McGovern R., Kaner E., Deluca P. et al.
Institute of Psychiatry, King's College London, 2012.
The primary health arm of the largest alcohol screening and brief intervention study yet conducted in Britain found that the proportion of risky drinkers fell just as much after the most minimal of screening and intervention methods as after more sophisticated and longer (but still brief) alternatives.
Summary This account has been superseded by an account based primarily on a later formally published report. It is retained here for archival purposes only. Please go to this analysis for the latest report.
This account is based on preliminary findings released by the SIPS project in the form of factsheets and conference presentations rather than peer-reviewed publication in academic journals. Later more detailed and scientifically formal accounts of these and other findings (such as what was actually done by the interventionists and what patients thought of it) will be incorporated as they emerge, and mailing list subscribers will be alerted to any alterations in the findings or their implications. Some of the documents to which links are provided may no longer be available on the SIPS project web site.
The project was 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 help them cut back. Other aims were to assess the feasibility of implementing such procedures in typical practice settings, and to discover what made these more or less likely to succeed.
Conducted in three English regions (London, the South East, and the North East), the project took the form of three randomised controlled trials in different types of settings: nine emergency departments; 29 GP surgeries; and 20 probation offices. After summarising common features across the three trials, this account focuses on the emergency department study, relying largely on a factsheet produced before formal publication of the findings.
All three trials involved random allocation of practices, departments or offender managers to different variants of screening and intervention. Staff seeing adult patients or offenders for usual purposes in these settings asked them to consent to screening and basic data collection. Those who screened positive were further asked to join the study of the interventions, usually The exception was the most intensive of the interventions in emergency departments and probation offices, intended to be reserved for specialist alcohol workers. to be delivered by the same staff after training by the study. To assess changes in their drinking and related issues, patients and offenders who were eligible for Across all three trials patients or clients already in treatment for drink problems were excluded as were those severely injured, suffering with a serious mental health problem, or who were grossly intoxicated or homeless. and agreed to participate in the intervention study were followed up six and 12 months later.
Three quick ways to identify risky drinkers were tested for feasibility and accuracy, the latter defined by how well they duplicated corresponding results from the AUDIT screening questionnaire, widely used to determine whether someone is probably drinking at hazardous, Scoring at least 8, the cut-off used by the study. harmful or possibly dependent levels.
Single question: The simplest and quickest method was to ask, "How often do you have eight (or for women, six) or more
Each drink is roughly a UK unit of 8gm alcohol.
on one occasion?" Monthly or more was considered a positive screen, meaning the respondent would be offered a brief intervention to help them cut back.
FAST Alcohol Screening Test: As used in the study, this begins with the question above and registers a positive screen if the response is weekly or more often. Otherwise three further questions About how often in the last six months the respondent has been unable to remember what happened during the previous night's drinking, failed due to drink to do what was normally expected of them, or experienced concern over their drinking from a relative, friend, or health professional. are asked. Scores in response to the four questions are summed So that, for example, people who have (even if in all cases less than monthly) drunk excessively, and forgotten what happened and failed to meet obligations would screen positive, as would someone who said they had never drunk excessively yet had either forgotten or failed to meet obligations at least weekly, or experienced concern on more than one occasion. to determine whether to proceed with intervention.
Paddington Alcohol Test (PAT): Used only in the emergency department study.
Patients identified as risky drinkers by these methods were all offered advice of some kind, so the study could not assess the absolute impact of this advice, only how the impacts of one variant differed from those of another. The main yardsticks These figures were adjusted for any significant differences between the patients on characteristics the study found related to how likely they were to end up drinking safely. were the proportions of patients who six and 12 months later did not score as hazardous (or worse) drinkers on the AUDIT questionnaire, which assesses alcohol intake and other indicators of harmful or dependent drinking. Other assessments included drink-related problems, quality of life, and use of services. Crime and health service costs before the study and over the 12-month follow-up were used to assess cost effectiveness in terms of gains in quality-adjusted years of life per £ change in costs to society.
All the patients and offenders in the intervention trial were given a standard The UK Department of Health's How much is too much? booklet, was the standard official public information available at the beginning the SIPS project. alcohol information and advice booklet, supplemented by a sticker with contact information for local alcohol treatment services. At issue was whether also offering different types and degrees of advice would make a difference to later drinking.Brief feedback: At its most basic, the booklet was accompanied only by very brief feedback from the health care or criminal justice practitioner who did the screening that the screening test had indicated the patient or offender was drinking "above safe levels, which may be harmful to you".
