Christine Godfrey

Effectiveness of treatment for alcohol problems: findings of the randomised UK Alcohol Treatment Trial (UKATT)

Abstract Objective To compare the effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. Design Pragmatic randomised trial. Setting Seven treatment sites around Birmingham, Cardiff, and Leeds. Participants 742 clients with alcohol problems; 689 (93.0%) were interviewed at three months and 617 (83.2%) at 12 months. Interventions Social behaviour and network therapy and motivational enhancement therapy. Main outcome measures Changes in alcohol consumption, alcohol dependence, and alcohol related problems over 12 months. Results Both groups reported substantial reductions in alcohol consumption, dependence, and problems, and better mental health related quality of life over 12 months. Between groups we found only one significant difference in outcome, probably due to chance: the social network group showed significantly better physical health at three months. Non-significant differences at 12 months in the motivational group relative to the social network group included: the number of drinks consumed per drinking day had decreased by an extra 1.1 (95% confidence interval −1.0 to 3.2); scores on the Leeds dependence questionnaire had improved by an extra 0.6 (−0.7 to 2.0); scores on the alcohol problems questionnaire had improved by an extra 0.5 (−0.4 to 1.4); but the number of days abstinent from drinking had increased by 1.2% less (−4.5% to 6.9%). Conclusion The novel social behaviour and network therapy for alcohol problems did not differ significantly in effectiveness from the proved motivational enhancement therapy.

Methods for assessing the cost-effectiveness of public health interventions: Key challenges and recommendations

RATIONALE Increasing attention is being given to the evaluation of public health interventions. Methods for the economic evaluation of clinical interventions are well established. In contrast, the economic evaluation of public health interventions raises additional methodological challenges. The paper identifies these challenges and provides suggestions for overcoming them. METHODS To identify the methodological challenges, five reviews that explored the economics of public health were consulted. From these, four main methodological challenges for the economic evaluation of public health interventions were identified. A review of empirical studies was conducted to explore how the methodological challenges had been approached in practice and an expert workshop convened to discuss how they could be tackled in the future. RESULTS The empirical review confirmed that the four methodological challenges were important. In all, 154 empirical studies were identified, covering areas as diverse as alcohol, drug use, obesity and physical activity, and smoking. However, the four methodological challenges were handled badly, or ignored in most of the studies reviewed. DISCUSSION The empirical review offered few insights into ways of addressing the methodological challenges. The expert workshop suggested a number of ways forward for overcoming the methodological challenges. CONCLUSION Although the existing empirical literature offers few insights on how to respond to these challenges, expert opinion suggests a number of ways forward. Much of what is suggested here has not yet been applied in practice, and there is an urgent need both for pilot studies and more methodological research.

Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review

AIM To determine the effects of computer-based interventions aimed at reducing alcohol consumption in adult populations. METHODS The review was undertaken following standard Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance for systematic reviews. The literature was searched until December 2008, with no restrictions on language. Randomized trials with parallel comparator groups were identified in the form of published and unpublished data. Two authors independently screened abstracts and papers for inclusion. Data extraction and bias assessment was undertaken by one author and checked by a second author. Studies that measured total alcohol consumption and frequency of binge drinking episodes were eligible for inclusion in meta-analyses. A random-effects model was used to pool mean differences. RESULTS Twenty-four studies were included in the review (19 combined in meta-analyses). The meta-analyses suggested that computer-based interventions were more effective than minimally active comparator groups (e.g. assessment-only) at reducing alcohol consumed per week in student and non-student populations. However, most studies used the mean to summarize skewed data, which could be misleading in small samples. A sensitivity analysis of those studies that used suitable measures of central tendency found that there was no difference between intervention and minimally active comparator groups in alcohol consumed per week by students. Few studies investigated non-student populations or compared interventions with active comparator groups. CONCLUSION Computer-based interventions may reduce alcohol consumption compared with assessment-only; the conclusion remains tentative because of methodological weaknesses in the studies. Future research should consider that the distribution of alcohol consumption data is likely to be skewed and that appropriate measures of central tendency are reported.

