Embedding routine alcohol screening and brief interventions in a rural general hospital

Issues. Alcohol screening and brief intervention approaches (SBI) are strongly supported by evidence, but few health‐care facilities have successfully introduced and sustained routine SBI. Approach. This paper describes the first 2 years of implementing SBI in an Australian rural general hospital. The SBI project aims were to universally screen presentations to Northeast Health Wangaratta (NHW), to provide brief interventions to people screening at medium risk of harm from drinking and enhanced referral for persons screening at high risk. Key Findings. In 2007 and 2008, the NHW SBI project conducted 11 079 screens for alcohol use disorders using the Alcohol Use Disorders Identification Screening Test screening tool. Eighty‐five per cent of persons screened at low risk of alcohol‐related problems, 11% at medium risk and 4% at high risk. Implications. Policy and planning bodies and hospital management's support and the appointment of a dedicated project worker are critical to successful SBI implementation. Conclusion. It is possible to establish a SBI service in a rural general hospital setting. The NHW SBI project broadened the focus from treatment of persons with severe dependency to detection, early intervention and prevention for the larger, more easily treated, cohort of persons drinking at hazardous/harmful but non‐dependent levels. The challenge for any organisation is to maintain routine SBI deployment over the long term. [Fahy P, Croton G, Voogt S. Embedding routine alcohol screening and brief interventions in a rural general hospital. Drug Alcohol Rev 2011;30;47–54]     

Organizational attributes and screening and brief intervention in primary care

Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening and brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that were included in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to the implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of the implementation of SBI and treatment.     

How and when health-care practitioners in Aboriginal Community Controlled Health Services deliver alcohol screening and brief intervention, and why they don't: a qualitative study

Introduction. Indigenous Australians experience a disproportionately high burden of alcohol‐related harm. Alcohol screening and brief intervention (SBI) offers the potential to reduce this harm if barriers to its delivery in Aboriginal Community Controlled Health Services (ACCHSs) can be optimally targeted. Aims. Examine health‐care practitioners' perceptions of, and practices in, alcohol SBI in ACCHSs. Methods. Semi‐structured group interviews with 37 purposively selected health staff across five ACCHSs. Results. Alcohol screening independent of standard health assessments was generally selective. The provision of brief intervention was dependent upon factors related to the patient. Four key factors underlying health‐care practitioners' perceptions of alcohol SBI were prominent: outcome expectancy; role congruence; utilisation of clinical systems and processes; and options for alcohol referral. Discussion. The influence of outcome expectancy and role congruence on health‐care practitioners' alcohol SBI practices has been identified previously, as has to a lesser extent, their less than optimal use of clinical systems and processes. The influence of options for alcohol referral on health‐care practitioners' willingness to deliver alcohol SBI primarily related to their misunderstanding of alcohol SBI and the lack of culturally appropriate alcohol referral options for their patients. Conclusion. An intervention combining interactive, supportive and reinforcing evidence‐based dissemination strategies is most likely required to enhance health‐care practitioners' knowledge and skills in alcohol SBI delivery, positively orientate them to their role in its delivery, and facilitate integration of evidence‐based alcohol SBI into routine clinical processes and locally available systems.[Clifford A, Shakeshaft A, Deans C. How and when health‐care practitioners in Aboriginal Community Controlled Health Services deliver alcohol screening and brief intervention, and why they don't: A qualitative study. Drug Alcohol Rev 2012;31:13–19]     

Breaking new ground in the study and practice of alcohol brief interventions

This article amplifies the decision to subtitle the INEBRIA2009 Conference 'Breaking New Ground'. The effectiveness of screening and brief intervention (SBI) for hazardous and harmful drinking is now well-established for primary health care and is promising for other medical settings. In addition, significant advances in the implementation of SBI are being made in various parts of the world. But, because of the need to establish efficacy and effectiveness, and perhaps too because of a preoccupation with meta-analysis of existing research findings, progress in other aspects of the theory and practice of SBI has been slower than ideal. There may also be a risk of complacency in the SBI field of study. For these reasons and others, the Conference Organizing Committee decided to focus the conference and invite presentations on a number of specific topics in the field of alcohol SBI and these are listed here followed by a discussion of other areas in which new ground needs to be broken.[Heather N. Breaking new ground in the study and practice of alcohol brief interventions.     