This account also draws on a description of the study's methodology and a conference presentation of the findings. In the UK, hazardous and harmful drinkers outnumber dependent drinkers 7:1. The greatest population-wide impact on alcohol-related problems can be made by identifying and intervening with these drinkers, even before they are aware of any problems or seek help. Primary care is an ideal setting, as this is generally the first point of contact with health services, one in five patients drink at hazardous or harmful levels, and studies have found brief interventions there reduce drinking by 4–5 standard drinks per week.
However, questions remain about the best screening strategy, whether longer or more sophisticated interventions work better, impacts in normal practice, and cost effectiveness, all questions addressed by the overall design of the SIPs trial. Additional to these common features, the primary care study tested its two screening methods (the single question and the FAST Alcohol Screening Test) in both a 'universal' form, which involved asking all eligible adult patients about their drinking, and in a 'targeted' form, which posed these screening questions only to those newly registering with the practice or whose complaints High blood pressure, mental health problems, gastrointestinal problems, or injuries. suggested excessive drinking – a strategy which might make screening more acceptable Partly because the questions can flow naturally from the main reason for the patient's attendance. to both staff and patients, and therefore more widely implemented. Also, the most extended intervention was to be delivered by specially trained practice staff rather than (as in emergency and probation studies) by specialist alcohol workers recruited for the trial.
In each of two areas (the North East; London and the South East) the aim was to recruit 12 GP practices Selected to have no existing programme of alcohol screening and brief intervention. to the study, and to randomise them in such as way that within each region, one practice was allocated to each of the possible 12 combinations of the two screening strategies, two screening methods, and three brief interventions. In the event, 29 practices were recruited. They were to be financially compensated for the time they would spend on research procedures and for each patient screened and advised or counselled about their drinking, with a greater payment for the more extended counselling option. Payments were intended to reflect those which might be applied if alcohol screening and brief intervention were among the national quality criteria agreed for general practice.
Despite staff enthusiasm, barriers to implementation cited by staff included workload pressures, lack of time, confidence or knowledge, concerns about patients' attitudes to being asked about drinking, and lack of follow-up services. Nevertheless, of the 29 practices, 17 managed to implement the trial as intended using only their own staff for recruiting patients to the study and for screening and intervention. At the other 12, researchers and the specialist alcohol workers who had trained the staff had to help out. Implementation was more successful where there were supportive managers and the research staff were able to engage with and provide ongoing support to individual staff.
In the end, over 15 months, 3562 patients were screened, of whom 2991 were eligible to participate in the study. Of these, 900 (3 in 10) screened positive and 756 agreed to join the intervention study. Typically white men, they averaged 44 years of age and an AUDIT score of 12–13, a medium severity Scores 8–15 inclusive. Higher scores represent a high level of alcohol problems; lower, non-hazardous drinking. of drinking problems, though around a quarter scored in the more severe range. Around 80% were followed up six and 12 months later.
Targeting screening meant fewer patients had to be screened in order to identify a given number who screened positive. Of the two screening tests, in terms of identifying people who screened positive for risky drinking on the AUDIT, the FAST Alcohol Screening Test was preferable (89% were identified) to the single question (81%), and significantly so at identifying people whose AUDIT scores indicated a medium severity of alcohol problems, the range thought appropriate for brief interventions.
Positive screen patients were then allocated to different forms of intervention. Virtually all allocated to brief feedback or advice received this plus the alcohol advice booklet, the full intended interventions. This was not the case for those allocated to lifestyle counselling; though nearly all received the five-minute brief advice and booklet delivered immediately after screening, only 57% attended a later appointment for more extended counselling.
Six and 12 months later the proportions of patients scoring as at least hazardous drinkers on the AUDIT questionnaire (initially around 80%) had fallen overall by 11% and nearly 17% respectively, but neither on this measure nor on all the other major yardsticks of patient drinking and welfare (average AUDIT scores, alcohol-related problems and health-related quality of life) had there been significantly greater changes after one type of intervention than another. The expected extra impacts of more extensive advice and counselling had not materialised; at 12 months the reductions were 17% after the two briefest options and only slightly more – 20% – among patients allocated to counselling. Neither The prior screening method through which the patient had been identified also made no difference to their later drinking. could it be shown that one intervention was better than another for particularly heavy drinkers.
