Implementation of Case Management in emergency departments: the view of the involved staff

Introduction

Frequent users of emergency departments (FUED; ≥ 5 ED visits in the previous 12 months) often present with somatic, psychological and substance use problems. Providing a Case Management (CM) intervention may reduce their number ED visits and improve their quality of life. However, there is limited knowledge about the implementation process of CM.

Methods

This study aimed to introduce CM into the EDs in the French-speaking part of Switzerland and to identify the facilitators, barriers and needs encountered in this process. Semi-structured interviews were conducted with ED involved staff. An inductive content analysis was conducted.

Results

Among 13 invited hospitals, 8 implemented CM (62%); 23 ED staff were sampled from all participating ED: 17 nurses (74%), 5 physicians (22%) and 1 healthcare manager (4%). The average age was 48,48 years (SD = 8,64) and 74% were female. Four main facilitators emerged from the analysis: 1) Direct hierarchy support and flexibility (e.g. time management, supplemental paid hours); 2) Exchange with colleagues (e.g. debriefing, support); 3) Supervision by the research team (training and toolkit consisting of a binder and USB stick containing the study presentation and implementation procedures); and 4) Motivation (pleasure to work on an innovative project, benefit for patients and caregivers). Lack of resources was an unanimously mentioned barrier (e. g., time to identify and contact FUED medical and social support). Finally, participants identified the following needs to enable CM implementation: official and protected time for the project, a dedicated room for CM, at least two team members involved in the project since its initiation with complementary skills (e.g.: somatic, psychiatric and social).

Conclusions

Our study suggests that successful CM implementation is a complex process that, in addition to motivated ED staff, requires significant dedicated resources, such as protected time and a devoted support team.

Key messages

Frequent users of ED’s perspectives about a case management intervention in Western Switzerland

Background

Management of frequent users of the emergency department (FUED; ≥5 visits/year) is a known challenge. Studies show that case management (CM) improves FUEDs' quality of life while reducing their number of emergency department visits and associated costs. However, little is known about FUEDs' own perspectives on CM.

Methods

This qualitative study was part of a larger study aiming to implement CM for FUED in French-speaking Switzerland. Participants were FUEDs included in the parent study, who had either completed the CM intervention or were still enrolled. Semi-structured qualitative interviews were conducted with 20 participants (75% female; mean age=40.55, SD = 12.84), randomly drawn from the parent study sample. Content analysis was performed by two researchers to assess participants' perceptions on the CM intervention.

Results

Most participants endorsed general positive perceptions of CM. CM differed from their usual treatment by two characteristics: its holistic approach and the quality of the relationship with the case manager. Also, moral support was perceived as a main benefit. FUEDs perceived four outcomes: an increase in motivation (e.g., day-to-day life or health-related), better orientation in and interaction with the healthcare system and improved health literacy. Finally, FUEDs identified two negative aspects to the CM: few perceived benefits (e.g., not enough concrete outcomes) and negative consequences (e.g., feeling ashamed to come back to ED). Three obstacles were identified: case manager's lack of time, COVID-19's influence (e.g., less personal contact) and uncertainty around the program (e.g., organization, aims). The personal relationship with their case manager was perceived as the main driver to positive outcomes.

Conclusions

FUED perceived the program as useful and considered the relationship with the case manager as key for positive outcomes. Our findings also suggest ways to improve CM, such as clarifying its organization and aims.

Key messages

In FUEDs’ opinion, the CM intervention had many positive outcomes, often relying on the relationship with the case manager.

However, the CM intervention had also some negatives.

The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers

AIMS

An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians.

METHODS

Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics.

RESULTS

We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women.

CONCLUSIONS

Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

Squamous cell carcinoma of the head and neck - screening in patients who misuse alcohol and tobacco in Switzerland: a prospective pilot study

Squamous cell carcinoma (SCC) of the head and neck is the sixth most common cancer worldwide. It is preceded by early asymptomatic lesions which, if identified early enough and removed, would prevent malignant transformation or avoid delaying diagnosis to advanced stages. Our aim was to evaluate the feasibility of a screening programme for SCC of the head and neck in a group of high-risk patients, and to investigate their addiction profile. Patients admitted to an inpatient alcohol addiction centre (n=101) were prospectively enrolled and asked to fill in a questionnaire about their use of tobacco and alcohol, and the presence of warning symptoms for SCC of the head and neck from 23 June 2014 to 21 January2016. Participants in the study had a physical examination by an alcohol addiction physician followed by a full examination of the head and neck by an otorhinolaryngologist to rule out premalignant or malignant lesions of the upper aerodigestive tract. Of the 101 patients, 62 (60%) had at least one warning symptom. Alcohol addiction physicians identified leukoplakia in six (6%) and erythroplakia in two. No pre-malignant or malignant lesions were confirmed on examination by the otolaryngologist. We were unable to draw conclusions about the cost-effectiveness or the yield of the screening programme. Despite our negative findings, we may need further investigation to clarify the relevance of such a programme on health-related outcome given the high compliance rate and minimal delay that was achieved by taking advantage of an in-patient alcohol rehabilitation centre.

