All perspectives need to be accounted for when determining the effectiveness of therapies for alcohol use disorder
Year: 2023
Type: letter
Abstract: We were pleased to read Rabiee et al.’s1 study of alcohol use disorder (AUD) treatment in high-risk veterans with liver disease. This is a critically important issue, and the report draws attention to the need to increase evidence-based AUD treatments in liver clinics, especially in those with cirrhosis.2 Implementation science and health equity frameworks challenge us to tackle evidence-to-practice gaps, such as these with active strategies to address implementation barriers at the patient, provider, and system levels, which are often difficult to parse out. The Veterans Affairs (VA) system has many important implementation facilitators, including a national medical record system, national clinical reminders, and an engaged proactive group of more than 200 hepatology clinicians who work on quality improvement projects.3 This system is also an excellent example of data transparency, engaged efforts to improve the quality of care, and a learning health care system approach to addressing evidence-to-practice gaps using state-of-the-art implementation methods, including pharmacological treatments for AUD.4 VA outperforms non-VA on several measures, including medications for alcohol use disorder (MAUD). In fact, our prior study also found that a non-VA system had had half the MAUD rate (2% in a non-VA high-volume quarternary liver transplant center vs 4% in VA).5 The finding that MAUD increased over time in the paper by Rabiee et al1 is encouraging and likely reflects national VA efforts to increase MAUD. Implementation science offers frameworks to consider the many barriers to implementation that requires a deeper study of the circumstances surrounding the AUD. These include the outer setting (eg, national alcohol policies and pricing, and insurance coverage of MAUD), inner setting barriers (eg, the clinic infrastructure), characteristics of individuals (eg, patient and provider self-efficacy), the characteristics of the innovation (eg, the relative advantage of MAUD versus behavioral therapy), and the implementation process (eg, strategies in place to address barriers).2 Thus, there are likely many causes of low MAUD adoption in and out of the VA and among patients with and without liver disease. The AUD treatment ideally includes a shared decision–making process, wherein patients are offered both evidence-based behavioral and pharmacological treatments. We found that many times patients declined offers for AUD treatment in a chart review study.6 Likewise, our non-VA study found strong evidence of provider stigma in these conversations and their notes, which may translate into patient decline.5 These findings emphasize the need for future work toward increasing AUD-related care, which starts with capturing data from all ends of the patient, caregiver, system, and societal spectrum.
Source: Hepatology Communications
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,700
OpenAlex ID: W4378783415