Christopher W. Dunn

Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence

OBJECTIVEnAlcoholism is the leading risk factor for injury. The authors hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and would decrease the rate of trauma recidivism.nnnMETHODSnThis study was a randomized, prospective controlled trial in a level 1 trauma center. Patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and short Michigan Alcoholism Screening Test (SMAST). Those with positive results were randomized to a brief intervention or control group. Reinjury was detected by a computerized search of emergency department and statewide hospital discharge records, and 6- and 12-month interviews were conducted to assess alcohol use.nnnRESULTSnA total of 2524 patients were screened; 1153 screened positive (46%). Three hundred sixty-six were randomized to the intervention group, and 396 to controls. At 12 months, the intervention group decreased alcohol consumption by 21.8+/-3.7 drinks per week; in the control group, the decrease was 6.7+/-5.8 (p = 0.03). The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they had 21.6+/-4.2 fewer drinks per week, compared to an increase of 2.3+/-8.3 drinks per week in controls (p < 0.01). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p = 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up).nnnCONCLUSIONnAlcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counseling for alcohol problems should be routine.

THE EMERGING EVIDENCE BASE FOR MOTIVATIONAL INTERVIEWING: A META-ANALYTIC AND QUALITATIVE INQUIRY

This article offers a meta-analytic, qualitative, and process review of the empirical literature for adaptations of motivational interviewing (AMIs), a promising approach to treating problem behaviors. AMIs are equivalent to other active treatments and yield moderate effects (from 0.35 to 0.56) compared to no-treatment/placebo for problems involving alcohol, drugs, and diet and exercise. Results do not support the efficacy of AMIs for smoking or HIV-risk behaviors. Conclusions regarding the mechanisms of action for AMIs are limited by methodological problems: confounding motivational interviewing with feedback, unclear definitions of the AMI interventions used, difficulties in therapist training, and limited use of treatment integrity rating scales. Extant research suggests that AMIs are equivalent in efficacy to and briefer than cognitive behavioral skills training (CBST) approaches. Since AMIs focus on readiness to change while CBST targets the change process, AMIs may be useful as preludes or additions to CBST.

Nationwide Survey of Alcohol Screening and Brief Intervention Practices at US Level I Trauma Centers

BACKGROUNDnIn 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement.nnnSTUDY DESIGNnTrauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice.nnnRESULTSnOne hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time.nnnCONCLUSIONSnThe investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.

Alcohol problems in women admitted to a level I trauma center: a gender-based comparison.

BACKGROUNDnMale patients constitute such a large proportion of trauma patients that most studies of alcohol problems in trauma patients have been carried out with clinical data largely or totally contributed by male patients. It may be incorrect to assume that the nature of alcoholism in women and men is identical, or that the size of the problem among women is small, eliminating the need to specifically study female patients. The purpose of this study was to perform a gender-based comparison of alcohol problems in trauma patients.nnnMETHODSnAdmitted injured patients underwent routine screening, including a blood alcohol concentration, serum gamma-glutamyl transpeptidase, and the Short Michigan Alcohol Screening Test. A random sample of screen positive women and men underwent a comprehensive alcohol use and psychosocial assessment, and the results were compared by gender.nnnRESULTSnThe screen-positive rate was higher for men, 51% versus 34% (p < 0.01). However, screen-positive women and men had similar problem severity as reflected by mean blood alcohol concentration (162 mg/dL vs. 142 mg/dL, p = 0.16) and Short Michigan Alcohol Screening Test scores (4.6 vs. 5.0, p = 0.32). The Alcohol Use Disorders Identification Test, NIMH-DIS, and Severity of Alcohol Dependence Data form showed that female trauma patients with alcohol problems have the same severity of dependence symptoms as men. However, women were significantly more likely to have liver dysfunction, depression, psychological distress, and recent physical, emotional, or sexual abuse.nnnCONCLUSIONnAlcohol problems are more common in male trauma patients, but women with alcohol problems are just as severely impaired, have at least as many adverse consequences of alcohol use as their male counterparts, and have more evidence of alcohol-related physical and psychological harm.

