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Academic ED SBIRT Research Collaborative.
Alcohol and Alcoholism: 2010, 45(6), p. 514–519.
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A few minutes with specially hired interventionists can curb the intake of heavy-drinking emergency patients, but in routine practice hospital staff will usually have to do this work. A US study tested this real-world scenario and found the modest drinking reductions were short-lived.
Summary Set in US emergency departments, this report investigates whether short-term (three months) drinking reductions among risky drinkers exposed to a brief alcohol intervention (reported earlier in Findings) would be sustained over the following nine months, a year in total since the intervention. The elements of the intervention – screening, brief intervention, and (if appropriate) referral for treatment – make the acronym SBIRT, which together with its emergency department setting formed the acronym for the study – ED SBIRT.
For the study, patients whose responses to a seven-question screening survey administered by research staff indicated that they were drinking above US national low-risk guidelines Men, more than 7 UK units (each unit is 8gm alcohol) in a day and no more than 24.5 in a week; women, no more than 5.25 units in a day and no more than 12.25 in a week. were recruited from 14 sites nationwide. Following screening, at each site these patients were sequentially allocated to form a comparison (or 'control') A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group simply given a list of local referral options, or to the SBIRT intervention. SBIRT patients received the same handout plus the 'Brief Negotiated Interview' intended to reduce unhealthy alcohol use. Based on motivational interviewing, during this highly scripted session lasting on average eight minutes, specially trained emergency department staff first fed back to the patient the results of the screening tests and expressed concern at their risky drinking, then sought to enhance motivation to cut back using motivational techniques such as exploring the pros and cons of drinking as the patient sees them, and reframing and reflecting back to the patient some of their own responses. The session was planned to end with the patient signing an agreement committing them to the drinking goals decided during the preceding discussion, and with referral to primary care or alcohol services as appropriate.
Follow-up surveys were conducted three, six and 12 months later by telephone using an interactive voice response system. 8908 patients were approached at the sites and 7751 agreed to be screened. Of these, 2051 exceeded low-risk limits and 1132 (55% of the identified risky drinkers) agreed to join the study and were enrolled. Of these, 62% completed the three-month follow-up survey, 50% at six months and 38% at 12. There were indications that patients most likely to miss the follow-ups were those least likely to respond well to the intervention. At the first and presumably too later follow-ups, they tended disproportionately to be men, without health insurance, and among the less well educated in the sample.
At three months there was a clear impact of the intervention. After adjusting for differences between the groups and estimating Because of these estimates results differ slightly from those previously reported. probable outcomes for patients who could not be followed up, patients allocated to the intervention reported consuming just over five UK units Three US standard drinks or 42gm alcohol. less per week than controls, and the maximum number of drinks per occasion was one and a third UK units 0.76 US standard drinks or 10.6gm alcohol. less. As a result, 26% of SBIRT patients no longer exceeded US low-risk alcohol consumption thresholds but just 17% of controls.
By six months and again at 12 months these promising effects had nearly or entirely dissipated and there were no statistically significant differences in alcohol consumption between intervention and control groups. At all three follow-up points, risky but probably not dependent CAGE screening test score under 2. drinkers did not respond Presumably correcting the earlier report on three-month outcomes which said risky but probably not dependent drinkers had responded better. significantly better to the intervention than possibly dependent CAGE screening test score 2 or more. drinkers.
Lack of intervention effects at 12 months is consistent with results from other recent emergency department studies and highlights the importance of multi-contact interventions and/or 'booster' sessions for maintaining the impact of brief interventions on risky drinking. The substantial literature on brief interventions in primary care settings provides strong support for this conclusion, as virtually all the studies reporting effects persisting beyond three months mounted multi-contact interventions. According to a recent review of brief primary care alcohol intervention studies, effects from all single contact interventions decayed markedly after three months. Given the success of primary care brief interventions, active referral to GPs offers an opportunity to enhance emergency department interventions. However, difficulties in this study in maintaining research contact over the follow-up period may mean that multi-contact interventions too will be poorly attended. Not only might this reduce their impact, it would also complicate the evaluation of such interventions as loss to follow-up will probably be conflated with loss to further intervention sessions.
