A realist review of brief interventions for alcohol misuse delivered in emergency departments

Experiences of a mobile phone delivered brief intervention for hazardous drinking: A qualitative study nested in the AMBIT trial from Goa, India

Background

This study explores the experiences of participants receiving a mobile-based brief intervention (BI) for hazardous drinking in India, to determine characteristics that influenced engagement and examine perceived reasons for change in alcohol consumption.

Methods

Semi-structured interviews were conducted with 10 adult hazardous drinkers who received a mobile-based BI in the intervention arm of a pilot randomised control trial. Data were coded through an iterative process and analysed using thematic analysis.

Findings

Study participants reported a positive experience, with factors such as customised intervention delivery and personal motivation facilitating their engagement. Participants reported a reduction in quantity and frequency of alcohol use. This was credited to the intervention, particularly, its provision of health-related information, goal-setting content and strategies to manage drinking. Apart from alcohol reduction, participants reported improvements in diet, lifestyle, wellbeing, and familial relations.

Implication

By providing a context to explain the impact of the intervention, the learnings from this study can be used to strengthen the implementation of mobile-based interventions. This study outlines the scope for further research in digital health, such as Internet-based health interventions, and incorporating digital interventions within the ambit of existing health care programmes.

Telephone-based motivational interviewing enhanced with individualised personality-specific coping skills training for young people with alcohol-related injuries and illnesses accessing emergency or rest/recovery services: a randomized controlled trial (QuikFix)

BACKGROUND AND AIMS

Recent meta-analyses of motivational interviewing (MI) for reducing risky alcohol use in young people have reported modest effects. Few studies have targeted individual patient factors to increase MI effectiveness. This study determined if MI enhanced with individualised personality-specific coping skills training (QuikFix) was more efficacious than standard MI or an assessment feedback/information (AF/I) control among young people with alcohol-related injuries or illnesses.

DESIGN AND SETTING

Single-centre, single-blind, three-group superiority randomized controlled trial with 1-, 3-, 6- and 12-months follow-ups. Telephone intervention, Brisbane, Australia.

PARTICIPANTS

A total of 398 young people (16-25 years; M age = 20.30 years, SD = 2.12; 54% female) with alcohol-related injuries and/or illnesses were recruited from an emergency department (ED) or rest/recovery service (RRS).

MEASURES

The primary outcome was total standard (10 g ethanol) drinks in the past month (Timeline Follow back [TLFB]) at 12 months (primary time point). Secondary outcomes were total drinking days and standard drinks per drinking day (TLFB) in the past month and the frequency of alcohol-related problems in the past 3 months (Rutgers Alcohol Problem Index).

INTERVENTIONS

Young people were randomized to two sessions of QuikFix enhanced with individualised personality-specific coping skills training (n = 132), two sessions of MI (n = 136) or one session of AF/I (n = 130), all delivered by telehealth.

FINDINGS

QuikFix resulted in greater reductions (all P < 0.0017) in the primary outcome of total standard drinks (M = 19.50, CI 99.75% = [11.31, 27.68]) than both MI (M = 32.61, CI 99.75% = [24.82, 40.40]; Cohen's D = 0.40) and AF/I (M = 34.12, CI 99.75% = [26.59, 41.65]; D = 0.45) at 12 months (retention n = 324/398, 81%). QuikFix had greater reductions on drinking days (M = 3.16, CI 99.75% = [2.37, 3.96]) than both MI (M = 4.53, CI 99.75% = [3.57, 5.48];D = 0.38) and AF/I (M = 4.69, CI 99.75% = [3.73, 5.65];D = 0.42) and fewer drinks per drinking day (M = 5.02, CI 99.75% = [3.71, 6.33]) than AF/I (M = 7.15, CI 99.75% = [5.93, 8.38;D = 0.47) at 12 months.

CONCLUSIONS

Young people with alcohol-related injuries and/or illnesses who attended ED and rest/recovery services and received an individualised personality-specific coping skills training intervention (QuikFix) had greater reductions in the amount of alcohol consumed at 12 months compared with those who received motivational interviewing or an assessment feedback/information intervention.

Systematic Review of Clinician-Reported Barriers to Provision of Brief Advice for Alcohol Intake in Hospital Inpatient and Emergency Settings

Hospital inpatient and emergency care settings provide frequent opportunities for clinicians to screen and provide brief interventions to patients who engage in the harmful use of alcohol. However, these services are not always provided, with several reasons given in different studies. We aimed to systematically review clinician-reported barriers in the provision of brief alcohol screening, brief advice, and intervention specific to hospital inpatient and emergency department (ED) settings. A systematic literature review was conducted in MEDLINE, PsycINFO, and CINAHL to identify the barriers perceived by healthcare workers in the provision of alcohol screening and brief intervention. These barriers were then categorized according to the capability, opportunity, and motivation (COM-B) model of behavior change theory. Twenty-five articles were included in this study, which involved questionnaires, surveys, interviews, and conference call discussions. The most commonly cited barriers (i.e., greater than half of the studies) were related to capability (lack of knowledge cited in 60% of studies); opportunity (lack of time and resources, 76 and 52% of studies, respectively); and motivation (personal discomfort in 60% of studies). Twenty-two other barriers were reported but with lower frequency. Clinicians cite a multitude of factors that impede their delivery of alcohol screening and brief interventions in the hospital inpatient and ED settings. These barriers were explored further under the framework of the COM-B model, which allows for intervention design. As such, changes can be made at the policy, managerial, and educational levels to address these barriers and help improve the self-efficacy and knowledge of clinicians who counsel patients on alcohol use.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight-related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context-mechanism-outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of "candidacy" (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

