Katherine Perryman

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

Background Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Methods and Findings Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. Conclusions SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Trial Registration Current Controlled Trials ISRCTN 93681536

Screening and brief interventions for hazardous alcohol use in accident and emergency departments: A randomised controlled trial protocol

BackgroundThere is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments.Methods/designThe study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation.DiscussionThis paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.Trial RegistrationISRCTN 93681536

Low identification of alcohol use disorders in general practice in England.

AIMS The prevalence of alcohol use disorders (AUDs) in the United Kingdom is estimated at 25%, and primary care has been identified as the first line of treatment for this population. However, there is a paucity of evidence regarding the current rates of identification of AUDs in primary care. The aim of the present study was to compare the observed rates of AUDs in general practice with expected rates, which are based on general population prevalence rates of AUDs. DESIGN, PARTICIPANTS AND MEASUREMENTS Epidemiological data on individuals aged 16-64 years with an AUD was obtained from the General Practice Research Database. General population prevalence rates of AUDs were obtained from the Psychiatric Morbidity Survey. Chi(2) tests and identification ratios were used to analyse the data. RESULTS There was a significant relationship between type of AUD and identification (chi(2)=1466.89, P<0.001), and general practitioners were poorer at identifying harmful/hazardous drinkers when compared with dependent drinkers. No gender differences in the identification of hazardous/harmful drinking were found, but female dependent drinkers were significantly more likely to be identified than males (identification ratio 0.07; 95% confidence interval 0.06-0.07). The identification of AUDs was significantly lower for the 16-24-year age group compared with all other age groups. CONCLUSION Despite attempts at targeting hazardous/harmful drinkers for brief interventions in primary care, the present findings suggest that this group are still under-identified. Furthermore, this under-identification is even more apparent in men and in young people who have high general population prevalence rates for AUDs. In conclusion, increasing identification rates could be incorporated into brief intervention strategies in primary care.

Adult attachment, reassurance seeking and hypochondriacal concerns in college students

An individual’s attachment style can be conceptualized as a working model for interactions with others, developed as result of experiences with childhood caregivers. People with hypochondriacal tendencies are preoccupied with thoughts of having an illness and constantly seek medical reassurance. We hypothesized that students with preoccupied attachment would score highly on a measure of hypochondriasis and investigated whether the association would be explained by the general tendency to seek reassurance in relationships. A total of 117 undergraduate students completed questionnaires measuring attachment style; negative affectivity; reassurance seeking in relationships and hypochondriasis. Participants with preoccupied attachment style (n = 17, 15%) had significantly higher hypochondriasis scores than those with other attachment styles. Hierarchical multiple regression analysis suggested that the association between the preoccupied attachment style and hypochondriasis was explained by the general tendency to seek reassurance in relationships, with negative affectivity, a dispositional variable, also acting as a significant predictor of hypochondriasis.

Alcohol Screening and Brief Interventions for Offenders in the Probation Setting (SIPS Trial): a Pragmatic Multicentre Cluster Randomized Controlled Trial

AIM To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling. METHODS A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of <8). Secondary outcomes were AUDIT status at 12 months, experience of alcohol-related problems, health utility, service utilization, readiness to change and reduction in conviction rates. RESULTS Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention. CONCLUSION Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.

The utility of different screening methods to detect hazardous drinking and alcohol use disorders in the Screening and Intervention Program for Sensible Drinking (SIPS) program

Numerous screening methods have been developed to detect hazardous and harmful drinking in a range of health settings. Recent research has focused on developing briefer screening tools to maximize implementation in busy practice settings, particularly emergency departments (EDs) and primary care. However the relative utility of these tools is not fully understood. Further, there is a need to identify the utility of universal screening, in which all patients approaching primary care are screened, compared with targeted screening, which includes only patients with certain “red flag” conditions or presentations. The Screening and Intervention Program for Sensible Drinking (SIPS) program compared the relative utility of different screening tools (e.g., the Single Alcohol Screening Question [SASQ] and the Fast Alcohol Screening Test [FAST]) and approaches (universal versus targeted screening) in primary care. In addition, the utility of the Paddington Alcohol Test (PAT), a targeted screening tool, was compared with SASQ and FAST in EDs. Compared with the Alcohol Use Disorders Identification Test (AUDIT), the FAST had a higher sensitivity than the SASQ in primary care. Although targeted screening in primary care is a more efficient screening method, it misses a large proportion of patients who could benefit from brief interventions. The SASQ performed better in EDs than either the FAST or PAT. These results have important implications for the choice of screening tools in different settings.

