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  • Measure Summary
  • NQMC:010799
  • Apr 2016
  • NQF-Endorsed Measure

Preventive care and screening: percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.

Physician Consortium for Performance Improvement® (PCPI®). Preventive care and screening performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 39 p. [50 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Physician Consortium for Performance Improvement® (PCPI). Preventive care & screening physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Sep. 34 p. [8 references]

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.

Rationale

This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption. About 30% of the United States (U.S.) population misuse alcohol, with most engaging in what is considered risky drinking (Saitz, 2005). A recent analysis of data from the National Alcohol Survey shows that approximately one-third of at-risk drinkers (32.4%) and persons with a current alcohol use disorder (31.5%) in the U.S. had at least one primary care visit during the prior year, demonstrating the potential reach of screening and brief counseling for unhealthy alcohol use in the primary care setting (Mulia et al., 2011). A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. In the National Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months (D'Amico et al., 2005). A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify - or fail to identify - substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients (The National Center on Addiction and Substance Abuse, 2000).

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

The U.S. Preventive Services Task Force (USPSTF) (2013) recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

Evidence for Rationale

D'Amico EJ, Paddock SM, Burnam A, Kung FY. Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care. 2005 Mar;43(3):229-36.

Mulia N, Schmidt LA, Ye Y, Greenfield TK. Preventing disparities in alcohol screening and brief intervention: the need to move beyond primary care. Alcohol Clin Exp Res. 2011 Sep;35(9):1557-60. PubMed External Web Site Policy

Physician Consortium for Performance Improvement® (PCPI®). Preventive care and screening performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 39 p. [50 references]

Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005 Feb 10;352(6):596-607. PubMed External Web Site Policy

The National Center on Addiction and Substance Abuse. Missed opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. New York (NY): The National Center on Addiction and Substance Abuse at Columbia University; 2000.

U.S. Preventive Services Task Force (USPSTF). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Aug 6;159(3):210-8. [35 references] PubMed External Web Site Policy

Primary Health Components

Unhealthy alcohol use; screening; counseling

Denominator Description

All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Importance of Topic

Incidence, Prevalence, & Cost

  • The 2006 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007) reports that:
    • Approximately half (50.9%; 125 million persons) of Americans age 12 years and older reported being current drinkers of alcohol
    • 23% (57 million) of persons age 12 years and older participated in binge drinking
    • Heavy drinking was reported by 6.9% (17 million) persons age 12 years and older
  • In 2001, excessive alcohol use was responsible for 75,000 preventable deaths and 2.3 million years of potential life lost (Centers for Disease Control and Prevention [CDC], 2004).
  • Economic costs associated with alcohol abuse are estimated to have been $184.6 billion in 1998. This represents a 25% increase over the previous estimate of $148 billion in 1992.

Opportunity for Improvement/Gap or Variation in Care

  • It has been reported that overall, adults receive approximately half of all recommended medical care (McGlynn et al., 2003; Asch et al., 2006).
  • From 1998 to 2000, 45% of patients were screened for problem drinking ("Technical appendix," 2006).

Evidence for Additional Information Supporting Need for the Measure

Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor-quality health care. N Engl J Med. 2006;354(11):1147-56. [32 references] PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). Alcohol-attributable deaths and years of potential life lost--United States, 2001. MMWR Morb Mortal Wkly Rep. 2004 Sep 24;53(37):866-70. PubMed External Web Site Policy

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-45. PubMed External Web Site Policy

Physician Consortium for Performance Improvement® (PCPI®). Preventive care and screening performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 39 p. [50 references]

Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2006 National Survey on Drug Use and Health: national findings [Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293]. Rockville (MD): Substance Abuse and Mental Health Services Administration (SAMHSA); 2007. 282 p.

Technical appendix to Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who is at greatest risk for receiving poor-quality health care. N Engl J Med. 2006;354(11):1147-56.