On one measure there was however a statistically significant extra improvement among patients allocated to counselling – the proportions who said they were at least trying to cut their drinking. Among brief feedback patients this barely changed over the course of the study, hovering around 30%, but among counselling patients it increased from 28% at baseline to 46% and then 48% six and 12 months later. Looking back 12 months later, counselling patients too were on average slightly but significantly more appreciative of the quality of the communication and the general manner of the interventions they had experienced.
Another difference was in costs, averaging £2.40 per patient for the brief feedback option, £18.71 for brief advice, and £71.00 for lifestyle counselling. These costs were however overshadowed by the costs of the patients' health service use and crime over the 12 months of the follow-up. These totalled £3040 for brief advice patients, due to high crime costs, several hundred pounds more than for the other two groups. Contrary to expectations, the least intensive option – brief feedback – resulted in the greatest gains in quality-adjusted life years. Valuing each of these years at £20,000, it meant there was a 62% probability that this was more cost effective than brief advice and 87% in relation to more extensive counselling.
Given financial incentives, training and ongoing specialist support, most typical primary health care practices can implement alcohol screening and brief intervention. Most difficult to implement was the lifestyle counselling intervention, which required appointments to be made and kept, rather than the seamless delivery of briefer interventions during the patient's initial attendance.
In terms of screening, the Fast Alcohol Screening Test option proved best at identifying risky drinkers.
When it came to how to respond to these risky drinkers, the more intensive interventions offered no significant clinical benefits, even for heavier drinkers. On average all were followed by reductions in the severity of drinking, results which may have been due to the interventions, but may instead have been due to natural changes in relatively extreme behaviour, or to the impact of being repeatedly assessed for drinking and recruited to a trial of drinking interventions.
commentary See these Findings analyses for the sister studies conducted in emergency departments and probation offices. The following commentary explores common themes across these settings and any differences, and supplements these with comments focused on the featured setting, primary care. The general picture was that implementation often required specialist support, and there were no great differences between how well the screening methods identified patients and no significant differences between how well the interventions helped them reduce the severity of their drinking. What was intended to be a 'control' condition against which scientifically developed and longer interventions could shine, turned out instead to be the better option, reaping what clinical benefits there were at the lowest direct cost in money and time.
Seeing the effectiveness of brief interventions as established in principle, the studies aimed to assess whether they would also work in normal practice. First issue was the feasibility of implementing such programmes with training, support and incentives of the kind that might routinely be available. In each setting, the intention was that usual staff would undertake screening and intervention, except for the longest intervention of the three, lifestyle counselling. In probation and emergency departments, this was delegated to a specialist alcohol worker provided by the SIPS project, an extra resource which mirrors how such programmes would probably be (and in emergency departments, commonly have been) implemented in routine practice. The project also undertook training, though for the briefer interventions this was minimal. Apart from research tasks, enough to enable screening involving an understanding of the 'standard drink' used by the study to assess alcohol consumption, and an hour on how to deliver the brief advice option. For these interventions too, no structured ongoing support and supervision is mentioned, except "Research staff and trainers will maintain regular contact with practices throughout the study period, including site visits and telephone support." http://dx.doi.org/10.1186/1471-2458-9-287 for the primary care study, though researchers and alcohol health workers may have been available to offer ad hoc support.
One possibly important way the studies departed from normal practice was that usual staff also undertook the research tasks involved in recruiting patients to the trial and collecting baseline information. Compared to brief screening and intervention, this must have been a relatively substantial extra burden, one which may have suppressed the numbers screened Little pre-screening data collection was required, but staff would have known that a positive screen would demand more explanation of the intervention study, obtaining consent and data collection. and offered intervention.
Broadly, each study found that while implementing the tested programmes was possible, at many sites researchers and specialist alcohol workers who had trained the staff had to help with screening and intervention. Workload pressures, lack of knowledge, and feeling there were insufficient back-up alcohol services, were common themes. In emergency departments and in probation, inability to implement was the norm. Incentivized with per patient payments, most primary care practices managed to implement fully, but still 4 in 10 were unable to do so. While the denominators in terms of overall patient and offender throughput are unknown, the numbers screened seem to have been small, equivalent to about 12 per emergency department per week, less than two per GP practice per week, and one or two a fortnight in each probation office – and this despite the intention that half or more of the sites would screen nearly all the adults they saw who were capable of participating in the trials.
