Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?

Applying the Consolidated Framework for Implementation Research to investigate factors of implementing alcohol screening and brief intervention among primary care physicians and nurses in Hong Kong, China: an exploratory sequential mixed-method study

BACKGROUND

Alcohol screening and brief intervention (SBI) is an evidence-based intervention recommended by the World Health Organization. This study applied the Consolidated Framework for Implementation Research (CFIR) to understand facilitators and barriers of SBI implementation in primary care settings in Hong Kong, China.

METHODS

This was a sequential mixed-method study. In-depth interviews of 21 physicians and 20 nurses working in the primary care settings from the public and private sectors were first conducted to identify CFIR constructs that were relevant to SBI implementation in the Chinese context and potential factors not covered by the CFIR. A questionnaire was then developed based on the qualitative findings to investigate factors associated with SBI implementation among 282 physicians and 295 nurses.

RESULTS

The in-depth interviews identified 22 CFIR constructs that were facilitators or barriers of SBI implementation in Hong Kong. In addition, the stigmatization of alcohol dependence was a barrier and the belief that it was important for people to control the amount of alcohol intake in any situation was mentioned as a facilitator to implement SBI. In the survey, 22% of the participants implemented SBI in the past year. Factors associated with the SBI implementation echoed most of the qualitative findings. Among physicians and nurses in both sectors, they were more likely to implement SBI when perceiving stronger evidence supporting SBI, better knowledge and self-efficacy to implement SBI, more available resources, and clearer planning for SBI implementation in the clinics but less likely to do so when perceiving SBI implementation to be complicated and of higher cost, and drinking approved by the Chinese culture. Participants were more likely to implement SBI when perceiving SBI fit better with the existing practice and better leadership engagement in the public sector, but not in the private sector. Perceiving a stronger need and greater importance to implement SBI were associated with higher likelihood of SBI implementation among physicians, but not among nurses. Perceiving better organizational culture supporting SBI was positively associated with SBI implementation among nurses, but not among physicians.

CONCLUSIONS

There was a significant gap between SBI evidence and its implementation. Some strategies to improve SBI implementation may be different between physicians and nurses and between those in the public and private sectors. The CFIR is a useful framework for understanding facilitators and barriers of SBI implementation in primary care settings.

Video-based communication assessment for weight management counseling training in medical residents: a mixed methods study

BACKGROUND

Physician delivered weight management counseling (WMC) occurs infrequently and physicians report lack of training and poor self-efficacy. The purpose of this study was to develop and test the Video-based Communication Assessment (VCA) for weight management counseling (WMC) training in medical residents.

METHODS

This study was a mixed methods pilot conducted in 3 phases. First, we created five vignettes based on our prior data and expert feedback, then administered the vignettes via the VCA to Internal Medicine categorical residents (n = 16) from a University Medical School. Analog patients rated responses and also provided comments. We created individualized feedback reports which residents were able to view on the VCA. Lastly, we conducted debriefing interviews with the residents (n = 11) to obtain their feedback on the vignettes and personalized feedback. Interviews were transcribed, and we used thematic analysis to generate and apply codes, followed by identifying themes.

RESULTS

Descriptive statistics were calculated and learning points were created for the individualized feedback reports. In VCA debriefing interviews with residents, five themes emerged: 1) Overall the VCA was easy to use, helpful and more engaging than traditional learning and assessment modes, 2) Patient scenarios were similar to those encountered in the clinic, including diversity, health literacy and different stages of change, 3) The knowledge, skills, and reminders from the VCA can be transferred to practice, 4) Feedback reports were helpful, to the point and informative, including the exemplar response of how to best respond to the scenario, and 5) The VCA provide alternatives and practice scenarios to real-life patient situations when they aren't always accessible.

CONCLUSIONS

We demonstrated the feasibility and acceptability of the VCA, a technology delivered platform, for delivering WMC to residents. The VCA exposed residents to diverse patient experiences and provided potential opportunities to tailor providers responses to sociological and cultural factors in WMC scenarios. Future work will examine the effect of the VCA on WMC in actual clinical practice.

Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review

BACKGROUND

Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors.

METHODS

The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies', interventions', and information-giving strategies' characteristics. PRISMA guidelines were followed.

RESULTS

Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients' behavioral outcomes.

DISCUSSION

Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health-related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019115791.

Práticas de Atenção Primária à Saúde na área de drogas: revisão integrativa

RESUMO O objetivo deste estudo foi o de identificar e analisar as práticas voltadas ao consumo prejudicial de drogas na Atenção Primária à Saúde. Trata-se de Revisão integrativa que buscou estudos nas fontes Medline e Lilacs utilizando os termos ‘Atenção Primária à Saúde’ e ‘Redução do Dano’. Como resultado, incluiram-se 52 estudos, analisados de acordo com os arcabouços teóricos que orientam as práticas em saúde. Tais estudos foram sintetizados em três categorias empíricas: comportamento de risco, que incluiu intervenção breve, programas para prevenir e diminuir o uso de drogas, entre outros; fatores determinantes, que incluiu visitas domiciliares, práticas grupais e organizacionais; e necessidades em saúde, que incluiu práticas educativas emancipatórias. Conclui-se que, majoritariamente, os estudos abordam o uso de drogas pela categoria risco, com proposição de práticas para adaptação social. As intervenções relativas aos determinantes promovem a saúde, propondo melhorias em ambientes de vida e trabalho. Práticas críticas às relações sociais estabelecidas pelo complexo das drogas são minoritárias e envolvem complexidade operacional.

Alcohol stigma as it relates to drinking behaviors and perceptions of drink drivers: A mixed method study in Moshi, Tanzania

BACKGROUND

Alcohol is a leading risk factor for road traffic injury in low- and middle-income countries, such as Tanzania. This research seeks to explore the drinking patterns, perceptions, and stigma of drink driving behavior of injury patients at Kilimanjaro Christian Medical Center in Moshi, Tanzania.

METHODS

This mixed methods study incorporated the Perceived Alcohol Stigma (PAS), an additive Likert scale, and the Alcohol Use Disorders Identification Test (AUDIT). Results are reported as medians with IQRs. Additionally, focus groups with injury patients, their families, and community members (n = 104) were conducted and analyzed in pairs using an inductive thematic content analysis approach.

RESULTS

Those who self-reported driving after ingesting 3 or more alcoholic drinks had a median AUDIT score (median = 11.0) significantly higher than those who denied drink driving (median = 5.5, p < 0.01). The PAS showed a high overall stigma against those who use alcohol but differed for drink drivers, drinkers, and abstainers (median = 20.8, 23.9, 34.9, p < 0.01). Thematic content analysis highlighted a 'disapproving of drink drivers', that 'problematic drinking is a drinking behavior which negatively affects others', and a 'passiveness toward drinking and drink driving'.