Screening and Brief Intervention Enter Their 5th Decade

SUMMARY

About 40 years since the first controlled study, screening and brief intervention (SBI) are being disseminated into practice. But many unanswered questions remain. Studies in this special issue address what we know and don't know about alcohol and drug SBI, cost-effectiveness, patient preferences, education for clinicians, quality performance measures, “no-contact” SBI, predictors of behavior change, and methodological concerns with the SBI literature. The best evidence for efficacy of SBI is that it can lead to decreased consumption in primary care patients with non-dependent unhealthy alcohol use. But further research is needed on brief drug screening tools, efficacy of SBI for drugs, effectiveness in real world settings, integration of SBI for alcohol and drugs with other health behaviors, effects of SBI on alcohol and drug consequences, effects on dependence among those not seeking help, and on how to best disseminate the efficacious elements of SBI into practice.     

The costs of screening and brief intervention for risky alcohol use

OBJECTIVE: The purpose of this study was to estimate provider-incurred costs of alcohol screening and brief intervention (SBI) for risky drinking as implemented in four managed care organizations (MCOs) participating in the Cutting Back project implemented by the University of Connecticut Health Center. METHOD: Each MCO provided two comparable primary care clinics in which two different SBI models were implemented: the "Practitioner" (P) model and the "Specialist" (S) model. Risky drinkers were identified based on responses to a health appraisal form. They were administered the AUDIT to determine an appropriate intervention. Using data collected from these sites, we separately estimated start-up and ongoing implementation costs of the intervention. RESULTS: SBI start-up costs per MCO ranged from approximately dollars 86,000 to dollars 115,000 across the four study MCOs. Across all four study MCOs, the estimated median ongoing implementation cost of administering the health appraisal was dollars 0.25 per patient appraised, and the estimated median cost of screenings was dollars 0.42 per patient screened. The estimated median cost of performing the brief intervention across the study MCOs was dollars 2.59 per patient receiving the intervention in the S clinics and dollars 3.43 per patient receiving the intervention in the P clinics. Labor costs dominated start-up and ongoing implementation. Technical assistance costs accounted for a significant proportion of start-up costs. Implementation in the S model is less costly than in the P model, largely because of the S model's use of less expensive nonphysician labor. CONCLUSIONS: Our analysis suggests that the cost of SBI is modest, and MCOs may want to consider adopting SBI as an alcohol use prevention tool. Although our results suggest that the S model is less costly than the P model, clinic-level implementation factors may affect the relative costs of the S versus P models.     

Screening and brief intervention enter their 5th decade.

About 40 years since the first controlled study, screening and brief intervention (SBI) are being disseminated into practice. But many unanswered questions remain. Studies in this special issue address what we know and don't know about alcohol and drug SBI, cost-effectiveness, patient preferences, education for clinicians, quality performance measures, 'no-contact' SBI, predictors of behavior change, and methodological concerns with the SBI literature. The best evidence for efficacy of SBI is that it can lead to decreased consumption in primary care patients with non-dependent unhealthy alcohol use. But further research is needed on brief drug screening tools, efficacy of SBI for drugs, effectiveness in real world settings, integration of SBI for alcohol and drugs with other health behaviors, effects of SBI on alcohol and drug consequences, effects on dependence among those not seeking help, and on how to best disseminate the efficacious elements of SBI into practice.     

Training medical providers to conduct alcohol screening and brief interventions.

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.     

The feasibility of alcohol screening and interventions in emergency care: a comparison of primary and specialised health care settings

Background: Implementation of alcohol screening and brief intervention in emergency departments is inadequate and the evidence base more mixed than in primary health care (PHC). This comparison study investigates the feasibility of alcohol screening and interventions by nurses in emergency departments, seven based in PHC and two in specialised health care clinics. The aim is to analyse barriers to implementation in these two contexts.