These findings have two possible implications. The first is to cast doubt over the potential for screening and intervention in these settings – as implemented and resourced in the trials – to make a significant contribution not just to the welfare of the individuals actually screened, but to the nation's health; numbers reached may simply be too small. Reinforcing this doubt was the uncertainty over the resultant impacts on those who were screened and advised (of which more below). Second is the possibility that those recruited to the trials and screened were not representative of all who might have been, and therefore too the possibility that how they reacted would not be duplicated in a national programme with the leverage to ensure widespread implementation.
Of all the settings commonly associated with brief interventions, primary care has the greatest potential to reach the greatest numbers, partly because of its coverage, and partly because there is a national requirement and framework for paying practices to undertake this work. The evaluation of Scotland's national brief intervention programme confirmed the SIPS finding that, decisively influenced by financial incentives, implementation was more acceptable to staff and more likely to succeed there than in emergency departments. Based on the three health board areas where these figures were known, the great majority of brief alcohol interventions were delivered in primary care. Though not averse to these unexpected discussions of drinking, patients rarely said they made any difference.
With GP practices looking for ways to improve incomes, the national requirement to offer screening and intervention contracts certainly has generated more activity. So far implementation has however been patchy, and the quality and even the reality of the services supposed to have been provided has been questioned. In London in 2010 a survey of staff responsible for local alcohol policy indicated low levels of investment in developing the role of GPs in screening and treating alcohol use disorders. Nearly two thirds of areas had yet to invest in or develop screening systems beyond those nationally required. In one large London borough not known for the rarity of its drinking problems, over half the practices which had contracted to provide screening failed to identify any risky drinkers using the stipulated screening survey, and in a year screening resulted in just ten people being referred for treatment. Whilst reluctance to address drinking 'out of the blue' is understandable, there is even reluctance to raise the topic in general health and well-being assessments.
In relation to screening, results from the trials have been amalgamated in a conference presentation. Of the three methods tested, the FAST Alcohol Screening Test had the broadest applicability, in all three settings virtually equalling or bettering the alternatives in terms of its ability to identify risky drinkers. Generally only the first (about frequency of excessive drinking) of the four questions had to be asked, and the test picked up 8 in 10 of the risky drinkers who would have been picked up by the longer AUDIT questionnaire, itself an accurate way of identifying hazardous drinkers in the British primary care context.
Whether screening is best implemented universally or targeted at certain patients or appointments was answered in favour of universal screening, if the yardstick was identifying the greatest number of risky drinkers and not missing out people (around 4 in 10 were missed) who would have screened positive. The most stringent test took place in the GP practices, where the same methods were used for universal and targeted screening. There the targeted method started with fewer eligible patients (1274 v. 1717) yet ended up netting more AUDIT-positive risky drinkers (461 v. 439), because (as intended) it did reserve screening for patients who were more likely to be risky drinkers. However, over a quarter who would not have been targeted turned out to score as risky drinkers. In a targeted strategy, their drinking risks being ignored. On the assumption that a universal strategy truly would be universally implemented, this may be the decisive consideration. But if targeting screening – favoured by primary care staff – encourages more complete implementation, the balance could shift in its favour.
The final link examined by the studies was how best to advise risky drinkers identified through screening. Once patients and offenders had been sorted in to risky drinkers who had agreed to join the intervention study, there was a remarkable uniformity in trends in their drinking. Six months later the proportions scoring as risky drinkers had fallen by 11%, 12 months later, by 16–17%. With one exception, on this, the primary yardstick used by the studies, an alcohol advice booklet plus a sentence or two of feedback alerting someone to their risky drinking was not improved on by adding more extended and individualised interventions. The exception was a fleeting extra reduction at six months among particularly heavy drinking offenders offered counselling. Given the many tests of significance made in the studies, this single finding may have breached the threshold of statistical significance purely by chance, but the concordance with reconviction data suggests a real effect. Even if this was the case among offenders, findings among the patients gave no grounds for triaging heavier drinkers in emergency or primary care settings to more extended brief advice.
As the researchers acknowledged, this does not mean the interventions were equally effective; they 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. Even before the interventions, 15–20% The figure is not available for probation. of emergency patients and nearly a third in primary care said they were trying to reduce their drinking. Apart from the possible reasons for the drinking reductions mentioned by the researchers, this in itself could account for the findings.
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 was intended in the interventions is clear, what was actually done is not. In particular, it seems reasonable to question whether brief feedback interactions really ended abruptly after a doctor, nurse or probation officer, had warned the person for whom they had welfare responsibilities that their drinking risked harm – that the recipients of this news did not respond and staff in turn respond back, in what could have become an interchange rivalling in length and perhaps exceeding in individualisation the brief advice option.
