Utility of prompting physicians for brief alcohol consumption intervention

Brief Intervention for Heavy Drinking in Primary Care: Role of Patient Initiation

BACKGROUND

Alcohol brief intervention (BI) in primary care (PC) is effective, but remains underutilized despite multiple efforts to increase provider-initiated BI. An alternative approach to promote BI is to prompt patients to initiate alcohol-related discussions. Little is known about the role of patients in BI delivery.

OBJECTIVES

To determine the characteristics of PC patients who reported initiating BI with their providers, and to evaluate the association between the initiator (patient vs provider) and drinking after a BI.

METHODS

In the context of clinical trial, patients (n = 267) who received BI during a PC visit reported on the manner in which the BI was initiated, readiness to change, demographics, and recent history of alcohol consumption. Drinking was assessed again at 6-months after the BI.

RESULTS

Fifty percent of patients receiving a BI reported initiating the discussion of drinking themselves. Compared with those who reported a provider-initiated discussion, self-initiators were significantly younger (43.7 years vs 47.1 years; P = 0.03), more likely to meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for current major depression (24% vs 14%; P = 0.04), and more likely to report a history of alcohol withdrawal symptoms (68% vs 52%; P < 0.01). Baseline readiness to change, baseline consumption rates, and current DSM-IV alcohol dependence were not different between groups. In the 2 to 3 weeks after BI, self-initiators reported greater decreases in drinks per week (5.7 vs 2.4; P = 0.02), and drinking days per week (1.0 vs 0.3; P = 0.002). At 6-month follow-up, self-initiators showed significantly greater reductions in weekly drinking compared to those whose provider initiated the BI (P = 0.002).

CONCLUSIONS

Patient- and provider-initiated BI occurred with equal frequency, and patient-initiated BIs were associated with greater reductions in alcohol use. Future efforts to increase the BI rate in PC should include a focus on prompting patients to initiate alcohol-related discussions.

Impact of system-level changes and training on alcohol screening and brief intervention in a family medicine residency clinic: a pilot study

Background

Although screening and brief intervention (SBI) are effective in reducing unhealthy alcohol use, major challenges exist in implementing clinician-delivered SBI in primary care settings. This 2006–2007 pilot study describes the impact of systems changes and booster trainings designed to increase SBI rates in a family medicine residency clinic which annually screened adults with a self-administered AUDIT-C questionnaire and used paper prompts to encourage physician interventions for patients with positive screens.

Methods

Investigators added the Single Alcohol Screening Question (SASQ) to nursing vital signs forms, added a checkbox for documenting brief interventions to the clinicians’ outpatient encounter form, and conducted one-hour nurse and clinician booster trainings. Impact was measured using chart reviews conducted before implementing systems changes, then six weeks and six months post-implementation.

Results

At all three time points screening rates using AUDIT-C plus SASQ exceeded 90%, however AUDIT-C screening decreased to 85% after 6 months (p=.025). Identification of unhealthy alcohol users increased from 4% to 22.9% at six weeks and 18.8% at six months (p=.002) using both screens. Nursing vital signs screening using the SASQ reached 71.4% six weeks after implementation but decreased to 45.5% at six months. Changes in clinician brief intervention rates did not achieve statistical significance.

Conclusions

This is the second study reporting sustained primary care alcohol screening rates of more than 90%. Screening patients with SASQ and/or AUDIT-C identified a higher percentage of patients with unhealthy alcohol use. Dissemination of effective strategies for identifying unhealthy alcohol users should continue, while future research should focus on identifying more effective strategies for increasing intervention rates.

New developments in brief interventions to treat problem drinking in nonspecialty health care settings

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.