Family interventions for alcohol problems

A growing body of evidence demonstrates that family interventions should be towards the top of the list of effective alcohol prevention and treatment approaches. A recent conference run by the UK Alcohol Education and Research Council presented some of this evidence (go to: aerc.org.uk then 'News' for a summary).     

Use of nonphysician health care providers for skin cancer screening in the primary care setting

BACKGROUND: Nonphysician health care providers are in an optimal position to provide cancer prevention and screening services. METHODS: We conducted a survey of primary care physicians to determine physician use and amenability to use of nonphysician health care providers to perform skin cancer screening in comparison with other cancer screening examinations. RESULTS: A total of 1,363 eligible physicians completed the survey. Of these, 631 physicians (46%) reported a nurse practitioner or physician assistant performing at least one type of cancer screening examination on their patients. Twenty-nine and 22% of all physicians reported nurse practitioners or physician assistants performing skin cancer screening, respectively. Family physicians were more likely to use nurse practitioners and physician assistants to perform these cancer screening examinations than internists (chi(2) test, P = 0.001 for each examination). Skin examinations were performed less frequently by nurse practitioners and physician assistants than all other cancer screening examinations. A total of 73-79% of family physicians and 60-70% of internists were amenable to having a nonphysician health care provider perform one or more of these examinations. CONCLUSIONS: Primary care physicians are currently utilizing nonphysician health care providers to perform cancer screening examinations and the majority of those surveyed are amenable to the use of these providers for such examinations. This suggests that one possible strategy for increasing skin cancer screening is through an expanded role of nonphysician health care providers.     

The detection of alcohol problems in a primary care clinic

The CAGE is a four item questionnaire which is used to help clinicians identify alcohol problems. Charts of 433 primary care patients who were given a medical health form containing the CAGE questions (experimental patients) were compared with charts of 451 patients given a similar form that did not contain the CAGE questions (control patients). Alcohol problems were detected more frequently in the experimental patients (10.6%) than in the control patients (6.7%) (p<0.05). This difference in detection tended to be most evident for persons with milder alcohol problems (problem drinking) as opposed to more well developed alcohol abuse. Experimental patients (3.7%) also tended to be more likely than control patients (2.9%) to receive active alcohol treatment during their initial medical visit. Medical health screening forms which include the CAGE questions may promote the identification of alcohol problems in primary care.Mark Olfson is Assistant Professor of Psychiatry and Robert L. Braham is Associate Professor of Medicine, both at the Cornell University Medical College.This research project was supported by a Reader's Digest Research Psychiatrist Fellowship to Dr. Olfson.     

The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis

OBJECTIVE: To perform a meta-analysis to assess diagnostic characteristics of the CAGE in screening for alcohol abuse or dependence in a general clinical population and to test a new method for pooling of ROC curves. METHODS: Medline search performed over the period 1/1/1974 to 31/12/2001. MEASUREMENT: Calculation of diagnostic values. RESULTS: We identified 35 articles using the DSM criteria as the gold standard to test the diagnostic value of the CAGE. Only 10 studies could be included for the meta-analysis. With a cutoff point > or =2, the pooled sensitivity is far better in inpatients (0.87) than in primary care patients (0.71) or ambulatory patients (0.60). The pooled specificity also differs for each group. The likelihood ratios seem to be relatively constant over the populations (overall LR+:3.44;LR-:0.18). We calculated a pooled AUC of 0.87 (95% CI 0.85-0.89). At low specificity values, the sensitivity was homogeneous over the studies, and at a low sensitivity, the specificity was heterogeneous. CONCLUSION: The diagnostic value of the CAGE is of limited value using this test for screening purposes at his recommended cutpoint of > or =2.     

Vital signs screening for alcohol misuse in a rural primary care clinic: a feasibility study.

CONTEXT: Alcohol misuse is more common in rural areas, and rural problem drinkers are less likely to seek alcohol treatment services. Rural clinics face unique challenges to implementing routine alcohol screening and intervention. PURPOSE: To assess the feasibility of using the single alcohol screening question (SASQ) during routine nursing vital signs in a rural clinic, and to determine its effect on alcohol screening and intervention rates. METHODS: Patient exit interviews were used to identify alcohol misuse and to measure changes in screening and intervention rates. Chi-square tests were used to compare rates of screening across study phases, while odds ratios from logistic regression analyses were used to quantify association between nurse screening and clinician intervention. FINDINGS: Exit interviews were completed by 126 current drinkers (41 before vital signs screening implementation and 85 afterward). Screening rates for alcohol misuse rose from 14.6% at baseline to 20.0% (P = .027) after screening implementation. Clinician intervention rates among alcohol misusers rose from 6.3% to 11.8% (P = .039). Nurse screening increased the odds of clinician intervention (OR 1.47; 95% CI 1.10-1.95). CONCLUSIONS: Vital signs screening proved to be feasible in this rural clinic and produced modest but significant increases in alcohol screening by nurses and brief interventions by clinicians. Additional studies are needed to define effective strategies for further increasing these rates.     