Extent of Measure Testing

The American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI) collaborated on a testing project in 2012 to ensure the Unhealthy Alcohol Use: Screening & Brief Counseling measure is reliable and evaluated for accuracy of the measure denominator, numerator and exceptions case identification. The testing projects were conducted utilizing electronic health record data. Three sites participated in the parallel forms reliability testing of the measure. Site A was comprised of a network of community health centers across the United States serving more than 2.5 million patients annually. Site B was a large independent multi-specialty group the Midwest comprised of over 315 physicians. Site C was a single physician owned adult primary care private practice in Chicago.

Measures Tested

  • Unhealthy Alcohol Use: Screening & Brief Counseling

Reliability Testing

The purpose of reliability testing was to evaluate whether the measure definitions and specifications, as prepared by the PCPI, yield stable, consistent measures. Data abstracted from electronic health records were used to calculate parallel forms reliability for the measure.

Reliability Testing Results

Parallel Forms Reliability Testing

Site A, Site B, and Site C

There were 120 observations from Site A, Site B and Site C used for the denominator analysis. The kappa statistic value of 0.31 demonstrates fair agreement between the automated report and manual reviewer.

The kappa statistic value of 0.31 demonstrates fair agreement. This is due to the high observed agreement rate and the concentration of observations in the YES, YES cell (81% of all observations [97/120]). This is an example of the limitation of the Kappa statistic. While agreement can be high, if one classification category dominates, kappa can be significantly reduced (Warrens, 2010; Feinstein & Cicchetti, 1990).

Of the 120 observations that were initially selected, 97 observations met the criteria for inclusion in the numerator analysis. The kappa statistic value of 0.82 demonstrates almost perfect agreement between the automated report and reviewer.

Reliability: N, % Agreement, Kappa (95% Confidence Interval)

Denominator: 120, 85.0%, 0.31 (0.10–0.52)
Numerator: 97, 91%, 0.82 (0.70–0.93)

Evidence for Extent of Measure Testing

Feinstein AR, Cicchetti DV. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol. 1990;43(6):543-9. PubMed External Web Site Policy

Physician Consortium for Performance Improvement® (PCPI®). Preventive care and screening performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 39 p. [50 references]

Warrens MJ. A formal proof of a paradox associated with Cohen’s kappa. J Classif. 2010;27:322-32.

State of Use

Current routine use

Current Use

Internal quality improvement

Pay-for-reporting

Professional certification

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Person- and Family-centered Care
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Case Finding Period

The measurement period

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Encounter

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Note: Refer to the original measure documentation for administrative codes.

Exclusions
None

Exceptions
Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons)

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
Patients who were screened for unhealthy alcohol use using a systematic screening method* at least once within the last 24 months AND who received brief counseling** if identified as an unhealthy alcohol user

Note: Refer to the original measure documentation for administrative codes.

*Systematic Screening Method: For the purposes of this measure, one of the following systematic methods to assess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for defining unhealthy alcohol use include:

  • Alcohol Use Disorders Identification Test (AUDIT) Screening Instrument (score greater than or equal to 8)
  • AUDIT-C Screening Instrument (score greater than or equal to 4 for men; score greater than or equal to 3 for women)
  • Single Question Screening: How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day? (response greater than or equal to 2)

**Brief Counseling: Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking.

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Alcohol Use Disorders Identification Test (AUDIT) Screening Instrument
  • AUDIT-C Screening Instrument

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Measure #3: unhealthy alcohol use: screening & brief counseling.

Measure Collection Name

AMA/PCPI Preventive Care and Screening Performance Measurement Set

Submitter

American Medical Association - Medical Specialty Society

Developer

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Preventive Care and Screening Measure Development Work Group