CONCLUSIONS

Stigma against those who use alcohol is present in Tanzania. Perceived stigma is significantly lower among those who drink drive than those who do not. Overall, there appears to be a community-wide disapproval of drinking and driving, which is coupled with feeling unable to change this risky behavior.

Identifying contexts and mechanisms in multiple behavior change interventions affecting smoking cessation success: a rapid realist review

Background

Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome.

Methods

This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis.

Results

Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts.

Conclusion

In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment).

Trial registration

PROSPERO registration number: CRD42017064430

Variation in SBIRT delivery among acute care facilities

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based process to recognize and intervene with people who use substances. Despite evidence to support the SBIRT effectiveness, this process is rarely used in acute care. To facilitate use of SBIRT in acute care, it is important to first understand the implementation processes.

PURPOSE

To describe SBIRT processes across 14 acute care facilities.

METHODS

A phone interview was conducted with site coordinators at 14 facilities to describe their SBIRT process and clinicians involved in each step.

FINDINGS

Seven different SBIRT processes were identified for people that use alcohol and/or drugs, and five different processes were identified for people that use tobacco. The function of SBIRT was consistent throughout facilities, but the form of implementation varied based on organizational context.

DISCUSSION

Future SBIRT dissemination efforts will need to first understand the local processes and clinicians involved within each facility to tailor implementation to local context.

Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Unhealthy alcohol use is common, increasing, and a leading cause of premature mortality.

OBJECTIVE

To review literature on the effectiveness and harms of screening and counseling for unhealthy alcohol use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through October 12, 2017; literature surveillance through August 1, 2018.

STUDY SELECTION

Test accuracy studies and randomized clinical trials of screening and counseling to reduce unhealthy alcohol use.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction by 2 reviewers. Counseling trials were pooled using random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drinks per week, exceeding recommended limits, heavy use episodes, abstinence (for pregnant women), and other health, family, social, and legal outcomes.

RESULTS

One hundred thirteen studies (N = 314 466) were included. No studies examined benefits or harms of screening programs to reduce unhealthy alcohol use. For adolescents (10 studies [n = 171 363]), 1 study (n = 225) reported a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) using the AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) to detect the full spectrum of unhealthy alcohol use. For adults (35 studies [n = 114 182]), brief screening instruments commonly reported sensitivity and specificity between 0.70 and 0.85. Two trials of the effects of interventions to reduce unhealthy alcohol use in adolescents (n = 588) found mixed results: one reported a benefit in high-risk but not moderate-risk drinkers, and the other reported a statistically significant reduction in drinking frequency for boys but not girls; neither reported health or related outcomes. Across all populations (68 studies [n = 36 528]), counseling interventions were associated with a decrease in drinks per week (weighted mean difference, -1.6 [95% CI, -2.2 to -1.0]; 32 studies [37 effects; n = 15 974]), the proportion exceeding recommended drinking limits (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; 15 studies [16 effects; n = 9760]), and the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]; 12 studies [14 effects; n = 8108]), and an increase in the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]; 5 studies [n = 796]) after 6 to 12 months. Health outcomes were sparsely reported and generally did not demonstrate group differences in effect. There was no evidence that these interventions could be harmful.

CONCLUSIONS AND RELEVANCE

Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.

Students' Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools

INTRODUCTION

Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling.

METHODS

Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018.

RESULTS

Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback.

CONCLUSIONS

Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Screening for At-Risk Alcohol Consumption in Primary Care: A Randomized Evaluation of Screening Approaches

Aims

The aim of the study was to explore the relative efficiency and effectiveness of targeted versus universal screening for at-risk alcohol use in a primary care population in the UK.

Methods

The study was a randomized evaluation of screening approach (targeted versus universal) for consecutive attendees at primary care aged 18 years or more. Targeted screening involved screening any patient attending with one of the targeted presentations, conditions associated with excessive alcohol consumption: mental health, gastrointestinal, hypertension, minor injuries or a new patient registration. In the universal arm of the study all presentations in the recruitment period were included. Universal screening included all patients presenting to allocated practices.

Results

A total of 3562 potential participants were approached. The odds ratio of being screen positive was higher for the targeted group versus the universal group. Yet the vast majority of those screening positive in the universal group of the study would have been missed by a targeted approach. A combination of age and gender was a more efficient approach than targeting by clinical condition or context.

Conclusions

While screening targeted by age and gender is more efficient than universal screening, targeting by clinical condition or presentation is not. Further universal screening is more effective in identifying the full range of patients who could benefit from brief alcohol interventions, and would therefore have greater public health impact.

Trial registration

Current Controlled Trials ISRCTN06145674.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.

OBJECTIVES

To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.

MAIN RESULTS

We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.

Would brief alcohol intervention be helpful in facial trauma patients?A Narrative Review

Facial trauma is commonly associated with excessive consumption of alcohol and is often associated with interpersonal violence or motor vehicle accidents. Alcohol-related trauma presentation to hospitals causes a major service burden, and there have been efforts to reduce such trauma load with educational programs and social support. Brief alcohol intervention (BAI) in an acute setting (emergency department or trauma centre) has been shown as an effective means to reduce future alcohol intake and the incidence of future alcohol-related injuries, especially in the period immediately following injuries. Less is known about the potential benefit of BAI when provided by the surgical team in the same clinical context. This article explores the individual component of brief alcohol intervention and its provision by an acute surgical service by way of a narrative review. The progress of research into brief alcohol intervention for facial trauma patients is also reviewed. The methods and rationale behind screening patients for targeted BAI are discussed in a separate article.

Community pharmacists require additional support to develop capacity in delivering alcohol-related health information to older adults

OBJECTIVES

This qualitative study explored the barriers and enablers influencing Western Australian (WA) community pharmacists' knowledge, confidence, willingness and practice in engaging older clients (>60 years) in alcohol-related health discussions.

METHODS

Two focus groups were conducted with a total of 14 community pharmacists who had previously completed a formative quantitative survey (n = 63), and indicated willingness to participate in a follow-up focus group. Focus group questions, informed by the survey results, explored participants' perceptions about barriers and enablers to delivering health information and advice about alcohol to older clients (60+ years). Shaw and colleagues' theoretical framework was used to understand barriers and enablers in relation to role legitimacy, role adequacy and role support.

KEY FINDINGS

Participants acknowledged that providing health information about alcohol to older clients is a legitimate part of a community pharmacist's role, and most were confident performing this role in situations perceived as core to their professional practice, such as while dispensing medicines. However, many participants identified limited knowledge, skills and confidence in assisting older clients who may have alcohol issues, beyond advising them on medication and alcohol use. Structural barriers such as time and financial barriers were also identified.