How alcohol use problem severity affects the outcome of brief intervention delivered in-person versus through computer-generated feedback letters

OBJECTIVE

The aim was to test if people with different alcohol use problem severity benefitted differentially from brief alcohol interventions delivered in-person versus through computer-generated feedback letters.

METHODS

Nine hundred sixty-one 18-64year old general hospital inpatients with at-risk alcohol use (mean age=40.9years [standard deviation=14.1], 75% men) were randomized to a) in-person counseling, b) computer-generated individualized feedback letters, or c) assessment only. Both interventions were delivered on the ward and 1 and 3 months later. Outcome was the change in the self-reported alcohol use per day at 6-, 12-, 18-, and 24-month follow-up. The Alcohol Use Disorder Identification Test (AUDIT) score was tested as a moderator of the effect of in-person counseling and computer-generated feedback letters, with higher AUDIT scores indicating more severe alcohol problems.

RESULTS

Compared to assessment only, computer-generated feedback letters more strongly reduced alcohol use over 24 months among persons with AUDIT scores of about 8 and lower (ps <0.05). In-person counseling tended to be superior over assessment only among persons scoring high on the AUDIT, but differences were not statistically significant. Six-, 12-, and 18-month differences between in-person counseling and computer-generated feedback letters were significant (ps<0.05) for persons with AUDIT scores below 7.1-7.7. The differences between both interventions attenuated at 24-month follow-up.

CONCLUSIONS

Computer-based intervention delivery may be superior over in-person delivery for people with low levels of alcohol use problem severity, whereas those with more severe alcohol problems may require more intensive care.

Reduced Drinking in Alcohol Dependence Treatment, What Is the Evidence?

Abstinence from alcohol has been the prevailing treatment goal for individuals with alcohol dependence (AD) within the context of specialty alcohol treatment. Yet, alcohol use has been conceptualized as existing on a continuum. Importantly, most people who meet criteria for AD and could benefit from treatment never receive treatment. About half of these individuals do not seek treatment because they report a desire to continue drinking. To increase acceptability of treatment, reductions in alcohol consumption have been examined as alternative outcomes in treatment trials for AD. The current study reviews data which indicate that long-term reduction in alcohol consumption among patients with AD is possible. Controlled studies have tested reduced alcohol consumption and show sustained improvements in drinking reductions for many patients following behavioral treatments and pharmacotherapy. Evidence-based treatment guidelines and medicines development guidance authorities have taken note of these developments and accept "intermediate harm reduction" (European Medicines Agency) or "low-risk drinking limits" (US Federal Drug Administration) as optional trial endpoints. In conclusion, while abstinence remains the safest treatment goal for individuals with AD, evidence supports that reduced drinking approaches may be an important extension in the treatment of AD.

A realist review of brief interventions for alcohol misuse delivered in emergency departments

BACKGROUND

Brief interventions (BIs) involve screening for alcohol misuse and providing feedback to patients about their use, with the aim of reducing alcohol consumption and related consequences. BIs have been implemented in various healthcare settings, including emergency departments (ED), where they have been found to contribute mixed results in their ability to address alcohol misuse among adults. Mechanisms through which BIs work and contextual factors impacting BI effectiveness are not clear. The purpose of this review was to understand how, for whom, and under what circumstances BIs work for adults misusing alcohol and who have been admitted to an ED. A realist review was chosen to answer these questions as realist reviews create context-mechanism-outcome configurations, leading to the development of comprehensive and detailed theories; in this case explaining how and for whom BIs work.

METHODS

Databases including PsycINFO, Healthstar, CINAHL, Medline, and Nursing and Allied Health were searched for articles published until December 2013. The search strategy focused on studies examining BIs that targeted alcohol misuse among adults admitted into the ED. The search identified 145 relevant abstracts, of which 36 were included in the review. The literature was synthesized qualitatively (immersion/crystallization).

RESULTS

Four mechanisms were found within reviewed studies, including engagement in/retention of BI materials, resolving ambivalence, increased awareness/insight into consequences of drinking, and increased self-efficacy/empowerment to use skills for change. The following contexts were found to impact mechanisms: emotional state, injury attributed to alcohol use, severity of alcohol use, and baseline stage of change.

CONCLUSIONS

This realist review provides advances in theories regarding which mechanisms to target during a BI and which contexts create the most favorable conditions for these mechanisms to occur, ultimately leading to optimal BI outcomes. These results can inform future clinical decision-making when delivering BIs in ED settings. Future research should conduct quantitative examination to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006549.