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Can brief alcohol interventions improve health population-wide?

Great store has been set on identifying risky drinkers by asking a few standard questions (screening) when they attend medical or other services for other purposes, and then briefly counselling or advising the risky drinkers (brief intervention) for typically from five minutes to half an hour to prompt them to (re)consider their drinking and subsequently cut back. Especially in the absence of effective population-level measures like increased price and diminished availability – which whether there is a desire to cut back or not, place real obstacles in the way of continued heavy drinking – screening and brief intervention offer a relatively inexpensive strategy which in theory can reach a large proportion not just of very heavy drinkers, but of the far greater number running lower risks from their drinking. GP primary care practices have the greatest reach of all medical services and are the prime target for embedding screening and brief interventions in everyday practice, so are the focus of this hot topic.

Does the SIPS trial mean do the least?

For the future of these efforts in Britain, studies do not get more important than those highlighted in an Effectiveness Bank bulletin issued in May 2012. It summarised findings released by the SIPS project, funded by the UK Department of Health in 2006 to evaluate the effectiveness and cost effectiveness of different ways of identifying risky drinkers through routine screening, and different forms of brief advice to prompt them to cut back. These preliminary findings in the form of factsheets and conference presentations were followed by formal journal publication of results from the primary care, probation and emergency department arms of the study.

Whatever the setting, a year later the proportion of risky drinkers had fallen by about the same proportion, and whatever the intervention, it made no substantial difference. Most basic was a simple warning that the patient or offender was drinking “above safe levels, which may be harmful to you”, plus an instruction to read the alcohol information booklet they were handed. Supplementing this with an individualised brief intervention based on relatively sophisticated counselling techniques and scientific understandings made no difference. Numbers screened also seem to have been small and achieving them often required specialist support.

Do just the minimum, is the message austerity-hit commissioners might take from the trials, encouraged by the “Less is more” take on the study from the Department of Health’s Director of Health and Wellbeing. That would, however, be to over-read their implications. Rather than being equally effective, all the interventions may have been equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. It cannot even be said that screening plus a sentence of feedback is all it takes to get whatever benefits are available. These came after patients and offenders were quizzed about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. Also, while what the interventions were intended to be clear, what was actually done is (as yet) not. British experts have stressed that the findings are far from justifying the conclusion that handing over an alcohol advice leaflet is all it takes to get whatever benefits might accrue from screening and brief intervention. Supporting them are studies showing that who does the intervention and how can make a difference to outcomes. But generally the SIPS trials show that extra impact cannot be guaranteed simply by extending the time period and sophistication of the intervention.

Ambition scaled back

Not so long ago virtually universal screening of adult primary care patients was seen as the prime way to start to reduce the burden of alcohol-related harm through screening and intervention. Now the ambition in England and in Scotland has been scaled back to screening new patients and/or those thought in advance to possibly be at risk (so-called ‘targeted’ screening), diluting the hoped-for public health benefits of a mass programme. This issue too was addressed by the SIPS project, which found in favour of universal screening if the yardstick was identifying the greatest number of risky drinkers and not missing out people who would have screened positive. But the SIPS findings are probably not definitive enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. These factors could also mean that targeted screening is more completely implemented than universal, potentially eliminating the latter’s advantages identified in the SIPS trial.

The route from screening nearly everyone to today’s less ambitious plans was punctuated by heated arguments over whether it was appropriate or feasible to ask GPs to question patients about their drinking, when this was not why they came to see the doctor and there was no apparent reason to raise the issue. Controversy peaked when in 2003 a review in the British Medical Journal concluded that on average 1000 patients have to be screened to gain just two or three no longer drinking to excess. It was not necessarily that brief advice was ineffective, but that so few patients got to the point of receiving it. Critics hit back, but British studies (referred to in this Effectiveness Bank analysis and detailed in these background notes) confirmed that very low rates of screening and intervention were the norm.

