Evaluating the Documentation of Risky Substance Use in the Community Health Center Setting

Introduction: Substance use is a highly prevalent problem in the U.S.; however, less than 30% of patients report that they have been screened for substance use in the primary care setting. Our objectives are to: 1) evaluate the presence and reliability of documentation of substance use among risky drug using primary care patients in community health center medical records; 2) ascertain whether Quit Using Drugs Intervention Trial (QUIT) affected reporting in the medical record of screening, diagnosis, counseling, clinician treatment, or health educator counseling for risky substance use among primary care patients.

Methods: QUIT, which consisted of a 3-4 minutes of brief clinician advice, 2 minutes of video doctor sessions, and two telephone health education sessions at 2 and 6 weeks post enrollment, is an RCT that was conducted at 5 Federally Qualified Health Centers (FQHCs) in Los Angeles County. Adult patients being seen for a general medical visit were screened in the waiting room for substance use utilizing a self-administered WHO ASSIST (Alcohol, Smoke and Substance Involvement Screening Test) screener. Those who screened positive for risky drug use were offered enrollment in the QUIT trial, where they were randomized to either receive usual care or the intervention. Based on chart availability and participant consent, 484 (94.5%) charts are eligible for review. A retrospective chart review of 447 participants from the QUIT was performed using a standardized abstraction form to assess for documentation of substance use six months prior to enrollment to six months after enrollment. The primary measures are documentation in the medical record of substance use screening, diagnosis, or treatment. Data analysis will be achieved by first utilizing univariate and bivariate analysis and then multi-level modeling or intra-cluster correlation coefficient from an ANOVA. Comparisons between groups were analyzed with chi-squared testing.

Results: Review of participants’ charts showed: 10.3% of visits included no mention of alcohol screening. Per documentation, 5% of those with documented use of alcohol received counseling and recommendations to reduce use. 20.6% of visit notes included no mention of drug use or drug use screening. 13.9% of those that document drug use record any counseling or recommendations to reduce/quit usage.

Conclusions: Rates of documentation regarding substance use screening and counseling are not ideal. Via further data collection and analysis, we hope to explore the gap in documentation and/or provision of services. We hope to evaluate the effect of race, gender, number of health conditions, patient’s clinician, study clinic, and enrollment in QUIT on documentation and provision of substance use care.