These notes expand on the commentary in the Findings analysis of the SIPS trials of screening and brief intervention in primary care in England. As well as formally published reports, they rely on preliminary findings released by the SIPS project on its web site in the form of factsheets and conference presentations rather than peer-reviewed articles in academic journals. At the time of writing, these sorts of documents are the main sources for findings from probation and emergency departments. Later more scientifically formal accounts of these findings will be incorporated as they emerge, so the detailed findings and perhaps too the conclusions are subject to change.
These extended notes first summarise key features of the featured primary care study, before setting these in context by exploring common themes across all three settings and any differences, especially in respect of primary care. Finally, policy implications are explored.
Taking in all the information available to date including preliminary reports, it seems that given financial incentives, training and ongoing specialist support, most typical primary care practices can implement alcohol screening and brief intervention, but in the circumstances at least of a research trial, they screen and intervene with few of their patients. Least well implemented 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 test proved best at identifying risky drinkers. When it came to how to respond to these risky drinkers, anticipated extra benefits from the longer and more sophisticated, theory-based interventions did not materialise, even It seems from preliminary reports. for heavier drinkers. It might be thought this was due to so many fewer patients actually going through the lifestyle counselling intervention for which they had to return to the surgery. But this was not the case, because the findings were unchanged when the analysis was limited to patients who had undergone their allocated intervention. This dashes any hopes that if only the counselling could have been delivered straight after screening and therefore to nearly all the patients, it would have proved more effective then the briefer interventions.
As a result the featured report argues that the study "strongly suggests" that the least intensive intervention is the best way to reduce hazardous and harmful drinking in primary care. But as the authors acknowledged, this was a suggestion the study was not set up to test because it did not feature a no-intervention or usual-care control group. Given ( below) how much control groups improve in brief intervention studies, it seems possible that doing nothing other than screening and usual care would have equalled the most effective of the interventions in the featured report, undermining the argument that at least the study showed the interventions were better than no intervention.
A relatively minor concern is that allocation of five practices which had reached their caseload targets to double up and then implement a more intensive intervention seems to have negated the assurance that randomisation gives of a level playing field. It meant that some of the practices implementing the more intensive interventions had been selected on the basis of their prior performance at recruiting patients and their willingness to have another go. This was not the case for the least intensive intervention. Had important significant differences been found between the three interventions, this would have cast some doubt over their validity.
Across the three settings, the general picture gleaned from preliminary reports is that implementation often required specialist support, 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. Brief feedback, consisting of an unadorned warning plus an information booklet, intended as 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.
Judging the effectiveness of brief interventions established in principle, the researchers 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 research 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 was a relatively substantial extra burden 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. In contrast, incentivised with per patient payments, most primary care practices managed to implement fully. 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.
In primary care, nine of the 14 practices did not recruit the targeted 31 patients over the 15 months of the trial. Preliminary reports revealed that 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 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 research staff were able to engage with and provide ongoing support to individual primary care workers.
These findings have two possible implications. The first is to cast doubt over the potential for screening and intervention As implemented and resourced in the trials. in these settings 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 low. Reinforcing this doubt was the uncertainty over resultant impacts on those who were screened and advised ( 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.
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 treatment. Whilst reluctance to address drinking 'out of the blue' is expected, there is even reluctance to raise the topic in general health and well-being assessments.
Screening results from the trials have been amalgamated in conference presentations ( 1 Coulton S. "What is the most efficient method for screening for alcohol use?" Presented at Alcohol Screening and Brief Interventions: from Research into Practice, London 5 March 2012. 2). Of the three methods tested, FAST 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 to identify hazardous drinkers in the British primary care context.
In primary care in particular FAST too was preferable, identifying 89% of risky drinking patients compared to 81% for the single question. It was also significantly better at identifying people whose AUDIT scores indicated a medium severity of alcohol problems, the range thought most appropriate for brief interventions.
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 reserved screening for patients 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 11–13%, 12 months later, by 16–18%. With one exception, on this primary yardstick an alcohol advice booklet plus a few sentences 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 patients gave no grounds for triaging heavier drinkers in emergency or primary care settings to more extended brief advice.