CONCLUSION

Routine professional practice including dispensing medicine and home medicine reviews may provide valuable opportunities to engage older clients in alcohol-related discussions. However, limited knowledge concerning appropriate strategies to assist older clients reduce their alcohol consumption, coupled with limited skills and confidence among community pharmacists in raising sensitive alcohol-related issues with clients, suggest the need for specific alcohol-related training and support.

Assessing efficacy of a retention-in-care intervention among HIV patients with depression, anxiety, heavy alcohol consumption and illicit drug use

OBJECTIVE

We evaluated whether heavy alcohol use, illicit drug use or high levels of anxiety, and depression symptoms were modifiers of the retention through enhanced personal contact intervention. The intervention had previously demonstrated overall efficacy in the parent study.

DESIGN

Randomized trial.

METHODS

A total of 1838 patients from six US HIV clinics were enrolled into a randomized trial in which intervention patients received an 'enhanced contact' protocol for 12 months. All participants completed an audio computer-assisted self-interview that measured depression and anxiety symptoms from the Brief Symptom Inventory, alcohol use from the Alcohol Use Disorders Identification Test-Consumption instrument, and drug use from the WHO (Alcohol, Smoking and Substance Involvement Screening Test) questions. The 12-month binary outcome was completing an HIV primary care visit in three consecutive 4-month intervals. The outcome was compared between intervention and standard of care patients within subgroups on the effect modifier variables using log-binomial regression models.

RESULTS

Persons with high levels of anxiety or depression symptoms and those reporting illicit drug use, or heavy alcohol consumption had no response to the intervention. Patients without these 'higher risk' characteristics responded significantly to the intervention. Further analysis revealed higher risk patients were less likely to have successfully received the telephone contact component of the intervention. Among higher risk patients who did successfully receive this component, the intervention effect was significant.

CONCLUSION

Our findings suggest that clinic-based retention-in-care interventions are able to have significant effects on HIV patients with common behavioral health issues, but the design of those interventions should assure successful delivery of intervention components to increase effectiveness.

Sex and age differences in the early identification and treatment of alcohol use: a population-based study of patients with alcoholic cirrhosis

AIM

To estimate sex differences in health-care utilization among harmful/hazardous drinkers in the period before alcoholic cirrhosis diagnosis, and estimate sex differences in the extent to which alcohol use and brief alcohol interventions were documented for these individuals compared with a control cohort.

DESIGN

Retrospective study using linked general practice and hospital admissions data in England.

SETTING

Three hundred and fifty-seven general practitioner (GP) practices in England.

PARTICIPANTS

A total of 2479 individuals with alcoholic cirrhosis (mean age at diagnosis=56 years), of whom 67% were men; and 24,790 controls without the disease.

MEASUREMENTS

Rates of primary care visits and hospital admissions prior to the diagnosis of alcoholic cirrhosis for men and women, and the proportion of men and women with alcohol consumption and/or alcohol brief intervention documented in their medical record.

FINDINGS

Compared with the general population, patients with alcoholic cirrhosis used primary and secondary health-care services more frequently in the years leading up to their diagnosis. In the years prior to diagnosis, men used primary and secondary health-care services more than did women (P for sex interaction P<0.0001). Men were more likely than women to have their alcohol use recorded [odds ratio (OR) men=1.96, 95% confidence interval (CI)=1.7-2.3; women=1.63, 95% CI=1.4-1.8, P for sex interaction P<0.0017]. By contrast, alcohol interventions were recorded more commonly among women (OR men=4.3, 95% CI=3.7-4.9; women=5.8, 95% CI=4.7-6.9, P for sex interaction=0.07), although less common with increasing age (P for age interaction=0.009).

CONCLUSIONS

In the United Kingdom, prior to alcoholic cirrhosis diagnosis, excess health-care utilization is higher in men than women and men are more likely than women to have their alcohol use recorded. However, women appear to be more likely than men to receive alcohol brief interventions.

Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis

BACKGROUND AND AIMS

Screening and brief interventions (SBI) delivered in primary health care (PHC) are cost-effective in decreasing alcohol consumption; however, they are underused. This study aims to identify implementation strategies that focus on SBI uptake and measure impact on: (1) heavy drinking and (2) delivery of SBI in PHC.

METHODS

Meta-analysis was conducted of controlled trials of SBI implementation strategies in PHC to reduce heavy drinking. Key outcomes included alcohol consumption, screening, brief interventions and costs in PHC. Predictor measures concerned single versus multiple strategies, type of strategy, duration and physician-only input versus that including mid-level professionals. Standardized mean differences (SMD) were calculated to indicate the impact of implementation strategies on key outcomes. Effect sizes were aggregated using meta-regression models.

RESULTS

The 29 included studies were of moderate methodological quality. Strategies had no overall impact on patients' reported alcohol consumption [SMD=0.07; 95% confidence interval (CI)=-0.02 to 0.16], despite improving screening (SMD=0.53; 95% CI=0.28-0.78) and brief intervention delivery (SMD=0.64;95% CI=0.27-1.02). Multi-faceted strategies, i.e. professional and/or organizational and/or patient-orientated strategies, seemed to have strongest effects on patients' alcohol consumption (P<0.05, compared with professional-orientated strategies alone). Regarding SBI delivery, combining professional with patient-orientated implementation strategies had the highest impact (P<0.05). Involving other staff besides physicians was beneficial for screening (P<0.05).

CONCLUSIONS

To increase delivery of alcohol screening and brief interventions and decrease patients' alcohol consumption, implementation strategies should include a combination of patient-, professional- and organizational-orientated approaches and involve mid-level health professionals as well as physicians.

Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial

BACKGROUND

Unhealthy alcohol use is a major contributor to the global burden of disease and injury. The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical settings since 2004. Yet less than one in six US adults report health care professionals discussing alcohol with them. Little is known about methods for increasing implementation; different staffing models may be related to implementation effectiveness. This implementation trial compared delivery of alcohol screening, brief intervention and referral to specialty treatment (SBIRT) by physicians versus non-physician providers receiving training, technical assistance, and feedback reports.

METHODS

The study was a cluster randomized implementation trial (ADVISe [Alcohol Drinking as a Vital Sign]). Within a private, integrated health care system, 54 adult primary care clinics were stratified by medical center and randomly assigned in blocked groups of three to SBIRT by physicians (PCP arm) versus non-physician providers and medical assistants (NPP and MA arm), versus usual care (Control arm). NIH-recommended screening questions were added to the electronic health record (EHR) to facilitate SBIRT. We examined screening and brief intervention and referral rates by arm. We also examined patient-, physician-, and system-level factors affecting screening rates and, among those who screened positive, rates of brief intervention and referral to treatment.