The video assessment of simulated encounters-revised (VASE-R): Reliability and validity of a revised measure of motivational interviewing skills

The video assessment of simulated encounters-revised (VASE-R) is a video-based method, administered in individual or group settings, for assessing motivational interviewing (MI) skills. The 18-item instrument includes three video-based vignettes, in which actors portray substance abusers, with each vignette followed by questions that prompt examinees to write responses that are then scored against MI standards. The VASE-R was administered to two independent samples: (1) substance abuse practitioners participating in a study of MI training methods, and (2) MI training facilitators with a high level of MI skill and expertise. This multi-study report describes basic VASE-R psychometric properties -- including scoring reliability, internal consistency, concurrent validity, and sensitivity to the effects of training -- and then presents proficiency standards based on administration to a sample of MI training facilitators (MI Experts). The findings indicate excellent inter-rater reliability using intra-class correlations for the full-scale score (.85) and acceptable levels for subscales (.44 to .73). The instrument displayed strong concurrent validity with the Helpful Responses Questionnaire (HRQ) and a behavioral sample of clinician behavior with a standardized patient scored using the MI Treatment Integrity (MITI) system, as well as good sensitivity to improvement in MI skill as a result of training. The findings provide an empirical basis for suggesting VASE-R benchmarks for beginning proficiency and expert MI practice.

Evaluating therapist adherence in motivational interviewing by comparing performance with standardized and real patients

OBJECTIVEnThe goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear.nnnMETHODnWe estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs).nnnRESULTSnICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapists adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures.nnnCONCLUSIONnDifferences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior.

Substance use and posttraumatic stress disorder symptoms in trauma center patients receiving mandated alcohol screening and brief intervention

In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.

A randomized evaluation of motivational interviewing training for mandated implementation of alcohol screening and brief intervention in trauma centers

The American College of Surgeons has mandated that level I and level II trauma centers implement universal alcohol screening and brief intervention (SBI) for injured patients. This study was a secondary analysis of a national, 20-hospital, cluster-randomized implementation trial focusing on practical issues of training and supervising alcohol SBI providers in motivational interviewing (MI). The purpose of this study was to examine whether real-world trauma center providers can be trained to provide higher quality counseling using MI as part of brief interventions for alcohol and whether MI skills can be maintained over time. Sites were randomly assigned to receive a 1day workshop training in MI for alcohol SBI or not, and all providers regardless of training completed up to seven standardized patient assessments of MI fidelity over 27months. Six domains on the Motivational Interviewing Treatment Integrity (MITI) coding system were assessed and compared to proficiency criteria. Providers in the intervention training group showed substantially improved MITI scores over the course of the 27-month time period. Domains that had particularly strong improvement were MI spirit and empathy; however, despite the overall improvement in the intervention group scores, expert-derived proficiency criteria were attained only for the global scores. Routine trauma center providers who receive MI training can deliver higher quality counseling in alcohol brief interventions, but may not, however, attain previously derived proficiency standards. Future implementation efforts in real-world acute care medical settings could further elucidate provider characteristics that predict training response and also strive to demonstrate that higher quality alcohol SBI implementation is associated with improved patient-level outcomes.

Advancing Methods for Reliably Assessing Motivational Interviewing Fidelity using the Motivational Interviewing Skills Code

The current paper presents novel methods for collecting MISC data and accurately assessing reliability of behavior codes at the level of the utterance. The MISC 2.1 was used to rate MI interviews from five randomized trials targeting alcohol and drug use. Sessions were coded at the utterance-level. Utterance-based coding reliability was estimated using three methods and compared to traditional reliability estimates of session tallies. Session-level reliability was generally higher compared to reliability using utterance-based codes, suggesting that typical methods for MISC reliability may be biased. These novel methods in MI fidelity data collection and reliability assessment provided rich data for therapist feedback and further analyses. Beyond implications for fidelity coding, utterance-level coding schemes may elucidate important elements in the counselor-client interaction that could inform theories of change and the practice of MI.

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

BACKGROUNDnThe 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.nnnMETHODSnWe 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).nnnRESULTSnNine 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.nnnCONCLUSIONSnIn 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 NPs taught by either method should undergo periodic continuing education to maintain the necessary skill set for performing BIs.