The alcohol use disorders identification test: an aid to recognition of alcohol problems in primary care patients.

BACKGROUND: Misuse of alcohol is associated with a range of medical problems. Fortunately, a simple pencil-and-paper measure, the Alcohol Use Disorders Identification Test, can effectively and efficiently screen for early-stage alcohol abuse as well as provide the physician information that can assist in brief intervention. OBJECTIVE: The objective of this article is to briefly summarize research published on the Alcohol Use Disorders Identification Test and suggest its potential role in brief intervention in primary care settings. METHODS: Scientific literature on the Alcohol Use Disorders Identification Test though 2000 was reviewed and synthesized to address issues relevant to use of the test in primary health care settings. RESULTS: The Alcohol Use Disorders Identification Test is quite sensitive and specific and compares favorably with alternative self-report screens for alcohol problems.     

Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians

AIMS: One of the many barriers to more frequent alcohol screening by primary care physicians is a reported concern that patients may be offended by questions about drinking. However, evidence suggests that patients do not object to alcohol screening and actually expect physicians to ask about lifestyle factors that influence their health. The aim of this study was to provide more detailed information on patient attitudes toward self-report and biomarker alcohol screening and to explore whether demographic variables were related to these attitudes. METHODS: We administered (i) a survey about attitudes towards alcohol screening, and (ii) the Alcohol Use Disorders Identification Test-C (AUDIT-C) to primary care outpatients at the time of their medical appointments. The survey contained 10 items on patient opinions about being screened for at-risk drinking by physicians. Participants rated their levels of agreement with each statement using a 5-point Likert scale. Participants also provided demographic information. RESULTS: The majority of patients reported that they were supportive of physician screening about alcohol use. Responses on 3 of the 10 statements were related to patient race, age, and/or AUDIT-C results. CONCLUSIONS: In general, results support the fact that patients are in favour of being screened for at-risk drinking by their physicians whether the screening instrument was a self-report measure or an alcohol biomarker laboratory test. In addition, the majority of patients are open to advice from physicians about their alcohol use.     

Syphilis screening in primary care

BACKGROUND. Reported cases of early syphilis have increased dramatically since 1987. Screening high-risk patients has been advocated as an intervention strategy to control the syphilis epidemic. METHODS. This study determined the prevalence of previously unrecognized positive syphilis serologies among patients at an urgent care center. Two hundred sixty-five patients treated empirically for gonorrhea were screened. RESULTS. Two patients had positive serology; both were previously treated for syphilis and had no evidence of recurrent infection. The yield from screening the study population was 0. CONCLUSIONS. Serologic diagnosis of syphilis is not reliable or cost effective in groups with a very low prevalence of disease. Routine screening for syphilis in asymptomatic high-risk patients may not be indicated in all primary care settings.     

Screening for psychosocial problems in primary care

Evaluating and understanding the physical, emotional, and social condition of a patient is an important component of primary care. Time constraints, however, often make it difficult for the physician to explore these areas in detail with every patient. One approach that can be helpful is the use of a simple questionnaire that can be completed by the patient in advance of seeing the physician. The use of one questionnaire, the Multifactor Health Inventory (MHI), in filling the need for such an instrument is detailed. The MHI helps the physician screen for psychophysiologic, psychiatric, attitudinal, and substance abuse problems. It also provides direction for productive follow-up interviewing. Research has shown that many patients with psychosocial problems are not identified by the physician. A questionnaire can help increase physician awareness of these patients and their problems.     