RESULTS

Screening rates were highest in the NPP and MA arm (51 %); followed by the PCP arm (9 %) and the Control arm (3.5 %). Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm. The PCP arm had higher brief intervention and referral rates (44 %) among patients screening positive than either the NPP and MA arm (3.4 %) or the Control arm (2.7 %). Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm.

CONCLUSION

Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation. Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models.

TRIAL REGISTRATION

Clinical Trials NCT01135654.

Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use

AIMS

To assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening.

DESIGN

Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated.

SETTING

Primary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA.

PARTICIPANTS

A total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian.

INTERVENTION(S) AND MEASUREMENT

Intervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up.

FINDINGS

Intervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P<0.001), and in the completed sample model, intervention patients used their HSD 2.2 fewer days than controls (P < 0.005). No compensatory increases in use of other measured substances were found.

CONCLUSIONS

A primary-care based, clinician-delivered brief intervention with follow-up coaching calls may decrease risky psychoactive drug use.

Comparison of provider-documented and patient-reported brief intervention for unhealthy alcohol use in VA outpatients

BACKGROUND

Performance measures for brief alcohol interventions (BIs) are currently based on provider documentation of BI. However, provider documentation may not be a reliable measure of whether or not patients are offered clinically meaningful BIs. In particular, BI documented with clinical decision support in an electronic medical record (EMR) could appear identical irrespective of the quality of BI provided. We hypothesized that differences in how BI was implemented across health systems could lead to differences in the proportion of documented BI recalled and reported by patients across health systems.

METHODS

Male outpatients with unhealthy alcohol use identified by confidential satisfaction surveys (2009-2012) were assessed for whether they reported receiving BI in the past year (patient-reported BI) and whether they had BI documented in the EMR during the same period (documented BI). We evaluated and compared the prevalence of documented BI to patient-reported BI across 21 VA networks to determine whether documented BI had a variable association with patient-reported BI across the networks.

RESULTS

Of 9896 eligible male outpatients with unhealthy alcohol use, 59.0% (95% CI 57.4-60.5%) reported BI (50.4-64.9% across networks) and 37.4% (95% CI 36.0-38.9%) had BI documented in the EMR (28.0-44.2% across networks). Overall, 72.9% (95% CI 70.8-75.5%) of patients with documented BI also reported BI. The association between documented BI and patient-reported BI did not vary across VA networks in adjusted logistic regression models.

CONCLUSIONS

Performance measures of BI that rely on provider documentation in EMRs appear comparable to patient report for comparing care across VA networks.

A comparison of the efficacy of brief interventions to reduce hazardous and harmful alcohol consumption between European and non-European countries: a systematic review and meta-analysis of randomized controlled trials

AIMS

The extent of variation attributable to regional differences for the efficacy of brief intervention (BI) to reduce hazardous and harmful alcohol consumption is unclear. The primary aim of this study was to determine overall efficacy of BI at 6- and 12-month follow-up in primary health care (PHC) and emergency department (ED) studies. The secondary aim was to examine whether variance in study outcome can be explained by the geographical region in which trials have taken place (European versus non-European).

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) published before August 2014 was undertaken. Twenty RCTs conducted in PHC settings with a total of 8226 participants (European = 4564/non-European = 3662) and eight RCTs conducted in ED settings with a total of 4799 participants (European = 2465/non-European = 2334) were eligible. Primary outcome measure was reduction in grams of alcohol consumed per week for BI and control groups at 6- and 12-month follow-up. An inverse variance model was applied to measure the effect of treatment in mean differences for BI and control groups at 6- and 12-month follow-up. Variance between study outcomes was explored using subgroup analysis of European versus non-European countries.

RESULTS

For PHC trials at 6-month follow-up, statistically significant benefits of BI were indicated [mean difference (MD) = -21.98 g/week; 95% confidence interval (CI) = -37.40 to -6.57; P = 0.005]. At 12-month follow-up, statistically significant benefit of BI was evident (MD = -30.86 g/week; 95% CI = -46.49 to -15.23; P = 0.0001). For ED trials at 6-month follow-up, statistically significant benefits of BI were indicated (MD = -17.97 g/week; 95% CI = -29.69 to -6.24; P =  .003). At 12-month follow-up, statistically significant benefit in favour of BI was evident (MD = -18.21 g/week; 95% CI = -26.71 to -9.70; P < 0.0001). No statistically significant differences were detected in subgroup analyses of outcomes for European versus non-European studies.

CONCLUSIONS

Brief intervention (BI) to reduce alcohol consumption is associated with reducing grams of alcohol consumed per week among hazardous and harmful drinkers at 6- and 12-month follow-up in primary health care and emergency department trials. The geographical region in which trials are undertaken does not appear to explain the variance in trial outcomes for reducing alcohol consumption.

Fast tracking the design of theory-based KT interventions through a consensus process

BACKGROUND

Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains.

METHODS

Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention.

RESULTS

Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors.

CONCLUSIONS

A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.

The Cost-effectiveness of Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency and Outpatient Medical Settings

OBJECTIVE

This study analyzed the cost-effectiveness of delivering alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency departments (ED) when compared to outpatient medical settings.

METHODS

A probabilistic decision analytic tree categorized patients into health states. Utility weights and social costs were assigned to each health state. Health outcome measures were the proportion of patients not drinking above threshold levels at follow-up, the proportion of patients transitioning from above threshold levels at baseline to abstinent or below threshold levels at follow-up, and the quality-adjusted life years (QALYs) gained. Expected costs under a provider perspective were the marginal costs of SBIRT, and under a societal perspective were the sum of SBIRT cost per patient and the change in social costs. Incremental cost-effectiveness ratios were computed.

RESULTS

When considering provider costs only, compared to outpatient, SBIRT in ED cost $8.63 less, generated 0.005 more QALYs per patient, and resulted in 13.8% more patients drinking below threshold levels. Sensitivity analyses in which patients were assumed to receive a fixed number of treatment sessions that met clinical sites' guidelines made SBIRT more expensive in ED than outpatient; the ED remained more effective. In this sensitivity analysis, the ED was the most cost-effective setting if decision makers were willing to pay more than $1500 per QALY gained.

CONCLUSIONS

Alcohol SBIRT generates costs savings and improves health in both ED and outpatient settings. EDs provide better effectiveness at a lower cost and greater social cost reductions than outpatient.

Addressing alcohol-related harms within maxillofacial trauma practice

PURPOSE

A brief intervention, conducted in the short-term care setting after an alcohol-related injury, has been reported to be highly beneficial in reducing the risk of reinjury and in reducing the subsequent level of alcohol consumption. This project aimed to understand Australasian oral and maxillofacial surgeons' attitudes, knowledge, and skills in alcohol screening and brief intervention within short-term care settings for patients admitted with facial trauma.