Methodological Challenges in Online Trials

Health care and health care services are increasingly being delivered over the Internet. There is a strong argument that interventions delivered online should also be evaluated online to maximize the trial’s external validity. Conducting a trial online can help reduce research costs and improve some aspects of internal validity. To date, there are relatively few trials of health interventions that have been conducted entirely online. In this paper we describe the major methodological issues that arise in trials (recruitment, randomization, fidelity of the intervention, retention, and data quality), consider how the online context affects these issues, and use our experience of one online trial evaluating an intervention to help hazardous drinkers drink less (DownYourDrink) to illustrate potential solutions. Further work is needed to develop online trial methodology.

Cost effectiveness treatment of alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT)

Abstract Objective To compare the cost effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. Design Cost effectiveness analysis alongside a pragmatic randomised trial. Setting Seven treatment sites around Birmingham, Cardiff, and Leeds. Participants 742 clients with alcohol problems; 617 (83.2%) were interviewed at 12 months and full economic data were obtained on 608 (98.5% of 617). Main economic measures Quality adjusted life years (QALYs), costs of trial treatments, and consequences for public sector resources (health care, other alcohol treatment, social services, and criminal justice services). Results Both therapies saved about five times as much in expenditure on health, social, and criminal justice services as they cost. Neither net savings nor cost effectiveness differed significantly between the therapies, despite the average cost of social behaviour and network therapy (£221;

Use of nicotine replacement therapy and the risk of acute myocardial infarction, stroke, and death

385; €320) being significantly more than that of motivational enhancement therapy (£129). If a QALY were worth £30 000, then the motivational therapy would have 58% chance of being more cost effective than the social therapy, and the social therapy would have 42% chance of being more cost effective than the motivational therapy. Conclusion Participants reported highly significant reductions in drinking and associated problems and costs. The novel social behaviour and network therapy did not differ significantly in cost effectiveness from the proved motivational enhancement therapy.

On-line Randomized Controlled Trial of an Internet Based Psychologically Enhanced Intervention for People with Hazardous Alcohol Consumption

Objective: To determine whether nicotine replacement therapy (NRT) is associated with an increased risk of acute myocardial infarction, acute stroke, or death. Design: Self control case series analysis of data from The Health Improvement Network (THIN) to estimate the relative incidence of myocardial infarction and stroke in four 14 day periods before and after the first prescription for NRT. Setting: THIN is a computerised general practice database. Subjects: Patients contributing data to THIN. Interventions: Observational study of NRT. Main outcomes: Acute myocardial infarction, acute stroke, and death. Results: 33 247 individuals had been prescribed NRT, of whom 861 had had a myocardial infarction and 506 a stroke. There was a progressive increase in the incidence of first myocardial infarction in the 56 days leading up to the first NRT prescription (overall incidence ratio 5.55, 95% confidence interval (CI) 4.42 to 6.98), but the incidence fell after this time and was not increased in the 56 days after starting NRT (incidence ratio 1.27, 95% CI 0.82 to 1.97). The results were similar for second myocardial infarction and stroke, and for subgroups of people with pre-existing angina and hypertension. There were 960 deaths in our cohort during a mean follow up period of 2.6 years after starting NRT, with no evidence of an increased mortality in the 56 days after the NRT prescription (incidence ratio 0.86, 95% CI 0.60 to 1.23). Conclusions: The use of NRT is not associated with any increase in the risk of myocardial infarction, stroke, or death.