Web-based screening and brief intervention for the spectrum of alcohol problems

CONTEXT: Many persons who drink excessively remain unidentified and do not receive interventions. Screening and intervention using the World Wide Web could make such services more accessible and therefore more widely used. OBJECTIVE: To evaluate the use of a novel alcohol screening and brief intervention Web site. DESIGN: A Web site was developed, posted, and its use was evaluated. We analyzed a sample of visitors who completed alcohol screening over a 14-month period to describe their alcohol use, and their use of portions of the Web site that provide information and referral resources. SETTING: The Internet. PATIENTS OR OTHER PARTICIPANTS: Web site visitors, with a focus on visitors who completed an alcohol-screening questionnaire about their own drinking. INTERVENTION: Brief intervention via the Web site, consisting mainly of feedback, advice, and a menu of change options and referral information. MAIN OUTCOME MEASURES: Self-reported drinking amounts and alcohol screening test scores, and utilization of Web site components. RESULTS: Visitors completed online alcohol screening questionnaires at a rate of 50,711/year of 115,925 visitors/year. In a 14-month period, 39,842 adults completed the questionnaire about their own drinking habits; 66% were men, 90% reported drinking hazardous amounts (per occasion or typical weekly amounts), 88% reported binge (per occasion) drinking, and 55% reported typically exceeding weekly risky drinking limits. Most (65%) had alcohol screening test results (AUDIT > or = 8) consistent with alcohol abuse or dependence; similar proportions of women and men were hazardous drinkers. One-fifth of visitors visited portions of the Web site that provided additional information about alcohol use and referrals. Visitors with possible alcohol abuse or dependence were more likely than those without these disorders to visit a part of the Web site designed for those seeking additional help (33% vs. 8%, P < 0.0001). CONCLUSIONS: A well-publicized, easily accessible, research-based screening and intervention Web site can attract many users, most of whom are drinking excessively, and many of whom avail themselves of referral information after receiving individualized feedback.     

Hazardous alcohol use: screening and brief intervention as routine practice in primary care

The variety of problems related to the so-called hazardous patterns of alcohol use make the latter a prominent public health concern. Screening instruments associated with brief interventions in primary care provide one of the frequently recommended secondary prevention strategies. The objective of this study was to assess the implementation of this strategy as a routine practice in primary health care services in the city of Juiz de Fora, Minas Gerais State, Brazil. A qualitative design was employed, including the application of semi-structured interviews for managers and health care professionals in the city's public health system, in addition to content analysis and participant observation. Results point to difficulties in the effective implementation of such routines both by managers and health care professionals. Health care professionals limit the approach to alcohol-dependent patients and demonstrate lack of motivation for preventive work. Health services managers experience difficulties in the organization and administration of such instruments, despite affirming their interest in the project.     

Rapid screening for disordered eating in college-aged females in the primary care setting.

PURPOSE: To identify an efficient, valid, and reliable instrument for use by primary care physicians during clinical encounters to screen female adolescents at risk for eating disorders. METHODS: We created a survey of 36 questions, including the Eating Attitude Test-26 (EAT-26) and additional test questions identified through focus groups and literature review. The EAT-26 is a valid and reliable tool to identify individuals with eating disorders (1). We randomly distributed the survey to 865 college freshman women residing in dormitories at the University of Florida. The EAT-26 portion of the survey was scored according to established protocol. A score of > or =20 identified individuals likely to have an eating disorder, including anorexia nervosa and bulimia nervosa. RESULTS: 402 women completed surveys for a response rate of 47%. Based on the EAT-26 scores greater than 20, 17% of our population had scores predictive of an eating disorder. Four test questions correlated with positive EAT-26 scores: "How many diets have you been on in the past year?"; "Do you feel you should be dieting?"; "Do you feel dissatisfied with your body size?"; and "Does your weight affect the way you feel about yourself?" CONCLUSIONS: These four test questions in written format screen for disordered eating among female college students in primary care settings.     

Use effectiveness of the Cytobrush in the primary care setting.

BACKGROUND: Numerous studies indicate that Papanicolaou smears contain better cellular material when the technique for collecting the sample employs the Zelsmyn Cytobrush. Few studies, however, have examined its ability to increase the percentage of abnormal Papanicolaou smear results in actual clinical practice. METHODS: This study looked at 7999 Papanicolaou smears done by 46 primary care physicians to determine the percentage of abnormal results during two different periods. The Cytobrush technique was then implemented; and after 6029 Papanicolaou smears, the percentage of smears with abnormal findings was recalculated. RESULTS: The proportion of Papanicolaou smears demonstrating significantly abnormal cells remained constant during the three observation periods: 1.81 percent during the first period, 1.96 percent during the second period (before the Cytobrush technique was implemented), and 1.96 percent during the third period (after the Cytobrush technique was implemented). CONCLUSIONS: It seems logical that Papanicolaou smears containing better cellular material from the squamocolumnar junction would increase the yield of Papanicolaou smears with cancerous and precancerous cells. Our study, however, did not confirm this supposition. While evaluation of Papanicolaou smear technique based on quantity and quality of cellular material is important, we believe the effectiveness of any technique must be evaluated from another perspective--the actual practice setting.     