MATERIALS AND METHODS

A Web-based survey was made available to all members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons (200 to 250 members), promoted through a number of e-mail bulletins sent by the association to all members. Implied consent was assumed for participants who completed the online survey. The survey explored the surgeons' current level of involvement in treating patients with alcohol-related facial trauma, as well as their knowledge of and attitudes toward alcohol screening and brief intervention. The survey also explored their willingness to undergo further training and involvement in implementing a screening and brief intervention program. Parts of the survey were based on a hypothetical case with facial injury and a drinking history that was presented to the participants, and the participants were asked to give their response to this scenario.

RESULTS

A total of 58 surgeons completed the online survey. Of the surgeons surveyed, 91% were men and 88% were consultant surgeons. Seventy-one percent would take an alcohol history, 29% would deliver a brief alcohol intervention, and 14% would refer the patient to an alcohol treatment service or clinician. Forty percent agreed that they had adequate training in managing patients with alcohol-related injuries, whereas 17% and 19% indicated that they had adequate time and adequate resources, respectively. Of the surgeons, 76% reported the need for more information on where to refer patients for appropriate alcohol treatment.

CONCLUSIONS

The study findings confirm the challenges and barriers to implementing a brief alcohol intervention in current practice. Service gaps, as well as opportunities for training, exist.

Need for increased promotion of physical activity by health care professionals

OBJECTIVE

Health care professionals play an integral role in promoting health-enhancing behaviors, such as physical activity. However, the extent to which health care professionals promote physical activity to inactive adults is relatively unknown. Therefore, the purpose of this study was to determine the degree to which inactive adults are encouraged by health care professionals to increase their physical activity levels.

METHODS

A national sample (NHANES 2011-2012) of U.S. adults (n=4315; ≥20yrs) completed a questionnaire assessing their physical activity levels (work, transportation, and recreation) and the degree to which healthcare professionals encouraged them to exercise in the past year.

RESULTS

In 2012, only 36.3% of adult Americans who had received healthcare in the past 12months had been told by a health care professional to increase their exercise. Among adults reporting no exercise engagement, only 44.9% of them had been told by a health care professional to increase their exercise levels. A low prevalence of exercise promotion was also observed for other various parameters, such as weight status, number of comorbidities, and race-ethnicity.

CONCLUSIONS

The majority of completely sedentary U.S. adults in 2012 were not told by a health care professional to increase their exercise levels.

A pilot feasibility cluster randomised controlled trial of screening and brief alcohol intervention to prevent hazardous drinking in young people aged 14–15 years in a high school setting (SIPS JR-HIGH)

Background

Approximately 33% of 15- to 16-year-olds in England report alcohol intoxication in the past month. This present work builds on the evidence base by focusing on Alcohol Screening and Brief Intervention (ASBI) to reduce hazardous drinking in younger adolescents.

Objectives

To explore the feasibility and acceptability of a future definitive cluster randomised controlled trial (cRCT) of ASBI in a school setting to staff, young people and parents; to explore the fidelity of the interventions as delivered by school learning mentors; to estimate the parameters for the design of a definitive cRCT of brief alcohol intervention, including rates of eligibility, consent, participation and retention at 12 months; and to pilot the collection of cost and resource-use data to inform the cost-effectiveness/utility analysis in a definitive trial.

Setting

Seven schools across one geographical area in North East England.

Methods

Feasibility of trial processes, recruitment and retention and a qualitative evaluation examined facilitators and barriers to the use of ASBI approaches in the school setting in this age group. A three-arm pilot cRCT (with randomisation at the school level) with qualitative evaluation to assess the feasibility of a future definitive cRCT of the effectiveness and cost-effectiveness of ASBI in a school setting, with an integrated qualitative component. The trial ran in parallel with a repeated cross-sectional survey, which facilitated screening for the trial.

Participants

Year 10 school pupils (aged 14–15 years).

Interventions

Young people who screened positive on a single alcohol screening question, and consented to take part, were randomised to one of three groups: (1) feedback that their drinking habits may be risky and provision of an advice leaflet (control condition,n = two schools); (2) feedback as for the control condition plus a 30-minute brief interactive session, which combined structured advice and motivational interviewing techniques, delivered by the school learning mentor (intervention 1,n = two schools); or (3) feedback as for the control condition plus a 30-minute brief interactive session as for intervention 1 plus a 60-minute session involving family members delivered by the school learning mentor (intervention 2,n = three schools). Young people were followed up at 12 months.

Main outcome measures

Feasibility and acceptability.

Randomisation

Randomisation was carried out at the school level. Randomisation achieved balance on two school-level variables (numbers of pupils in school year and proportion receiving free school meals).

Blinding

School staff, young people and researchers were not blind to the intervention allocated.

Results

A total of 229 young people were eligible for the trial; 182 (79.5%) were randomised (control,n = 53; intervention 1,n = 54; intervention 2,n = 75). Of the 75 randomised to intervention 2, 67 received intervention 1 (89%). Eight received both intervention 1 and intervention 2 (11%). In total, 160 out of 182 were successfully followed up at 12 months (88%). Interviews were carried out with six school lead liaisons, 13 learning mentors, 27 young people and seven parents (n = 53). Analysis shows that the school setting is a feasible and acceptable place to carry out ASBI, with learning mentors seen as suitable people to do this. Intervention 2 was not seen as feasible or acceptable by school staff, parents or young people.

Outcomes/conclusions

It is feasible and acceptable to carry out a trial of the effectiveness and cost-effectiveness of single-session ASBI with young people in the school setting, with learning mentors delivering the intervention. Future work should include a definitive study that does not include a parental arm.

Trial registration

Current Controlled Trials ISRCTN07073105.

Funding

The National Institute for Health Research Public Health Research programme.

An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration

AIMS

The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.

DESIGN

Observational, retrospective cohort study using secondary clinical and administrative data.

SETTING

Thirty VA facilities.

PARTICIPANTS

Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%).

MEASUREMENTS

Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).

FINDINGS

Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50).

CONCLUSIONS

During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

Efficacy of the telephone-based Brief Motivational Intervention for alcohol problems in Brazil

BACKGROUND

The Brief Motivational Intervention (BMI) is an effective treatment for alcohol misuse but has not been adequately tested for use in helplines for alcoholics. The main objective of this study was to evaluate the efficacy of a telephone-based BMI for Brazilians seeking help with alcohol use cessation.

METHODS

A randomized, controlled trial was performed with Brazilian subjects. Participants were randomly assigned to either the minimal intervention group (i.e., given reference materials) or the BMI group. Alcohol abstinence was evaluated in a 6-month follow-up telephone counseling session. The analysis was based on the intention to treat (ITT).