commentary This report from a large-scale and important US study underlines the fragility of the evidence base for emergency department brief alcohol interventions, which are best seen as having an established potential for curbing drinking and injuries, but one inconsistently realised. By training the hospitals' own emergency staff to conduct the intervention rather than relying on 'imported' specialists, the study went part way to testing a more real-world implementation of brief interventions than most other studies, but still the screening element was conducted by research staff. When hospital staff are relied on, unless they are motivated and committed, few people who might benefit from intervention are identified. Despite research-aided screening, on average each interventionist in the featured study counselled just one patient every 19 days, a figure which might have risen to one every 10–11 days without the encumbrance of research procedures. In the absence of dedicated screening personnel, throughput would probably have been much less.
Emergency staff who conducted the intervention were unable to fully sustain practice improvements after a single training workshop in the intervention. Though still higher than before training, 12 months later they were using the intervention less often than three months after training and felt slightly less confident about using it and less responsibility for its implementation. Untouched by the training were the barriers they felt to implementing such interventions, including the need for institutional support, continued supervised clinical practice, time constraints, reimbursement problems and the lack of referral options for patients needing follow-on care. The conclusion was that booster training sessions might help, though clearly some of the barriers would also be barriers to further training and would continue to impede implementation of that training.
Further distancing the study from routine implementation was the fact that all the trial sites were academic departments, whose commitment to staff training and evidence-based practice is unlikely to be matched across the board. In particular, they were selected partly because they already had weekly conferences for resident education. Elsewhere training and implementation might have been less successful and drinking reductions seen fleetingly at the three-month follow-up might have been less apparent.
The study was carefully designed and eliminated major threats to the validity of its findings, but suffered from an inability to follow-up patients, a testament to the transient nature Half were not working and over a quarter had failed to complete compulsory schooling. On average they typically drank 23.5 US drinks per week (329gm alcohol or 41 UK units). of US heavy drinking emergency patients. Over 60% who started the trial were missing at the last follow-up. Together with identified at-risk drinkers who did not join the study, it meant that the final follow-up involved just a fifth of the patients who might have been targeted for alcohol intervention. No current estimation method can eliminate concerns that such a study is an inadequate (even if one of the best we have) guide to how the intervention might perform if routinely applied to all at-risk drinkers seen by emergency departments.
Along with the small size of the extra Extra that is compared to research procedures, screening, and the handing over of a list of treatment services. drinking reductions attributable to the interview and their dissipation within six months, the study does not offer much reassurance on the effectiveness or cost-effectiveness of training emergency department staff in structured alcohol interventions as opposed to simple advice-giving and referral.Previous studies have shown that just a few minutes counselling at-risk drinkers among emergency patients can reduce consumption and alcohol-related injuries, improve welfare, promote treatment uptake, and cut the future workload of emergency services. But there have also been negative findings, and the research record is fairly evenly balanced between these and more positive findings. A recent synthesis of research on interventions conducted actually in the emergency department rather than after admission found that overall such interventions have not been shown to significantly reduce alcohol consumption, while impacts on drink-related problems have been variable. More positively, three studies did together indicate that six to 12 months after the interventions patients were half as likely as comparison patients to have suffered an alcohol-related injury, but all three were from the USA, and two involved only teenage patients whose drinking would have been illegal in that country. In all three the patients were known to have recently been drinking or had a history of drink problems rather than merely having tested as exceeding national drinking guidelines, underscoring the possibility that heavy drinkers are most affected by such interventions.
Patchy findings have prompted attempts to identify why some interventions have worked in some situations but others have failed, but the evidence is insufficient to answer this question. In particular, it remains unclear whether a relatively elaborate, theory-based approach really is needed. One well designed US study, which managed to follow-up nearly all the patients it recruited, found that an intervention very similar to that in the featured study was no more effective than one minute of straightforward advice at discharge that (among other things) the patient cut their drinking. As in the featured study, both interventions were conducted by emergency department staff.