Family history taking and genetic counselling in primary care.

OBJECTIVES: We aimed to evaluate the feasibility and acceptability of taking routine family histories and subsequent counselling. METHODS: The study was set in primary care in the UK. The subjects were patients between the ages of 20 and 34 years registered at one general practice. Patients were invited by letter to attend a clinic in their GP surgery, run by a GP and health visitor. A family history was constructed and counselling undertaken for any identified problems. A telephone survey of a sample of nonattenders was also performed. The outcome measures were attendance rate, patient views, patient anxiety as measured by the short form of the Spielberger State-Trait Anxiety Inventory and referrals to secondary care. RESULTS: In total, 16.1% patients attended the clinic; 40.3 % had a family history of at least one disease with a possible genetic component. Anxiety levels fell immediately after the consultation and rose to pre-clinic levels at 12 weeks. The clinic generated three referrals to secondary care and a further seven patients who were counselled by the investigators following advice from a consultant geneticist. CONCLUSIONS: It is possible to take detailed family histories and provide genetic counselling advice in primary care with minimal training of clinical primary care staff. The service is acceptable to patients, does not induce anxiety and has little effect on numbers of patients referred.     

Implementation and dissemination of methods for prevention of alcohol problems in primary health care: a feasibility study

Secondary prevention of alcohol problems in health care has been proved efficacious in many studies, yet its implementation remains scarce, and its effectiveness in regular health care remains unknown. This article reports results from a feasibility study of dissemination of alcohol prevention methods in primary health care in Stockholm. Initial interviews with general practitioners (GPs) and district health nurses indicated that few raised the issue of alcohol with patients, made notes about alcohol in patient charts or found working with alcohol issues rewarding. The impact of a training session, where a project nurse visited all willing GPs and nurses, was limited. Although the uptake of the prevention package was high, follow-up at 3 months indicated that little use was made of the materials. Specifically, screening rates were low. In the future, secondary prevention of alcohol problems will require better adaptation to the realities of primary care.     

Glaucoma screening in primary care: the role of noncontact tonometry.

BACKGROUND. Guidelines for glaucoma screening by the primary care physician have not been firmly established. Despite its limitations as a screening test, intraocular pressure measurement by tonometry remains the mainstay of glaucoma monitoring but is not widely used in the primary care setting. The purpose of this study was to compare the effectiveness of noncontact tonometry using the Pulsair instrument with that of conventional tonometry using the Goldmann applanation tonometer as a screening tool for glaucoma. METHODS. Intraocular pressure was measured by non-contact and Goldmann applanation tonometry in both eyes of 50 volunteers who enrolled in a glaucoma screening program at a primary care clinic. RESULTS. Noncontact tonometry correctly identified over 90% of the patients with intraocular pressures greater than 22 mm Hg. CONCLUSIONS. Noncontact tonometry is an easy, practical, and well-tolerated method of intraocular pressure measurement. When combined with direct ophthalmoscopy, noncontact tonometry can easily be used in routine primary care health examinations to detect glaucoma.     

Validation of the primary care alcohol severity measure

Alcohol-related disorders are common in primary care settings; many primary care physicians are ill-equipped to manage patients with alcohol-related disorders. The objective of this prospective cohort study was to develop and validate a patient-based measure, the Primary Care Alcohol Severity Measure, to determine which primary care patients with alcohol-related disorders would benefit from referral to alcohol treatment services. Four Boston-area Department of Veterans Affairs ambulatory care clinics were chosen as study sites. Two hundred seventy-eight male patients, mean age 55.5 years, 89.9% Caucasian, 42.5% married, all with CAGE Questionnaire scores greater than or equal to 2 and drinking within past year, participated in the study. We developed a multidimensional, 30-item measure that contained 2 subscales that assessed 2 symptom clusters of alcohol-related disorders: Physical and Behavioral. Each subscale's score was higher (more severe) for patients with a current Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised diagnosis of alcohol dependence or abuse: P < .01 for the physical subscale and P < .0001 for the behavioral subscale. Patients with more physical symptoms had poorer physical and mental health status, whereas patients with more behavioral symptoms had poorer mental health status. Scores on the 2 subscales, along with age and history of prior treatment, predicted the use of alcohol treatment services in the following year: c = 0.90 in logistic regression. The Primary Care Alcohol Severity Measure is a valid measure of alcohol severity in primary care patients and predicts the use of alcohol treatment services. It is relatively brief and easy to use, requiring only standard medical history items and patient reports of behavioral symptoms. It may be a useful tool to improve the quality of care for primary care patients with alcohol-related disorders.