An Emergency Department Nudge-Based Strategy to Screen and Treat Patients With Alcohol Misuse

Abstract

Study objective To examine the effectiveness and implementation of a multicomponent strategy to increase emergency department (ED) initiation of evidence-based treatment for patients with alcohol misuse. Methods Setting was an academic health system with 6 hospitals. Interventions occurred in the ED at 4 of the hospitals, with the other 2 serving as controls. We launched interventions in 2 phases: (1) ED discharge order set with clinical decision support (May 20, 2024); (2) screening for patient concerns about alcohol use and facilitating treatment conversations (August 21, 2024). Multivariate logistic regression assessed changes relative to baseline in the primary outcome, proportion of ED patients with an alcohol-related discharge diagnosis who were discharged with a naltrexone prescription. A difference-in-difference analysis compared intervention hospitals to controls. Results Across the 43-month study period, there were 8,909 (2.0%) ED patients discharged with an alcohol-related diagnosis code. At intervention hospitals, there were 13 (0.2%) discharged with a naltrexone prescription at baseline, 18 (2.7%) during phase 1, and 81 (3.2%) during phase 2. At control hospitals, the rate of naltrexone prescribing was flat across these periods (0.0%, 0.0%, and 0.3%, respectively). In the multivariate model, patients with alcohol-related diagnoses at intervention hospitals were more likely to be discharged with naltrexone in phase 1 (odds ratio [confidence interval] = 12.3 [6.0 to 25.7]) and phase 2 (14.6 [8.4 to 27.4]) compared to baseline. The difference-in-difference analysis showed a 2.9% [2.4% to 3.5%] greater absolute increase in naltrexone prescribing among intervention hospitals. Conclusion A triage-based ED protocol that integrated universal screening, electronic health record banners, and clinical decision support increased initiation of naltrexone to treat alcohol misuse and alcohol use disorder.