20 years, markedly between 2019 and 2020. The highest rates are among individuals aged 55 to 64 years, primarily attributable to alcoholic liver disease and psychiatric disorders due to use of alcohol. This study investigates potential geographic disparities in documentation of alcohol-related problems in primary care electronic health records, which could lead to undertreatment of alcohol use disorder.
To identify disparities in documentation of alcohol-related problems by practice-level social deprivation.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study using secondary data from the Integrating Behavioral Health and Primary Care clinical trial (September 21, 2017, to January 8, 2021) was performed. A national sample of 44 primary care practices with co-located behavioral health services was included in the analysis. Patients with 2 primary care visits within 2 years and at least 1 chronic medical condition and 1 behavioral health condition or at least 3 chronic medical conditions were included.
The primary exposure was practice-level Social Deprivation Index (SDI), a composite measure based on county income, educational level, employment, housing, single-parent households, and access to transportation (scores range from 0 to 100; 0 indicates affluent counties and 100 indicates disadvantaged counties).
Documentation of an alcohol-related problem in the electronic health record was determined by International Classification of Diseases, 9th Revision, Clinical Modification and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes or use of medications for alcohol use disorder in past 2 years. Multivariable models adjusted for alcohol consumption, screening for a substance use disorder, urban residence, age, sex, race and ethnicity, income, educational level, and number of chronic health conditions.
A total of 3105 participants (mean [SD] age, 63.7 [13.0] years; 64.1% female; 11.5% Black, 7.0% Hispanic, 76.7% White, and 11.9% other race or chose not to disclose; 47.8% household income <$30 000; and 80.7% urban residence). Participants had a mean (SD) of 4.0 (1.7) chronic conditions, 9.1% reported higher-risk alcohol consumption, 4% screened positive for substance use disorder, and 6% had a documented alcohol-related problem in the electronic health record. Mean (SD) practice-level SDI score was 45.1 (20.9). In analyses adjusted for individual-level alcohol use, demographic characteristics, and health status, practice-level SDI was inversely associated with the odds of documentation (odds ratio for each 10-unit increase in SDI, 0.89; 95% CI, 0.80 to 0.99; P = .03).
In this study, higher practice-level SDI was associated with lower odds of documentation of alcohol-related problems, after adjusting for individual-level covariates. These findings reinforce the need to address primary care practice-level barriers to diagnosis and documentation of alcohol-related problems. Practices located in high need areas may require more specialized training, resources, and practical evidence-based tools that are useful in settings where time is especially limited and patients are complex.
在过去的 20 年里，与酒精相关的死亡人数有所增加，尤其是在 2019 年至 2020 年之间。发病率最高的是 55 至 64 岁的人群，主要归因于酒精性肝病和因使用酒精而导致的精神障碍。本研究调查了初级保健电子健康记录中与酒精相关问题记录的潜在地理差异，这可能导致酒精使用障碍的治疗不足。
按实践层面的社会剥夺程度来确定与酒精相关问题记录的差异。
设计、地点和参与者：本研究采用二次数据分析了一项名为“整合行为健康和初级保健”的临床试验（2017 年 9 月 21 日至 2021 年 1 月 8 日）。该分析纳入了一个全国性的 44 个初级保健实践样本，这些实践都有共同的行为健康服务。参与者需要在 2 年内有 2 次初级保健就诊，并且至少有 1 种慢性疾病和 1 种行为健康状况，或至少有 3 种慢性疾病。
主要暴露因素是实践层面的社会剥夺指数（SDI），这是一个基于县收入、教育水平、就业、住房、单亲家庭和交通便利性的综合衡量指标（得分范围从 0 到 100；0 表示富裕县，100 表示贫困县）。
电子健康记录中与酒精相关问题的记录通过国际疾病分类第 9 修订版临床修正（ICD-9-CM）和国际疾病分类第 10 修订版临床修正（ICD-10-CM）代码或过去 2 年中使用治疗酒精使用障碍的药物来确定。多变量模型调整了酒精摄入量、物质使用障碍筛查、城市居住、年龄、性别、种族和民族、收入、教育水平和慢性健康状况的数量。
共纳入 3105 名参与者（平均[标准差]年龄 63.7[13.0]岁；64.1%为女性；11.5%为黑人，7.0%为西班牙裔，76.7%为白人，11.9%为其他种族或选择不披露；47.8%的家庭收入<30000 美元；80.7%的人居住在城市）。参与者平均（标准差）有 4.0（1.7）种慢性疾病，9.1%报告了更高风险的酒精消费，4%筛查出物质使用障碍阳性，6%在电子健康记录中有与酒精相关的问题记录。平均（标准差）实践层面的 SDI 得分为 45.1（20.9）。在调整了个体层面的酒精使用、人口统计学特征和健康状况后，实践层面的 SDI 与记录的可能性呈反比（SDI 每增加 10 个单位，比值比为 0.89；95%置信区间为 0.80 至 0.99；P=0.03）。
在这项研究中，在调整了个体层面的协变量后，较高的实践层面 SDI 与记录与酒精相关问题的可能性降低有关。这些发现强调了需要解决初级保健实践层面在诊断和记录与酒精相关问题方面的障碍。位于高需求地区的实践可能需要更多的专门培训、资源和实用的循证工具，这些工具在时间特别有限且患者情况复杂的环境中非常有用。