It seems likely that (as in a US study) when emergency department alcohol interventions do curb drinking, impacts are concentrated among relatively heavy and/or dependent drinkers rather than those who only modestly exceed low-risk drinking limits.
In 2008 an audit of alcohol health service provision in England found that advice-giving at accident and emergency departments was rare. Commissioners have reportedly found it hard to persuade staff to undertake this work.
The best researched example is the programme at St. Mary's hospital in London, which uses trained and motivated (performance feedback is important) emergency unit staff to screen suspected heavy drinkers or patients with complaints linked to heavy drinking. Doctors explain to positive screen patients that drinking is damaging their health and offer an appointment with an on-site health worker, typically the same or the next working day. In these circumstances, two-thirds of patients attend for advice. Offering this service was found to reduce later drinking and return visits to the department. This last finding may be attractive to commissioners seeking to meet national targets to reduce alcohol-related hospital admissions. Further analysis based on the same study found that total public service costs and productivity losses over the following 12 months were roughly equivalent whether or not the intervention was offered, but that offering it was the most cost-effective option for reducing drinking. Another study at the unit demonstrated the (at least temporary) feasibility of tasking reception staff to hand out screening questionnaires to all adult ambulant patients, and the willingness of over half the patients to fill in and return the forms.
In England directors of public health are expected to include alcohol brief interventions among attempts to address the population-wide determinants of ill health. This policy is in line with recommendations from Britain's National Institute for Health and Clinical Excellence (NICE), which in 2010 saw screening and brief interventions targeted at risky drinkers as an effective way to prevent drinking problems, though one less important at a population level than policy changes affecting the price and availability of alcohol. Among the sites NICE envisaged for this work were emergency departments, and the recommended approach was the FRAMES model. Feedback (on the client's risk of having alcohol problems), responsibility (change is the client's responsibility), advice (provision of clear advice when requested), menu (what are the options for change?), empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism about the behaviour change). However, the guidance acknowledged that (in contrast to primary care) research on emergency department interventions was scarce and the barriers to implementation were considerable.
In Scotland national policy prioritises screening and brief intervention in primary care, antenatal care, and accident and emergency departments, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions across the three years supported by dedicated funding. Set in the context of what was in any event 111,200 primary care consultations for alcohol misuse in a single year in 2006/07, this target of around 50,000 a year across all three priority settings may seem to lack ambition.
The Welsh substance misuse strategy recognises the potential value of brief alcohol interventions in accident and emergency departments, but its action plan made no commitment to their expansion; neither did the strategy for Northern Ireland.
Given findings to date and the policy context in most of the UK, commissioners and emergency department managements may not feel alcohol screening and intervention initiatives are mandated either on the evidence or by policy levers. However, neither should they ignore the possibility that patients' health can be improved, and department workloads relieved, by brief advice to risky drinkers identified through a rapid screening procedure and/or through indications Such as blood alcohol levels, reports on the precipitating incident, or the nature of the patient's complaint. that the attendance was alcohol-related. If procedures permit, screening questions should be built in to routine assessment/triage procedures. Unless actively and continuously monitored and encouraged, screening may be applied haphazardly and to only a small proportion of the patients who could benefit. If possible the intervention should be conducted while the patient is waiting in the department or on the ward if admitted as an inpatient. If a follow-up reminder and progress check (in person or by telephone or letter) can be factored in, outcomes can be monitored and are likely also to be improved. More severely dependent patients require referral to treatment, preferably actively pursued then and there by hospital staff. A letter to the GPs of positive-screen patients would alert them to the need to pay attention to the patient's drinking, and offer a second chance of intervention if counselling in the hospital proved impractical or was refused.
In the UK advice on brief interventions is available from the Alcohol Learning Centre. US guidance is available on the specific intervention used in the featured study and on emergency department alcohol screening and intervention in general.
Thanks for their comments on this entry in draft to Robert Patton of the National Addiction Centre in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 11 March 2011
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