In the primary care study it was remarkable that even when the analysis was confined to people who had actually received their allocated intervention, still the extra 20 minutes of counselling made no significant difference to the proportions of risky drinkers at both follow-up points. In this analysis not only did the counselling have the intended advantage of time and its supposed active psychological ingredients, it also had the presumed advantage of being tested only on patients concerned and diligent enough to return for counselling, while the other two interventions were applied immediately to nearly all patients.
As the researchers acknowledged, this does not necessarily 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 a quarter in primary care said they were trying to reduce their drinking. This in itself could account for the findings. Reinforcing doubts over the impact of the interventions is the general finding that many 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. groups in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts equal to or greater than AUDIT score reductions in the SIPS trials. Though the reviews (1 2) which collated these findings did not single these out, studies which offered only usual care to control patients often also registered such reductions.
One of the reviews found that when (as in the SIPS trials) the study had been conducted in westernised English-speaking countries and had recruited mixed-age and mixed-gender samples, in half the 16 studies the reduction in consumption equalled or exceeded The largest reduction was 19.9% in the brief lifestyle counselling group, down from 13.1 at baseline to 10.49 a year later. Figure one in the review shows that alcohol consumption in control groups in the 16 studies conducted in English speaking countries not confined to particular ages or to men v. women exceeded or equalled 20% in eight studies. the largest reduction in AUDIT score of the three groups in the SIPS primary care trial. Across all 26 studies where this could be calculated, this was the case for 12 of 26. Calculated from figures one two and three eliminating duplicate figures studies. Of the 26, 14 were in primary care and in 16 the control groups were offered no intervention or only usual care, though whether they were offered something closer to the briefest intervention in SIPS made no significant difference A correction to the study admitted that the basis on which these calculations had been made was incorrect, but this error would the authors said have increased the degree to which studies seemed to produce differing levels of control group reductions in consumption. Had the correct method been used, the implication is that the studies would have differed less, making it less likely that the different 'interventions' offered to control groups would have been reflected in different degrees of drinking reduction. to the findings.
The other review confined itself to studies of adults in English-speaking countries which did not restrict the caseload to certain ages or to men or women. Across the 16 studies (11 in primary care) the average reduction in consumption generally a year later was 32%, greater than the AUDIT score reduction of at most about 20% in the SIPS primary care study.
Set against this is the record of brief interventions in previous trials. A synthesis of international research convincingly showed that in controlled trials, brief intervention has led to greater reductions in drinking among risky drinkers than usual care or just asking about drinking. However, it 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 interventions' potential, but not necessarily that they 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 or improving quality of life ( below) than a brief warning.
Neither can it be said that screening plus booklet and a few sentences of feedback is all it takes to get whatever benefits are available. These came after patients and offenders had been 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. It would seem natural for the recipients of this news to respond and staff in turn to respond back, in what could have become an interchange rivalling in length and perhaps exceeding in individualisation the brief advice option.
In the primary care study, where the longest intervention did score over a brief warning was in the impression it (or offering it) made on patients. Later they were more likely to claim they were trying to cut their drinking and 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 the briefest intervention directly cost least, but on the health service's primary yardstick – quality-adjusted life years – in both probation and primary care, it 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 life of the three intervention groups and catching up somewhat in a natural levelling up.
In the primary care study in particular, according to preliminary reports the brief feedback option averaged £2.40 per patient, brief advice £18.71, and lifestyle counselling £71.00. 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. The advantage of the briefest of the interventions would presumably have become clearer as higher values were assigned to each high 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. Discounting such possible benefits of substance use as judged by consumers also makes a substantial difference to cost-benefit calculations.
The alcohol strategy for England published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in 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 incentivise 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 were 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 Woodeson L. "SIPS Findings: Implications for health policy" Presented at Alcohol Screening and Brief Interventions: from Research into Practice, London 5 March 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 yet more may have been) done with the patients. 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.
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