RESULTS

Of the 5,896 drug users who called the helpline, 700 (12%) used alcohol, 637 of whom enrolled in this study. At 6-month follow-up, 70% of the BMI group had stopped consuming alcohol compared to 41% in the control group (odds ratio = 1.5; 95% confidence interval = 1.2-1.9; p = 0.001).

CONCLUSIONS

A helpline-based BMI helps alcohol users achieve abstinence.

Evidence based psychosocial interventions in substance use

In recent years, there has been significant progress and expansion in the development of evidence-based psychosocial treatments for substance abuse and dependence. A literature review was undertaken using the several electronic databases (PubMed, Cochrane Database of systemic reviews and specific journals, which pertain to psychosocial issues in addictive disorders and guidelines on this topic). Overall psychosocial interventions have been found to be effective. Some interventions, such as cognitive behavior therapy, motivational interviewing and relapse prevention, appear to be effective across many drugs of abuse. Psychological treatment is more effective when prescribed with substitute prescribing than when medication or psychological treatment is used alone, particularly for opiate users. The evidence base for psychological treatment needs to be expanded and should also include research on optimal combinations of psychological therapies and any particular matching effects, if any. Psychological interventions are an essential part of the treatment regimen and efforts should be made to integrate evidence-based interventions in all substance use disorder treatment programs.

Are nurse-conducted brief interventions (NCBIs) efficacious for hazardous or harmful alcohol use? A systematic review

AIM

The aim of this study was to compare the efficacy of nurse-conducted brief interventions in reducing alcohol consumption, by looking at with treatment as usual compared with other treatments and general physician-delivered brief interventions within the literature.

BACKGROUND

Globally, the consumption of alcohol is at a worrying level and has significant effects on health when consumed to excess. Numerous studies have reported that brief intervention is effective in reducing excessive drinking. However, evidence on the efficacy of such interventions by nurses is still inconclusive.

METHODS

We included randomized controlled trials of brief interventions in which nurses were primarily involved as therapists, and were designed to achieve a reduction in alcohol consumption and related problems. We used online searches to locate randomized controlled trials in this area published from 1995 till 2012.

FINDINGS

Eleven trials were found meeting inclusion criteria, comparing nurse-conducted brief interventions with a control group or with other treatments. Five trials reported a statistically significant reduction in alcohol consumption in the intervention group with 6-12-month follow-up period and two trials concluded that brief interventions delivered by nurses was as efficacious as by physicians.

IMPLICATIONS FOR NURSING POLICY

The findings of the review have important policy implications for the preparation of nurses as therapists for brief interventions to reduce excessive drinking in a broad range of settings such as primary healthcare and hospital settings. The adoption of this intervention into contemporary nursing practice should be considered by the International Council of Nurses and nurses around the world as, according to the literature, it provides an evidence base for the independent functioning of nurses within the realms of nursing profession and addiction medicine.

CONCLUSION

The results of the review suggest that nurse-conducted brief interventions are an effective strategy for reducing alcohol consumption. We advocate more rigorous randomized controlled trials to underpin its efficacy in both research and real life scenario.

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries

BACKGROUND

Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap.

OBJECTIVES

To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review).

DATA COLLECTION AND ANALYSIS

Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect.

MAIN RESULTS

The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care.

AUTHORS' CONCLUSIONS

Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.

Health-related outcomes associated with patterns of risk factors in primary care patients

It is important to find ways to identify prevalent co-occurring health risk factors to help facilitate treatment programming. One method is to use electronic medical record (EMR) data. Funderburk et al. (J Behav Med 31:525-535, 2008) used such data and latent class analysis to identify three classes of individuals based on standard health screens administered in Veterans Affairs primary care clinics. The present study extended these results by examining the health-related outcomes for each of these identified classes. Follow-up data were collected from a subgroup of the original sample (N = 4,132). Analyses showed that class assignment predicted number of diagnoses associated with the diseases that the health screens target and number of primary care behavioral health, and emergency room encounters. The findings illustrate one way an EMR can be used to identify clusters of individuals presenting with multiple health risk factors and where the healthcare system comes in contact with them.

Alcohol use of diabetes patients: the need for assessment and intervention

It is well known that diabetes self-care behaviors are critical to disease progression. Unfortunately, many patients do not adhere to diabetes self-care recommendations despite their importance. Alcohol use has been identified as a barrier to diabetes self-care adherence. Excessive alcohol consumption not only negatively impacts diabetes self-care adherence but also affects the course of diabetes. Diabetes patients who are at-risk drinkers are likely to have poor diabetes treatment adherence, leading to increased morbidity and mortality. Alcohol consumption by diabetes patients is often inadequately assessed and addressed in their medical care. Brief interventions to reduce at-risk drinking have been well validated in a variety of patient populations and offer the potential to improve diabetes treatment adherence and outcome. Assessment and treatment of at-risk drinking could be readily incorporated into routine diabetes care. Strategies for brief assessment of and intervention for at-risk drinking are offered.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature

OBJECTIVES

To systematically review the literature on the relative effectiveness of face-to-face communication-related behavior change techniques (BCTs) provided in primary care by either physicians or nurses to intervene on patients' lifestyle behavior.

METHODS

PubMed, EMBASE, PsychINFO, CINAHL and The Cochrane Library were searched for studies published before October 2010. Fifty studies were included and assessed on methodological quality.

RESULTS

Twenty-eight studies reported significantly favorable health outcomes following communication-related BCTs. In these studies, 'behavioral counseling' was most frequently used (15 times), followed by motivational interviewing (eight times), education and advice (both seven times). Physicians and nurses seem equally capable of providing face-to-face communication-related BCTs in primary care.

CONCLUSION

Behavioral counseling, motivational interviewing, education and advice all seem effective communication-related BCTs. However, BCTs were also found in less successful studies. Furthermore, based on existing literature, one primary care profession does not seem better equipped than the other to provide face-to-face communication-related BCTs.

PRACTICE IMPLICATIONS

There is evidence that behavioral counseling, motivational interviewing, education and advice can be used as effective communication-related BCTs by physicians and nurses. However, further research is needed to examine the underlying working mechanisms of communication-related BCTs, and whether they meet the requirements of patients and primary care providers.

A 5A's communication intervention to promote physical activity in underserved populations

Background

The present study protocol describes the trial design of a clinician training intervention to improve physical activity counseling in underserved primary care settings using the 5As. The 5As (Ask, Advise, Agree, Assist, Arrange) are a clinical tool recommended for health behavior counseling in primary care.