Methods: A questionnaire was used among emergency nurses in the Kymenlaakso hospital district in Finland. The response rate was 71% (N?=?112; PHC clinics n?=?42; specialised clinics n?=?38). The statistical differences in responses were analysed using the χ² test. Open-ended questions were analysed qualitatively.

Results: The nurses in specialised clinics treated patients with alcohol-attributable conditions/traumas more often than the nurses in PHC did (p?p?p?Conclusions: The results indicate an intervention paradox in the emergency care setting: compared to nurses in PHC clinics, nurses in specialised health care clinics work more often with intoxicated patients but they are less willing to implement alcohol screening and interventions. The findings highlight the need for institutional-level support in addition to capacity building among nurses.     

Country-wide distance training for delivery of screening and brief intervention for problematic substance use: A pilot evaluation of participant experiences and patient outcomes

ABSTRACT

Background: In this study, the authors evaluated if the 120-hour distance learning (DL) course SUPERA (an acronym in Portuguese meaning “System for detection of excessive use or dependence on psychoactive substances: brief Intervention, social reinsertion and follow-up”) was an effective way to train health professionals and social workers to apply screening and brief intervention (SBI) for patients with substance use disorders. Methods: In the first phase, 2420 health professionals or social workers, who had completed the course, answered an online survey about their use of the SBI. In the second phase, 25 of those professionals applied the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) followed by a brief intervention (BI) to patients with substance use disorders. Three months after the SBI delivery, independent researchers followed up 79 patients who had received SBI, reapplying the ASSIST and a questionnaire to evaluate the patients'/clients' satisfaction with the intervention they received. Results: In the first phase, it was found that most health professionals and social workers who completed the course applied the SBI in their work and felt very motivated to do it. In the second phase of the study, at a 3-month follow-up, most patients had significantly reduced their ASSIST scores in respect of alcohol and cocaine/crack in relation to their baseline levels. Those patients classified by their ASSIST score as “suggestive of dependence” presented a significant reduction in their scores regarding alcohol, tobacco, and cocaine/crack, whereas those classified as “at risk” presented a reduction in respect of alcohol problems only. Patients associated changes in their substance use with the SBI received. Conclusions: A reduction in substance use–related problems was associated with the SBI applied by the health professionals or social workers trained by the DL course SUPERA. Two significant limitations of this study were the small number of participants (professionals and patients in the follow-up) and the absence of a control group in the second phase of the study.     

Risky drinking among community pharmacy customers in New Zealand and their attitudes towards pharmacist screening and brief interventions

Introduction and Aims. To estimate the prevalence of risky drinking among customers in community pharmacies and to explore customer attitudes towards screening and brief intervention (SBI). Design and Methods. Cross‐sectional, anonymous survey, using random selection of community pharmacies in New Zealand to collect data using self‐completion questionnaires and an opportunity to enter a prize draw. Participants were customers/patients attending the community pharmacy on a specific, randomly selected day (Monday to Friday) in one set week. Alcohol Use Disorder Identification Test (AUDIT)‐C using a cut‐off score of 5 was used to measure risky drinking. Attitudes towards pharmacists engaging in SBI for risky drinkers were measured. Results. 2384 completed customer/patient questionnaires from 43 participating pharmacies. Almost 84% ever drank alcohol and using a score of 5 or more as a cut‐off, 30% of the sample would be considered as risky drinkers. Attitudes were generally positive to pharmacists undertaking SBI. Logistic regression with AUDIT‐C positive or negative as the dependent variable found those taking medicines for mental health and liver disease being more likely to score negative on the AUDIT‐C, and smokers and those purchasing hangover cures were more likely than average to have a positive AUDIT‐C screen. Discussion and Conclusions. This study indicates there is scope for community pharmacists to undertake SBI for risky drinking, and that customers find this to be acceptable. Targeted screening may well be useful, in particular for smokers. Further research is required to explore the effectiveness of SBI for risky drinkers in this setting.[Sheridan J, Stewart J, Smart R, McCormick R. Risky drinking among community pharmacy customers in New Zealand and their attitudes towards pharmacist screening and brief interventions. Drug Alcohol Rev 2012;31:56–63]     

