Project Summary Unhealthy use of alcohol remains a critical problem with high-risk drinking increasing by almost 30% between 2001-2002 and 2012-2013. Excessive alcohol use is the third leading cause of preventable death, and is linked to chronic medical conditions, lost productivity and direct cost to health systems. Evidence-based practices are available to prevent and treat unhealthy alcohol use and its detrimental consequences. To facilitate uptake of these practices, health systems use quality measures to identify aspects of care being done well and monitor areas for improvement. The National Quality Forum has endorsed several care quality measures for unhealthy alcohol use, which have been adopted for routine decision-making by health systems. These include indicators for initiation and engagement in treatment for alcohol and other drug (AOD) abuse or dependence (equivalent to substance use disorder), as well as follow-up after an emergency department visit for AOD abuse or dependence. Another area proposed for broader adoption is universal screening for unhealthy alcohol use. Despite adoption of these five measures by health systems, the generalizability of these alcohol-related quality measures has not been fully established. This includes the lack of knowledge on the expected variability and reliability of quality measured at different levels of a health system (e.g., clinics, providers). In addition, limited information exists on the meaningful drivers of improved performance to guide health systems with quality improvement efforts. This study seeks to address these scientific evidence gaps through the following two specific aims: 1) examine the variability and reliability of care quality measures for unhealthy alcohol use, and 2) identify multi-level factors associated with care quality for unhealthy alcohol use. For each of the five quality measures of focus, hierarchical modeling will be applied to characterize the variability and reliability at four levels of health care delivery: patient, provider, clinic and community. Hypothesis generating analyses in Aim 2 will extend hierarchical models from Aim 1 and examine the influence of an expansive set of explanatory variables conceptually related to receipt of guideline concordant care. Research in all aims will be conducted within the Kaiser Permanente Washington (KPWA) Health System, which is part of one of the largest nonprofit healthcare systems in the US. KPWA is an ideal setting given its hierarchical structure and extensive administrative and electronic health record data to measure quality and multi-level determinants of care quality. Together, scientific insights gained from this study will provide best practices for the measurement of quality indicators and enhance reporting tools that disseminate quality information. This will support the study team's long-term goal of increasing the effectiveness of strategic performance reporting to accelerate efforts to improve care quality...