Methods/Design

The study is a two-arm randomized pilot pragmatic trial to examine a primary care clinician communication intervention on use of the 5As in discussion of physical activity in audio-recorded office visits in an ethnically diverse, low-income patient population. The study setting consists of two federally qualified community health centers in Rochester, NY. Eligible clinicians (n=15) are recruited and randomized into two groups. Group 1 clinicians participate in the training intervention first; Group 2 clinicians receive the intervention six months later. The intervention and its outcomes are informed by self-determination theory and principles of patient-centered communication. Assessment of outcomes is blinded. The primary outcome will be the frequency and quality of 5As discussions as judged by evaluating 375 audio-recorded patient visits distributed over baseline and in the post-intervention period (immediately post and at six months). Secondary outcomes will be changes in patients’ perceived competence to increase physical activity (Aim 2) and patients and clinicians beliefs regarding whether pertinent barriers to promoting exercise have been reduced. (Aim 3). Exploratory outcomes (Aim 4) are potential mediators of the intervention’s effect and whether the intervention affects actual enrollment in the community program recommended for exercise. The analysis will use repeated measures (in the form of recorded office visits) from each clinician at each time point and aggregate measures of Groups 1 and 2 over time.

Discussion

Results will help elucidate the role of 5As communication training for clinicians on counseling for physical activity counseling in primary care. Results will explore the effectiveness of the 5As model linked to community resources for physical activity promotion for underserved groups.

Screening and brief intervention for unhealthy drug use in primary care settings: randomized clinical trials are needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

A linguistic study of patient-centered interviewing: emergent interactional effects

OBJECTIVES

To evaluate interactional effects of patient-centered interviewing (PCI) compared to isolated clinician-centered interviewing (CCI).

METHODS

We conducted a pilot study comparing PCI (N=4) to CCI (N=4) for simulated new-patient visits. We rated interviews independently and measured patient satisfaction with the interaction via a validated questionnaire. We conducted interactional sociolinguistic analysis on the interviews and compared across three levels of analysis: turn, topic, and interaction.

RESULTS

We found significant differences between PCI and CCI in physician responses to patients' psychosocial cues and concerns. The number and type of physician questions also differed significantly across PCI and CCI sets. Qualitatively, we noted several indicators of physician-patient attunement in the PCI interviews that were not present in the CCI interviews. They spanned diverse aspects of physician and patient speech, suggesting interactional accommodation on the part of both participants.

CONCLUSIONS

This small pilot study highlights a variety of interactional variables that may underlie the effects associated with patient-centered interviewing (e.g., positive relationships, health outcomes). Question form, phonological accommodation processes, and use of stylistic markers are relatively unexplored in controlled studies of physician-patient interaction.

PRACTICE IMPLICATIONS

This study characterizes several interactional variables for larger scale studies and contributes to models of patient-centeredness in practice.

Patient-reported measures of psychosocial issues and health behavior should be added to electronic health records

Recent legislation and delivery system reform efforts are greatly expanding the use of electronic health records. For these efforts to reach their full potential, they must actively involve patients and include patient-reported information about such topics as health behavior, preferences, and psychosocial functioning. We offer a plan for including standardized, practical patient-reported measures as part of electronic health records, quality and performance indexes, the primary care medical home, and research collaborations. These measures must meet certain criteria, including being valid, reliable, sensitive to change, and available in multiple languages. Clinicians, patients, and policy makers also must be able to understand the measures and take action based on them. Including more patient-reported items in electronic health records would enhance health, patient-centered care, and the capacity to undertake population-based research.

Routine outcome monitoring and feedback on physical or mental health status: evidence and theory

OBJECTIVES

Routine Outcome Monitoring (ROM) is an important quality tool for measuring outcome of treatment in health care. The objective of this article is to summarize the evidence base that supports the provision of feedback on ROM results to (mental) health care professionals and patients. Also, some relevant theoretical aspects are considered.

METHODS

Literature study (Pubmed, Medline, PsychINFO, Embase Psychiatry, 1975-2009) concerning randomized controlled trials (RTC's) of ROM and feedback on physical or mental health status of patients of all ages. Main search terms were routine outcome monitoring/measurement, feedback, health status measurement, patient reported outcome measures.

RESULTS

Included were 52 RCT's concerning ROM and feedback with adult or older patients: of these seven RCT's were exclusively focused on physical health and 45 RCT's (also) on the mental health of the patient, although not always in a mental health care setting or as primary outcome measure. There appears to be a positive impact of ROM on diagnosis and monitoring of treatment, and on communication between patient and therapist. Other results were less clear. There were no published RCT's on this topic with children or adolescents.

CONCLUSIONS

ROM appears especially effective for the monitoring of patients who are not doing well in therapy. Further research into this topic and the clinical-and cost-effectiveness of ROM is recommended, especially in mental health care for both adults and children. Also, more theory-driven research is needed with relevant conceptualizations such as Feedback Intervention Theory, Therapeutic Assessment.

The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: evidence from rural Australia

OBJECTIVE

This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice.

METHOD

A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia.

FINDINGS

Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and BI are increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197.

CONCLUSION

These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.

Meeting standards set for non self-harm presentations to emergency departments

OBJECTIVES

The commonest psychiatric presentation in most emergency departments (EDs) is deliberate self-harm. However, there are other significant categories of psychiatric presentation which include alcohol and substance misuse, acute psychosis and mood disorder. In addition to the NICE Guidelines for deliberate self-harm, there are good practice guidelines available for the management of other psychiatric attendances to the ED. The aim of this study was to identify the psychiatric attendances other than deliberate self-harm to Beaumont Hospital ED over a 12-month period with the objective of studying the rates and characteristics of attendances and to investigate whether good practice guidelines were met.

METHOD

From a total of 657 psychiatric attendances other than deliberate self-harm which were recorded, data was collected on demographics, provision of a psychosocial assessment and adherence to good practice guidelines.

RESULTS

Alcohol (38%) was the most common reason for presentation. Of the total number of attendees, only 44% received a psychosocial assessment compared to 59% of attendees who had presented following deliberate self-harm during the same 12-month period.

CONCLUSIONS

The attendees who did not receive a psychosocial assessment represent a vulnerable group in which the levels of psychosocial assessment need to be improved in order to meet good practice guidelines standards of care.

A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement

BACKGROUND

Total knee replacement (TKR) is a common and effective surgical procedure to relieve advanced knee arthritis that persists despite comprehensive medical treatment. Although TKR has excellent technical outcomes, significant variation in patient-reported functional improvement post-TKR exists. Evidence suggests that consistent post-TKR exercise and physical activity is associated with functional gain, and that this relationship is influenced by emotional health. The increasing use of TKR in the aging US population makes it critical to find strategies that maximize functional outcomes.