Costs of employee smoking in the workplace in Scotland

Background Interventions delivered via the Internet have the potential to address the problem of hazardous alcohol consumption at minimal incremental cost, with potentially major public health implications. It was hypothesised that providing access to a psychologically enhanced website would result in greater reductions in drinking and related problems than giving access to a typical alcohol website simply providing information on potential harms of alcohol. DYD-RCT Trial registration: ISRCTN 31070347. Methodology/Principal Findings A two-arm randomised controlled trial was conducted entirely on-line through the Down Your Drink (DYD) website. A total of 7935 individuals who screened positive for hazardous alcohol consumption were recruited and randomized. At entry to the trial, the geometric mean reported past week alcohol consumption was 46.0 (SD 31.2) units. Consumption levels reduced substantially in both groups at the principal 3 month assessment point to an average of 26.0 (SD 22.3) units. Similar changes were reported at 1 month and 12 months. There were no significant differences between the groups for either alcohol consumption at 3 months (intervention: control ratio of geometric means 1.03, 95% CI 0.97 to 1.10) or for this outcome and the main secondary outcomes at any of the assessments. The results were not materially changed following imputation of missing values, nor was there any evidence that the impact of the intervention varied with baseline measures or level of exposure to the intervention. Conclusions/Significance Findings did not provide support for the hypothesis that access to a psychologically enhanced website confers additional benefit over standard practice and indicate the need for further research to optimise the effectiveness of Internet-based behavioural interventions. The trial demonstrates a widespread and potentially sustainable demand for Internet based interventions for people with hazardous alcohol consumption, which could be delivered internationally. Trial Registration Controlled-Trials.com ISRCTN31070347

Opportunistic screening for alcohol use disorders in primary care: comparative study

BACKGROUND Employers have responded to new regulations on the effects of passive smoking by introducing a range of workplace policies. Few policies include provision of smoking cessation intervention. OBJECTIVE To estimate the cost to employers of smoking in the workplace in Scotland to illustrate the potential gains from smoking cessation provision. Costs vary with type of smoking policy in place; therefore, to estimate these costs results from a survey were combined with evidence drawn from a literature review. STUDY DESIGN A telephone survey of 200 Scottish workplaces, based on a stratified random sample of workplaces with 50 or more employees, was conducted in 1996. Additional evidence was compiled from a review of the literature of smoking related costs and specific smoking related effects. RESULTS 167 completed responses were received, of which 156 employers (93%) operated a smoking policy, 57 (34%) operated smoke free buildings, and 89 (53%) restricted smoking to a “smoke room”. The research literature shows absenteeism to be higher among smokers when compared to non-smokers. The estimated cost of smoking related absence in Scotland is £40 million per annum. Total productivity losses are estimated at approximately £450 million per annum. In addition, the resource cost in terms of losses from fires caused by smoking materials is estimated at approximately £4 million per annum. In addition, there are costs from smoking related deaths and smoking related damage to premises. CONCLUSION This study shows how smoking cessation interventions in the workplace can yield positive cost savings for employers, resulting in gains in productivity and workplace attendance which may outweigh the cost of any smoking cessation programme.

The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: a randomized trial

Abstract Objective To evaluate the efficacy and relative costs of different screening methods for the identification of alcohol use disorders in an opportunistic screening programme in primary care in the United Kingdom. Design Comparative study. Setting Six general practices in south Wales. Participants 194 male primary care attendees aged 18 or over who completed an alcohol use disorders identification test (AUDIT) questionnaire. Main outcome measures Scores on alcohol use disorders identification test and measures of γ-glutamyltransferase, aspartate aminotransferase, per cent carbohydrate deficient transferrin, and erythrocyte mean cell volume. Hazardous alcohol consumption, weekly binge consumption, and monthly binge consumption were ascertained using the time line follow back method over the previous 180 days. Alcohol dependence was determined using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Unit costs were established from published resource references and from actual costs of analysing the biochemical tests. Results A significant correlation was observed be alcohol consumption and score on the alcohol use disorders identification test (Pearsons correlation coefficient r = 0.74) and measures of γ-glutamyltransferase (r = 0.20) and per cent carbohydrate deficient transferrin (r = 0.36) but not aspartate aminotransferase (r = 0.08) or erythrocyte mean cell volume (r = 0.02). The alcohol use disorders identification test exhibited significantly higher sensitivity, specificity, and positive predictive value than all of the biochemical markers for hazardous consumption (69%, 98%, and 95%), weekly binge consumption (75%, 90%, and 71%), monthly binge consumption (66%, 97%, and 91%), and alcohol dependence (84%, 83%, and 41%). The questionnaire was also more cost efficient, with a lower cost per true positive for all consumption outcomes. Conclusion The alcohol use disorders identification test questionnaire is an efficient and cost efficient diagnostic tool for routine screening for alcohol use disorders in primary care.