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 be haviors, 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 (m ean age, 18.1 years; 67% female: 88% white; 69% with juvenile rheumatoid ar thritis) 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 p erceptions 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 underg oing screening at follow-up, 20 (36%) of 56 patients reported any alcohol u se and 11 (20%) reported current alcohol use. Of those reporting current us e, 7 (64%) were counseled or referred. Methotrexate use increased the likel ihood 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<.00 1) from baseline to follow-up up. Of 51 females undergoing screening at fol low-up, 31 (60%) were sexually active. Eleven (41%) of 27 sexually active f emales were not using contraception other than condoms (4 were not asked ab out contraceptive counseling. Seven of these were referred for contraceptiv e counseling. Seven rheumatologists completed in-depth semistructured inter views after the intervention. All reported time as a main barrier to screen ing. Other barriers included logistical problems, discomfort with the subje ct 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 immunos uppressive therapy and risk behaviors, Few rheumatologists adequately scree n the behavior of their adolescent and young adult patients. Time constrain ts, organizational issues, and physician beliefs remain barriers to widespr ead screening.