Even among patients who do receive brief advice, it remains unclear whether impacts found in research projects will be replicated in normal practice. An attempt to address this issue divided primary care trials in to those which more versus less approximated how brief interventions would be conducted in practice. Finding no difference between the two sets of trials in the impact of the interventions, the analysts argued that the combined results of all the trials would be applicable to routine practice. A later synthesis was based on eight of the same primary care trials plus two others, and again found brief intervention created statistically significant drinking reductions compared usually to screening only. But a close look at each of the reviewed trials, including the screening phase essential to testing the brief intervention, reveals that few if any of those categorised as relatively real-world can be considered to have been conducted in truly real-world conditions (1 2). There have been trials which more closely approximated what can be expected to be routine practice, but it seems these have foundered due to non-implementation of the interventions and/or did not find significant effects.

Strong management levers can extend intervention

The US Veterans Affairs (‘VA’) medical service for former military personnel offers a large-scale exception to the implementation shortfalls typical in real-world conditions, but their evaluations show that despite this achievement, many risky drinkers are not identified and there may at best be only minor impacts on drinking.

Faced with a high proportion of risky drinkers among its largely male primary care caseloads, the service mounted possibly the most determined and successful effort yet in a national health service to routinely implement virtually universal screening for risky drinking and to prompt primary health care staff to respond with brief counselling or referral to alcohol services. Deploying powerful management levers which hit the wallets and purses of managers if performance targets were not met, the service screened over 90% of outpatients nationwide using a single question to establish if the patient drank at all, followed if they did by the three questions of the AUDIT-C questionnaire. Though quantity was there, screening quality was called in to question when it was found that 61% of patients who screened positive when sent a postal survey did not do so when the same questions were asked as part of their routine care.

The next step was to prompt clinicians to intervene with positive-screen patients and to embody this too in a performance target. As with screening, this substantially elevated brief intervention rates. It also seemed to reduce drinking, but only as long as there were management expectations on the clinicians not to dismiss the electronic reminders. However, the interventions stimulated in this way reduced drinking only slightly, and without randomising clinics or patients to be counselled or not, the results were vulnerable to bias, leaving as yet no convincing demonstration that this effort had the intended impacts. In turn this may have been due to the inability to assess or influence the quality of the counselling, and even whether, despite the clinician having recorded this, it really happened.

Across an entire VA region’s 30 medical centres, drinking outcomes after brief intervention have been also been disappointing. Using VA records, it was found that patients who screened positive for risky drinking and were re-screened around a year later were no more likely to have stopped risky drinking if their records indicated that had participated in a brief intervention than if they did not. The remission proportions were virtually identical – adjusted for other factors, 47% with advice, 48% without. Results from this early phase of the new national system offered no encouragement to its continuation, though results may change as the system beds in and is developed.

To standardise quality and improve the consistency of delivery rates, the service tried automating brief intervention via a web-based program, but it had no demonstrable impact on drinking over and above the service’s mandated but patchily delivered usual alcohol advice requirements. The program featured the strategy of feeding back to positive-screen drinkers the degree to which they exceeded typical drinking amounts, also featured in real-world trials of web-based brief intervention among college students in Sweden and New Zealand. These too found no or at best very small extra reductions in drinking which might not have been due to due the interventions, meaning real-world web-based intervention has largely failed at both ends of the age spectrum in very different populations.

Veterans Affairs is not the only service to have shown that implementation barriers can be overcome. Elsewhere too, ‘booster’ training and incorporating screening questions in simple-to-implement procedures which matter to the service (in this case, for their quality accreditation) has resulted in over 80% of patients being screened. Recorded brief intervention rates too were elevated to over 60% by making it easy to record an intervention and doing so in a way which included this in quality reviews of the clinician’s performance. Even in the unpromising environment of an emergency department, near universal screening and acceptable intervention rates can be achieved if the need to screen/intervene for each patient is visible to staff and made easy to meet, and staff supervision includes monitoring performance and correcting underperformance.

Though the more complete the implementation the greater the chance of population-wide benefits, patchy delivery and modest impacts do not necessarily mean a programme is worthless. In a health care system which repeatedly sees the same patients, low rates of intervention can cumulate over the years to a programme which touches a high proportion of patients, and minor gains per individual can sum to appreciable public health gains.

UK policy and guidance

Even in its more limited targeted form, still screening plus brief intervention remains an important policy strand in the UK. In England, directors of public health are expected to include it among attempts to address the population-wide determinants of ill health, in line with guidance from the National Institute for Health and Clinical Excellence on prevention and treatment of drinking problems and associated quality standards and guidance for commissioners. These documents’ insistence that commissioners and managers of NHS-commissioned services “must” ensure staff have enough time and resources to carry out screening and brief intervention work effectively seems a tall order, given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation and the need for specialist support – and this in services which had volunteered to participate in the studies.