Measuring Performance of Brief Alcohol Counseling in Medical Settings

SUMMARY

Brief alcohol counseling is a top US prevention priority but has not been widely implemented. The lack of an easy performance measure for brief alcohol counseling is one important barrier to implementation. The purpose of this report is to outline important issues related to measuring performance of brief alcohol counseling in health care settings. We review the strengths and limitations of several options for measuring performance of brief alcohol counseling and describe three measures of brief alcohol counseling tested in the Veterans Affairs (VA) Health Care System. We conclude that administrative data are not well-suited to measuring performance of brief alcohol counseling. Patient surveys appear to offer the optimal approach currently available for comparing performance of brief alcohol counseling across health care systems, while more options are available for measuring performance within health care systems. Further research is needed in this important area of quality improvement.     

Alcohol screening and brief intervention in primary care settings: implementation models and predictors

OBJECTIVE: This study compared two different implementation strategies for Cutting Back, a primary care alcohol screening and brief intervention (SBI) program for hazardous and harmful drinkers. It also identified organizational factors contributing to the success or failure of SBI implementation. METHOD: Cutting Back was implemented in 10 primary care practices associated with managed care organizations (MCOs) in five states, through a system of planning, training, technical assistance and clinic feedback. Clinics were randomly assigned to one of two brief intervention systems: In the P Model, medical providers were responsible for delivering interventions, whereas in the S Model mid-level professionals (usually nurses) acted as the clinic specialists to provide that service. Data were collected to measure the performance of screening and delivery of interventions in each clinic. RESULTS: The S Model screened a higher percentage of patients than did the P Model during the best month of program operation (50% vs 44%) and over all months of operation (24% vs 19%). Of those patients who screened positive, more patients in the S condition received an intervention than in the P condition (73.1% vs 57.1%), but there was a considerable range of performance among the five sites within each condition. Results at the clinic level were mixed, with some MCOs performing alcohol SBI significantly better with the S model and others doing better with the P model. The ability of clinics to conduct SBI was significantly correlated with both provider characteristics and organizational factors (e.g., prior SBI experience, MCO stability, number of clinicians trained and the quality of the MCO coordinator's work). Lack of provider time, staff turnover and competing priorities correlated negatively with SBI performance. CONCLUSIONS: The extent to which a given delivery model is likely to work best within an MCO depends on complex provider and organizational characteristics.     

Methodological issues in alcohol screening and brief intervention research.

The research literature on screening and brief intervention (SBI) for unhealthy alcohol use is large and diverse. More than 50 clinical trials and 9 systematic reviews have been published on SBI in a range of healthcare settings, and via a variety of delivery approaches, in general practice, hospital wards, emergency departments, addiction treatment centres, and more recently, via computers and the Internet. The aim of this paper was to discuss methodological issues which arise in the design, analysis, interpretation, and reporting of SBI trials. Principal among these are the challenge of detecting small effects, standards of analysis, reporting, and interpretation, the risks of bias arising from self-report of outcomes, and the need to ensure that results have the potential to be applied in practice to reduce the burden of disease and injury attributable to unhealthy alcohol use.     