Reinforcing doubts over the impact of the interventions is the general finding that 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 signi ficant. 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. groups in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts comparable to those seen in the SIPs trials. Though the review which collated these findings did not single these out, the studies which offered only usual care to control patients often also registered such reductions.
Regarding primary care in particular, a synthesis of international research has convincingly shown that in controlled trials, brief intervention has led to greater reductions in drinking among risky drinkers than usual care or just asking about drinking, but left considerable doubt over whether such reductions would survive once intervention was 'scaled up' to practices in general, and applied by the general run of doctors to the general run of patients. These concerns applied no less to Britain, where the two positive trials demonstrated brief intervention's potential, but not necessarily that it would work in typical practices which themselves identified patients for intervention, and with patients not subject to the multiple selection gateways applied by the studies. The featured study, an attempt to answer the question about real-world impact, found that in these circumstances, recommended methods scientifically developed and tested were no more effective in reducing drinking and no more cost-effective in improving quality of life ( below) than a brief warning.
Where the longer interventions did score over this warning was in the impression they (or their offer) made on patients. Later they were more likely to claim they were trying to cut their drinking and the counselling patients were more satisfied with aspects of the intervention. Both make sense in ways which need bear no relation to whether patients actually did cut down. Patients seeing their GP or practice nurse who really were just told they were drinking at possibly harmful levels and offered no further advice might well have felt short-changed and uncared for, while those on whom the practice had (in primary care terms) 'lavished' several minutes or even more on their drinking might feel obliged at least to say they were trying to cut back.
The clearest difference between the interventions was in cost, likely to be persuasive given equivocal or no evidence that spending more gained more. Not only did this directly cost least, but on the health service's primary yardstick – quality adjusted life years – in both probation and primary care, the briefest intervention gained most years for each £ of social costs incurred by the drinkers. Only in emergency departments did the longest intervention have the edge, but this was minimal, and may have been partly due to these patients starting the study with the lowest quality of the three intervention groups and catching up somewhat in a natural levelling up.
In the primary care study in particular, the advantage of the briefest of the interventions would presumably have become clearer as higher values were assigned to each good quality year of life. The £20,000 value used in the illustrative figures is at the lower end of estimates.
All quality of life calculations are partly dependent on how quality is measured. SIPS used a health-related measure, ill equipped to capture losses or gains in the quality of social and leisure life, major domains within which drinking plays a role and is seen by consumers to have value (for which they are prepared to pay), just as excessive drinking can cause damage. Discounting such possible benefits of substance use as judged by consumers also makes a substantial difference to cost-benefit calculations.
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. Already screening for risky drinking is among the practices commissioners must incentivize through cash rewards, and audit procedures are intended to ensure this is followed by brief interventions or referral for dependent drinkers. From April 2013 this work will be incorporated in the NHS Health Check for older adults. 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.
In general, all areas covered by the strategy are expected to implement 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 For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief intervention Guidance explains that this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended 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 guidelines' preferences for targeted screening may also need to be re-evaluated, though SIPS' findings on this issue are probably not definitive enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. It seems questionable too whether the precision of the 10-item AUDIT screening questionnaire is sufficient to warrant the guidelines' preference for this as a first-line option, or as a triaging tool if a briefer screen is positive. The FAST method picked up 8 in 10 of the risky drinkers who would have been picked up by the AUDIT, and there was few signs of extra benefits from triaging higher risk patients to extended counselling. However, SIPS so far has nothing to say about whether AUDIT should still be used to identify, not higher risk drinkers for extended advice, but dependent drinkers for referral to treatment, the role envisaged in the reimbursement framework for screening by GPs in England.
Where guidance is clearly at odds with the findings is in its backing for the equivalent of the mid-level intervention, brief advice, and, subject to local conditions, the most extended option – motivationally based counselling – for heavier but probably still non-dependent drinkers. As highlighted in 2012 by the Department of Health's Director of Health and Wellbeing, the appealing message from the studies is that "Less is more". On the face of it, the findings go even further than her presentation suggests, offering most consistent backing for merely informing patients of screening results. For reasons outlined above, this message may be misleading because much more was and may have been done. But with no convincing reason to spend more money and time, it is easy to imagine that hard-pressed staff and austerity-hit commissioners will do the least seemingly justified by studies on which the government itself said it would rely for its policy decisions.
Last revised 19 May 2012. First uploaded