METHODS/DESIGN

This randomized clinical trial (RCT) will test the efficacy of a theory-based telephone-delivered Patient Self-Management Support intervention that seeks to enhance adherence to independent exercise and activity among post- TKR patients. The intervention consists of 12 sessions, which begin prior to surgery and continue for approximately 9 weeks post-TKR. The intervention condition will be compared to a usual care control condition using a randomized design and a probabilistic sample of men and women. Assessments are conducted at baseline, eight weeks, and six- and twelve- months. The project is being conducted at a large healthcare system in Massachusetts. The study was designed to provide greater than 80% power for detecting a difference of 4 points in physical function (SF36/Physical Component Score) between conditions (standard deviation of 10) at six months with secondary outcomes collected at one year, assuming a loss to follow up rate of no more than 15%.

DISCUSSION

As TKR use expands, it is important to develop methods to identify patients at risk for sub-optimal functional outcome and to effectively intervene with the goal of optimizing functional outcomes. If shown efficacious, this peri-TKR intervention has the potential to change the paradigm for successful post-TKR care. We hypothesize that Patient Self-Management Support to enhance adherence to independent activity and exercise will enhance uniform, optimal improvement in post-TKR function and patient autonomy, the ultimate goals of TKR.

Evaluation of physical activity counseling in primary care using direct observation of the 5As

BACKGROUND

The 5As (ask, advise, assess, assist, arrange) are recommended as a strategy for brief physical activity counseling in primary care. There is no reference standard for measurement, however, and patient participation is not well understood. This study's objectives were to (1) develop a coding scheme to measure the 5As using audio-recordings of primary care visits and (2) describe the degree to which patients and physicians accomplish the 5As.

METHODS

We developed a coding scheme using previously published definitions of the 5As, direct-observation measures, and evaluation of audio-recorded discussions of physical activity. We applied the coding scheme to 361 audio-recorded visits by patients reporting low levels of physical activity and 28 physicians in northeast Ohio.

RESULTS

The coding scheme achieved good inter-rater agreement for each of the 5As (κ = 0.62-1.0). A total of 135 visits included discussion of physical activity. Although ask tasks occurred in 91% of visits, it infrequently elicited sufficient detail about current activity. Patient readiness to change physical activity (assess) was infrequently directly elicited by the physician (24%), but readiness was commonly expressed by the patient in response to an assessment of current level of physical activity (53%). Ambivalence was infrequently followed by physician assistance (49%).

CONCLUSIONS

Our newly developed measure showed that (1) physicians infrequently assess patient readiness to change, (2) patient expressions of ambivalence are common, and (3) specific mention of recommended guidelines for exercise is nearly absent. Future work should increase clinician skills in exploring ambivalence and readiness to change, as well as improve explicit mention of recommended guidelines for physical activity.

Brief interventions for heavy alcohol users admitted to general hospital wards

BACKGROUND

Brief interventions involve a time-limited intervention focusing on changing behaviour. They are often motivational in nature using counselling skills to encourage a reduction in alcohol consumption.

OBJECTIVES

To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units.

SEARCH STRATEGY

We searched the Cochrane Drug and Alcohol Group Register of Trials (March 2011) the Cochrane Central Register of Controlled Trials (The Cochrane Library March 2011), MEDLINE January 1966-March 2011, CINAHL 1982-March 2011, EMBASE 1980-March 2011 and www.clinicaltrials.gov to April 2011 and performed some relevant handsearching.

SELECTION CRITERIA

All prospective randomised controlled trials and controlled clinical trials were eligible for inclusion. Participants were adults and adolescents (16 years or older) admitted to general inpatient hospital care for any reason other than specifically for alcohol treatment and received brief interventions (of up to 3 sessions) compared to no or usual care.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected the studies and extracted data. Where appropriate random effects meta-analysis and sensitivity analysis were performed.

MAIN RESULTS

Forteen studies involving 4041 mainly male participants were included. Our results demonstrate that patients receiving brief interventions have a greater reduction in alcohol consumption compared to those in control groups at six month, MD -69.43 (95% CI -128.14 to -10.72) and nine months follow up, MD -182.88 (95% CI -360.00 to -5.76) but this is not maintained at one year. Self reports of reduction of alcohol consumption at 1 year were found in favour of brief interventions, SMD -0.26 (95% CI -0.50 to -0.03). In addition there were significantly fewer deaths in the groups receiving brief interventions than in control groups at 6 months, RR 0.42 (95% CI 0.19 to 0.94) and one year follow up, RR 0.60 (95% CI 0.40 to 0.91). Furthermore screening, asking participants about their drinking patterns, may also have a positive impact on alcohol consumption levels and changes in drinking behaviour.

AUTHORS' CONCLUSIONS

The main results of this review indicate that there are benefits to delivering brief interventions to heavy alcohol users admitted to general hospital wards in terms of reduction in alcohol consumption and death rates. However, these findings are based on studies involving mainly male participants. Further research is required determine the optimal content and treatment exposure of brief interventions within general hospital settings and whether they are likely to be more successful in patients with certain characteristics.

Alcohol-related brief interventions as a criterion for American College of Surgeons Level I Trauma Center verification: how best to train the interventionists?

BACKGROUND

The American College of Surgeons Committee on Trauma recently required that Level I trauma centers have the capability to perform counseling in the form of brief interventions (BIs) for injured patients identified as problem drinkers. However, it is not yet known what type of training is optimal for trauma center personnel who will conduct these BIs.

METHODS

We conducted a prospective cohort study at the University of California, Davis Medical Center, a Level I trauma center. We compared two methods of training trauma nurse practitioners (NPs) without prior counseling expertise to conduct BIs: formal workshop training versus "on-the-job" (OTJ) training. We also evaluated whether a further "booster" training session would improve BI skills. We assessed BI skills in blinded fashion during interviews with a standardized patient actor using a 21-point checklist of BI counseling tasks ("FLO" score).

RESULTS

Nine workshop- and five OTJ-trained NPs participated. FLO scores did not markedly differ between the two groups after initial training (total FLO score, 9.6 ± 2.4 and 7.8 ± 0.4, workshop vs. OTJ, respectively; 95% confidence interval of difference, -4.1 to 0.6). FLO scores did however improve in both groups after booster training (9.1 ± 2.0 and 16.0 ± 2.2, time 1 vs. time 2, respectively; 95% confidence interval of difference, 4.7-9.1). The magnitude of improvement in FLO scores after the booster session did not differ between the workshop and OTJ groups.

CONCLUSIONS

In preparing NPs to conduct BIs, OTJ training by an experienced peer does not seem to differ markedly from workshop training by expert counselors. Interventionist knowledge and performance can be improved in the short term by follow-up training. This indicates that NP's taught by either method should undergo periodic continuing education to maintain the necessary skill set for performing BIs.

The effectiveness of brief alcohol interventions in primary care settings: a systematic review

ISSUES

Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials.

APPROACH

A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted.

KEY FINDINGS

The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials.

CONCLUSIONS

Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.