The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of primary care practice. As of the 2015/16 arrangements, it seems the decision for England was not to. However, screening for risky drinking and follow-on brief intervention – formerly merely required to be incentivized in each local area – are from April 2015 required of every GP practice in England for all newly registered patients as part of the core national contract for primary care services. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses.

Under the contract with GPs, screening is to be done with the three or four questions of the FAST or AUDIT-C questionnaires, and followed up for positive-screen patients with the full ten questions of the AUDIT questionnaire. Based on the risk level revealed by the last screening step, patients should be offered brief advice, more extended counselling, or referral to specialist services, though so far results from the SIPS trial have not indicated that brief advice or more extended counselling offer extra benefits compared to a basic warning and leaflet, even for higher risk drinkers. Each step of the process is to be recorded by GPs for a nationally collected dataset and the records are intended to be audited by local commissioners to ensure the required actions were completed. In theory this would enable the identification of practices which, with no financial incentive to screen and advise, either fail to screen or record an abnormally high proportion of patients as not needing further testing or advice.

Similar work has also been incorporated in the NHS Health Check for older adults, intended to be repeated for each patient every five years. From local studies it seems clear that universal alcohol screening and advice has not been incorporated in the checks, though still many patients have been prompted to think about their drinking who might not otherwise have done so. Uptake of the check has sometimes been below expectations, but each year it engages substantial minorities of patients (1 2). Data collected in 2011/12 from Gloucestershire primary care practices showed that 54% of patients who attended a health check were screened for risky drinking, the lowest proportion of all the lifestyle risk factors. Based on the population there were expected to have been 839 referrals for further intervention for problem drinkers, but there were just 17; how many took up the referral was not reported. Alcohol was raised with about 52% respondents to a survey of health-check attendees at risk of cardiovascular disease among GP patients in Stoke-on-Trent, and of these 36% said they had as a result cut down on their drinking. In numbers this was 82 patients, though in the survey just 27 had owned up to drinking excessively. In England’s north-east region, interviews with 29 patients who had attended a health check revealed that 24 could not recall their drinking being discussed.

Scottish national alcohol policy prioritised screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded and similar targets were set for the following years and again exceeded, topping 94,000 in both 2011/12 and 2012/13 and reaching 104,356 in 2013/14. The targets relate to meeting the corresponding standard of service intended to sustain and embed alcohol brief interventions in primary care, emergency departments and antenatal clinics, and extend them to other arenas. The recommended brief intervention approach for primary care leans heavily on motivational interviewing. Like the English guidance, it ignores the apparent lesson of the SIPS trial that a basic warning and leaflet is as effective as longer and more sophisticated counselling.

An evaluation found that “healthcare staff see the delivery of [alcohol brief interventions] as a worthwhile activity for NHS staff”. But of the three settings, only primary care practices really accepted the challenge: head-count financial incentives, the ability to seamlessly advise after screening, and more of a feeling that this was an appropriate activity, lifted their performance way above emergency departments and antenatal clinics. But even in GPs’ practices it seems most risky drinkers attending the practices were not screened and the quality of the work was unclear. The barriers identified in an international review remained evident, particularly in antenatal and emergency care settings, which accounted for relatively small numbers of interventions. Competing priorities, not enough time, concerns over relationships with patients, feelings that this was not what you should be doing, all hampered implementation. These influences were also evident in the SIPS trials in England, where payments to primary care practices seemed decisive in their greater (though still disappointing) throughput. Nevertheless a simulation model of the health impacts of the Scottish national programme estimated that it had made a small contribution to the decline in alcohol-related harm in Scotland, even if the brief interventions had been successful in only 15% of cases. To reach this estimate the report did however have to make some bold assumptions about the drinking and mortality reductions to be expected from the programme.

Brief interventions have tremendous public health potential; consistently realising that potential is today’s challenge. See all our relevant analyses by running this hot topic search, or go to the first row of the Alcohol Treatment Matrix to home in on seminal and key studies, reviews and guidance.

Last revised 01 October 2015. First uploaded 01 May 2010

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