Community pharmacy service users' views and perceptions of alcohol screening and brief intervention

Introduction and Aims. Community pharmacists have the potential to deliver alcohol screening and brief interventions (SBI) to pharmacy users. However, little is known if SBI would be utilised and views of people who might use the service. Therefore, the aim was to investigate potential barriers and enablers of pharmacy SBI. Design and Methods. Purposive sampling was used to select four pharmacies within the London borough of Westminster, UK. Semistructured interview schedule recorded participants' views of pharmacy SBI. The Alcohol Use Disorder Identification Test‐Consumption (AUDIT‐C) was incorporated to record views of high and low‐risk drinkers. Categorical data were analysed and content analysis undertaken. Results. Of the 237 participants (149 female) approached 102 (43%) agreed to be interviewed (63 female). Of these 98 completed AUDIT‐C, with 51 (52%) identified as risky drinkers. Risky drinkers were significantly identified among the younger age group (χ² = 11.03, P = 0.004), professional occupations (χ² = 10.41, P = 0.015), with higher qualifications (χ² = 10.46, P = 0.033), were least frequent visitors to a pharmacy (χ² = 11.58, P = 0.021) and more frequently identified in multiple pharmacy establishments than independents (χ² = 8.52, P = 0.004). Most were willing to discuss drinking (97, 96%) and accept written information (99, 98%). Accessibility and anonymity were reported as positive aspects and concerns were expressed about lack of privacy and time (pharmacist and user). Discussion and Conclusions. This study reports the first results of pharmacy users' views on SBI. Regardless of drinking status, most were willing to utilise the service and positive about pharmacists' involvement.[Dhital R, Whittlesea CM, Norman IJ, Milligan P. Community pharmacy service users' views and perceptions of alcohol screening and brief intervention. Drug Alcohol Rev 2010;29;596–602]     

The Cost-Effectiveness and Cost-Benefit of Screening and Brief Intervention for Unhealthy Alcohol Use in Medical Settings

SUMMARY

Economic evaluation can be a valuable tool for assessing the efficiency and value of health care programs. To examine the literature on the economic evaluation of alcohol screening and brief intervention in medical settings, relevant studies were identified in the MEDLINE database (1966 through November 2006) and by hand-searching the references of identified articles and relevant journals. The 15 identified studies used a range of economic evaluation methods, including cost analysis, cost-benefit, cost-effectiveness, and cost-utility. Nearly all of the studies supported the use of alcohol screening and brief intervention. The studies that prospectively collected cost and effect data and/or conformed closely to methodological guidelines demonstrated a strong economic benefit of alcohol screening and brief intervention when compared to usual care. Overall, the reviewed studies support alcohol SBI in medical settings as a wise use of health care resources and illustrate the usefulness of economic evaluation for assessing alcohol prevention and treatment programs.     

Electronic screening and brief intervention for unhealthy alcohol use in primary care waiting rooms – A pilot project

Abstract

Background: In primary care, electronic self-administered screening and brief interventions for unhealthy alcohol may overcome some of the implementation barriers of face-to-face intervention. We developed an anonymous electronic self-administered screening brief intervention device for unhealthy alcohol use and assessed its feasibility and acceptability in primary care practice waiting rooms. Two modes of delivery were compared: with or without the presence of a research assistant (RA) to make patients aware of the device’s presence and help users. Using the device was optional. Methods: The devices were placed in 10 participating primary care practices waiting rooms for 6?weeks, and were accessible on a voluntary basis. Number of appointments by each practice during the course of the study was recorded. Access to the electronic brief intervention was voluntary among those who screened positive. Screening and brief intervention rates and characteristics of users were compared across the modes of delivery. Results: During the study, there were 7270 appointments and 1511 individuals used the device (20.8%). Mean age of users was 45.3 (19.5), and 57.9% screened positive for unhealthy alcohol use. Of them, 53.8% accessed the brief intervention content. The presence of the RA had a major impact on the device’s usage (59.6% vs 17.4% when absent). When the RA was present, participants were less likely to screen positive (49.4% vs 60.7%, P?=?0.0003) but more likely to access the intervention (62.7% vs 51.4%, P?=?0.009). Results from the satisfaction survey indicated that users found the device easy to use (93.5%), questions useful (89–95%) and 77.2% reported that their friends would be willing to use it. Conclusions: This pilot project indicates that the implementation of an electronic screening and brief intervention device for unhealthy alcohol is feasible and acceptable in primary care practices but that, without human support, its use is rather limited.