National survey of alcohol treatment agencies in England: Characteristics of treatment agencies

Background: To map and contact all specialist alcohol treatment services in England and to investigate the characteristics of responding agencies. Methods: A national cross-sectional survey of alcohol treatment agencies in England. A questionnaire was designed to gather information about agency characteristics, including the service structure, staffing, modalities of treatment, and associated funding. Results: A total of 696 alcohol treatment agencies were mapped, of which 388 (55.7%) responded to the survey. Variations in agency characteristics were noticed across geographical regions, as well as across sectors. The estimated annual spending on alcohol treatment was £217 million. Conclusions: Whereas the regional variation in agency characteristics has implications for access to particular types of treatment, the inter-sector variation has implications for the allocation of funding. The estimated annual spending of £217 million is greater than previous national estimates. A national framework for alcohol service mapping could benefit identification of areas for improvement and lead to more successful treatment outcomes.

The Perceived Challenges Facing Alcohol Treatment Services in England: a qualitative study of service providers

Background: Although there is currently a high level of need for alcohol treatment in the United Kingdom, there has been a lack of research into alcohol treatment to date. This study reports on what the current challenges to alcohol treatment services in England are, what resources might help to improve services, and which groups are poorly served by alcohol treatment services, as perceived by service providers. Methods: Qualitative data was obtained in three open-ended questions from a sample of 207 alcohol treatment agencies that responded to the national alcohol needs assessment postal survey. Results: Lack of funding, a general lack of resources to provide services, inadequate access to detoxification and rehabilitation services, and a lack of trained staff to deliver services were key challenges presented. More staff, improved access to detoxification and rehabilitation services, better premises, more funding allocation, improved links with other services, and better resources in general to provide services were the key factors reported to improve services. Clients with complex needs (e.g., dual diagnosis, brain damage), women with children, homeless people, and ethnic minorities were perceived to be poorly served by alcohol treatment services. Conclusions: Alcohol treatment services in England face many challenges which should be incorporated into future alcohol treatment service development.

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.

A randomized controlled trial of different methods of alcohol screening and brief intervention in routine accident and emergency department care: 12-month outcomes

There is a wealth of evidence on the detrimental impact of excessive alcohol consumption on physical, psychological, and social health. There also exists a substantial evidence base for the efficacy of alcohol brief intervention (BI) aimed at reducing consumption across a range of settings. Research conducted in emergency departments (EDs) has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness of BI. However, the majority of this research has been conducted in a single center, and there is little evidence of the generalizability of SBI implementation across EDs. This pragmatic cluster randomized controlled trial randomized nine EDs to a combination of screening tools (the Modified Single Alcohol Screening Question [M-SASQ], the Fast Alcohol Screening Test [FAST], or the Screening and Intervention Program for Sensible Drinking modified Paddington Alcohol Test [SIPS-PAT]) and interventions (patient intervention leaflet [PIL], brief advice [BA], or brief lifestyle counseling [BLC]). The primary hypothesis was that BLC delivered by an alcohol health worker would be more effective than BA or PIL delivered by ED staff. Outcomes were assessed at six and 12 months. Overall, 5992 patients were screened for eligibility in 9 EDs; of these, 3737 (62%) were found eligible, and 1491 screened positive for an alcohol use disorder (40%). Of those who screened positive, 1204 (81%) consented to participate in the trial. The mean age of participants was 35 years, and the mean AUDIT score at baseline was 12.4. The majority of the sample was male (65%) and white (88%). At 12 months, 803 (67%) of participants were followed up. No significant differences in follow-up rates were observed between intervention groups. Overall, the proportion of participants positive for an alcohol use disorder reduced significantly by 16.3%. This reflected a significant decrease of 18.8% in the PIL group and 15.1% in both the BLC and BA groups. An adjusted logistic regression model found no significant effects of intervention group, screening approach, or baseline AUDIT score.