Summer Collier, DNP, MSN, FNP-BC

Abstract:

Background: Alcohol-associated liver disease (ALD) is the leading cause of liver-related morbidity and mortality in North America. Despite strong evidence supporting pharmacologic treatment for alcohol use disorder (AUD), pharmacotherapy remains significantly underutilized in hepatology settings. Identified barriers include provider unfamiliarity, safety concerns in cirrhosis, and system-level workflow limitations. Aim: To increase prescription rates of AUD pharmacotherapy in a high-volume hepatology clinic through targeted, scalable quality improvement interventions integrated into existing workflows. Methods: This single-center, quasi-experimental quality improvement study compared two cohorts of adults with ALD and active alcohol use seen in a hepatology clinic: pre-intervention (January–March 2023; n=143) and post-intervention (January–March 2025; n=175). Interventions included provider education, standardized alcohol screening, integration of decision-support tools (including a prescribing algorithm and documentation templates), and improved access to long-acting injectable medication. Outcomes were assessed via retrospective chart review. Multivariable logistic regression using backward stepwise elimination was performed to identify predictors of alcohol use disorder pharmacotherapy initiation. Results: AUD pharmacotherapy prescribing increased significantly from 10% pre-intervention to 43% post-intervention (p<0.00001). Documented discussions of pharmacotherapy rose from 33% to 80% (p<0.00001), while deferral to psychiatry or primary care decreased from 7% to 1% (p=0.006), indicating enhanced provider engagement and prescribing autonomy. Among those prescribed treatment, use of first-line agents such as oral naltrexone and acamprosate increased, and long-acting medication (Vivitrol) was newly adopted. Regression analysis (AUC=0.77) identified three independent predictors of pharmacotherapy initiation: post-intervention year (OR=6.03, 95% CI [3.20–11.34], p<0.001), recent positive phosphatidylethanol (PEth) test (OR=2.44 vs. no PEth, 95% CI [1.28–4.64], p=0.007), and a trend toward lower Child-Turcotte Pugh (CTP) scores (OR=0.87, 95% CI [0.75–1.00], p=0.057). Model deviance R² was 16.2%, reflecting moderate fit likely influenced by unmeasured variables such as patient readiness for behavioral change. Conclusion: Embedded, interdisciplinary quality improvement interventions can substantially increase alcohol use disorder pharmacotherapy rates in hepatology without requiring structural clinic overhauls. This approach enhanced provider autonomy, reduced unnecessary deferrals, and optimized the use of clinical tools such as PEth testing. Findings support broader implementation of pragmatic, evidence-based strategies to improve alcohol use disorder care for patients with alcohol-associated liver disease in specialty settings.

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