Improving rheumatologists' screening for alcohol use and sexual activity

Objectives: To design, implement, and assess the impact of an office-based intervention designed to improve rheumatologists' identification of risk behaviors, especially alcohol use and sexual activity, among adolescents and young adults with chronic rheumatologic conditions. Design: Prospective intervention study. Setting: Midwestern academic pediatric rheumatology practice. Participants: Ten attending rheumatologists and fellows and 178 patients (mean age, 18.1 years; 67% female: 88% white; 69% with juvenile rheumatoid arthritis) seen in the practice during the baseline and intervention years. Main Outcome Measures: Change in the rate of screening for alcohol use and sexual activity from the baseline to the intervention year, and physician perceptions of the intervention. Results: Screening for alcohol use increased from 4.2% (9/208) at baseline to 31.6% (56/177) after the intervention (P<.001). Of those patients undergoing screening at follow-up, 20 (36%) of 56 patients reported any alcohol use and 11 (20%) reported current alcohol use. Of those reporting current use, 7 (64%) were counseled or referred. Methotrexate use increased the likelihood of alcohol screening (43% [33/76] vs 26% [23/87]; P = .02). Screening for sexual activity increased from 12.4% (27/218) to 36.2% (64/177) (P<.001) from baseline to follow-up up. Of 51 females undergoing screening at follow-up, 31 (60%) were sexually active. Eleven (41%) of 27 sexually active females were not using contraception other than condoms (4 were not asked about contraceptive counseling. Seven of these were referred for contraceptive counseling. Seven rheumatologists completed in-depth semistructured interviews after the intervention. All reported time as a main barrier to screening. Other barriers included logistical problems, discomfort with the subject area, ambivalence about whether risk behavior screening is the province of pediatric rheumatologists. and perceived lack of applicability to their patients. Conclusions: Despite knowledge and concern about the interaction of immunosuppressive therapy and risk behaviors, Few rheumatologists adequately screen the behavior of their adolescent and young adult patients. Time constraints, organizational issues, and physician beliefs remain barriers to widespread screening.