Work Group Members*

  • Martin C. Mahoney, MD, PhD (Co-Chair) (family medicine)
  • Stephen D. Persell, MD, MPH (Co-Chair) (internal medicine)
  • Gail M. Amundson, MD, FACP (internal medicine/geriatrics)
  • Joel V. Brill MD, AGAF, FASGE, FACG (gastroenterology)
  • Steven B. Clauser, PhD
  • Will Evans, DC, PhD, CHES (chiropractic)
  • Ellen Giarelli, EdD, RN, CRNP (nurse practitioner)
  • Amy L. Halverson, MD, FACS (colon & rectal surgery)
  • Charles M. Helms, MD, PhD (infectious disease)
  • Kay Jewell, MD, ABHM (internal medicine/geriatrics)
  • Daniel Kivlahan, PhD (psychology)
  • Paul Knechtges, MD (radiology)
  • George M. Lange, MD, FACP (internal medicine/geriatrics)
  • Trudy Mallinson, PhD, OTR/L/NZROT (occupational therapy)
  • Jacqueline W. Miller, MD, FACS (general surgery)
  • Adrienne Mims, MD, MPH (geriatric medicine)
  • G. Timothy Petito, OD, FAAO (optometry)
  • Rita F. Redberg, MD, MSc, FACC (cardiology)
  • Barbara Resnick, PhD, CRNP (nurse practitioner)
  • Sam JW Romeo, MD, MBA
  • Carol Saffold, MD (obstetrics & gynecology)
  • Robert A. Schmidt, MD (radiology)
  • Samina Shahabbudin, MD (emergency medicine)
  • Melanie Shahriary RN, BSN (cardiology)
  • James K. Sheffield, MD (health plan representative)
  • Arthur D. Snow, MD, CMD (family medicine/geriatrics)
  • Richard J. Snow, DO, MPH
  • Brooke Steele, MD
  • Brian Svazas, MD, MPH, FACOEM, FACPM (preventive medicine)
  • David J. Weber, MD, MPH (infectious disease)
  • Deanna R. Willis, MD, MBA, FAAFP (family medicine)
  • Charles M. Yarborough, III, MD, MPH (occupational medicine)

Work Group Staff

American Medical Association

  • Kerri Fei, MSN, RN
  • Kendra Hanley, MS
  • Karen Kmetik, PhD
  • Liana Lianov, MD, MPH
  • Kimberly Smuk, BS, RHIA
  • Litjen Tan, MS, PhD
  • Samantha Tierney, MPH
  • Richard Yoast, PhD

PCPI Consultants

  • Rebecca Kresowik
  • Timothy Kresowik, MD

*The composition and affiliations of the work group members are listed as originally convened in 2007 and are not up-to-date.

Financial Disclosures/Other Potential Conflicts of Interest

Conflicts, if any, are disclosed in accordance with the Physician Consortium for Performance Improvement® conflict of interest policy.

Endorser

National Quality Forum

NQF Number

2152

Date of Endorsement

2014 Oct 1

Measure Initiative(s)

Physician Quality Reporting System

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Apr

Measure Maintenance

Coding/specifications updates occur annually. The Physician Consortium for Performance Improvement (PCPI) has a formal measurement review process that stipulates regular (usually on a three-year cycle, when feasible) review of the measures. The process can also be activated if there is a major change in scientific evidence, results from testing or other issues are noted that materially affect the integrity of the measure.

Date of Next Anticipated Revision

2017 Apr

Measure Status

This is the current release of the measure.

This measure updates a previous version: Physician Consortium for Performance Improvement® (PCPI). Preventive care & screening physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Sep. 34 p. [8 references]

Source(s)

Physician Consortium for Performance Improvement® (PCPI®). Preventive care and screening performance measurement set. Chicago (IL): American Medical Association (AMA); 2016 Apr. 39 p. [50 references]

Measure Availability

Source available from the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® Web site External Web Site Policy.

For further information, please contact AMA staff by e-mail at cqi@ama-assn.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on February 13, 2009. The information was verified by the measure developer on March 25, 2009.

This NQMC summary was retrofitted into the new template June 9, 2011.

This NQMC summary was updated by ECRI Institute on June 8, 2016. The information was verified by the measure developer on June 30, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Complete Physician Performance Measurement Sets (PPMS) are published by the American Medical Association, on behalf of the Physician Consortium for Performance Improvement.

For more information, contact the American Medical Association, Clinical Performance Evaluation, 330 N. Wabash Ave, Chicago, IL 60611.

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