Does case management provides support for staff facing frequent users of emergency departments?

Background

Frequent users of emergency departments (FUED; 5 ED visits during the preceding 12 months) account for a disproportionate part of ED visits, causing a wide range of work difficulties to ED staff potentially leading to FUED discrimination. Whereas case management (CM) tailored to FUED leads to a reduction in ED visits, CM impact on ED staff has not been explored yet. This study aimed to compare ED staff perceptions of FUED with and without dedicated CM support.

Methods

Participants (N = 253) were ED staff (81 physicians; 172 nurses/assistant nurses) of two Swiss university hospitals, one with CM and one without CM support. Perceptions regarding FUED (i.e., knowledge and awareness of the issue extent; related work difficulties; FUEDs’ legitimate use of ED resources) were measured with a 25-item online survey (4 to 10-level Likert scales). Multivariable regression analyses were conducted to 1) explore the associations between CM implementation and FUED perceptions, and 2) test the moderating effect of profession (physician or nurse/nurse assistant) on these associations. All analyses were adjusted by gender and years of practical experience.

Results

Physicians with CM considered FUED as a less important problem (=.375, R2=.11, p <.05) and rated their knowledge of FUED issue higher (=.245, R2=.077, p <.05) compared to those without CM. In contrast, nurses without CM perceived fewer FUED-related work difficulties (i.e., feeling of failure and helplessness) than nurses with CM. (=-1.01, R2=.06, p <.05) No significant difference was found regarding ED staff’s perceptions of FUEDs’ legitimate use of ED resources and frequentation, nor on nurses’ knowledge of the issue.

Conclusions

These results suggest that CM intervention for FUED is a potential source of support for ED physicians working with FUED. Further qualitative research is needed to explore why nurses without CM support reported feeling less failure and helplessness regarding FUED.

Key messages

By highlighting a different impact of CM on nurses’ perception, this study illustrates where CM intervention might be improved. This study supports CM as a promising intervention for FUED by potentially having a positive impact on ED physicians’ perception besides the one previously proved on FUEDs’ number of visits and QOL.

Healthcare providers’ perceptions of difficulties related to frequent users of emergency departments

Background

Frequent users of emergency department (FUEDs; ≥ 5 ED visits/ year) are often vulnerable individuals cumulating medical, social and substance use problems. FUEDs often require complex and sustained care coordination generally unavailable in ED and are commonly considered contributing to ED crowding. In view of supporting ED health-care providers through specific training and interventions tailored to FUEDs, this study aimed to explore ED healthcare providers’ perceptions of difficulties related to FUEDs.

Methods

Participants (N = 208) were ED healthcare providers (i.e., nurses, physicians) from 75 university and community hospitals in Switzerland (71% of all EDs) who answered a questionnaire on FUEDs. They were asked to indicate the extent to which FUEDs represent a problem in their ED. Perceived difficulties related to FUEDs were elicited by an open-ended question. Conventional content analysis was used to extract common categories and themes.

Results

Among the 208 participants, 134 (64%) reported that FUEDs represent a problem. Of those, 132 provided 1 to 5 answers to the open-ended question. Twenty-eight categories were identified and organized in 4 themes. First, participants reported difficulties related to FUEDs’ characteristics themselves (e.g., problem’s chronicity; behavioural difficulties) leading to healthcare complexity. Second, participants perceived negative consequences related to the presence of FUEDs in the ED (e.g., work overload, staff helplessness and fatigue). Third, ED healthcare offer was considered inappropriate and inefficient to respond to FUEDs needs and fourth collaborating with FUEDs’ existing healthcare network was perceived as difficult.

Conclusions

ED healthcare providers experience a wide range of difficulties related to the management of FUEDs. Providing training and implementing a case management intervention tailored to FUEDs might support ED health-care providers and contribute to address FUEDs’ complex needs.

Key messages

ED healthcare providers perceive FUEDs to represent a problem. Perceived difficulties might decrease through training and case management support might contribute to better address FUEDs complex needs.

[Adaptation of a peer pressure scale in French and German: the Peer Pressure Inventory]

BACKGROUND

Peer pressure is regarded as an important determinant of substance use, sexual behavior and juvenile delinquency. However, few peer pressure scales are validated, especially in French or German. Little is known about the factor structure of such scales or the kind of scale needed: some scales takes into account both peer pressure to do and peer pressure not to do, while others consider only peer pressure to do. The aim of the present study was to adapt French and German versions of the Peer Pressure Inventory, which is one of the most widely used scales in this field. We considered its factor structure and concurrent validity.

METHODS

Five thousand eight hundred and sixty-seven young Swiss men filled in a questionnaire on peer pressure, substance use, and other variables (conformity, involvement) in a cohort study.

RESULTS

We identified a four-factor structure, with the three factors of the initial Peer Pressure Inventory (involvement, conformity, misconduct) and adding a new one (relationship with girls). A non-valued scale (from no peer pressure to peer pressure to do only) showed stronger psychometric qualities than a valued scale (from peer pressure not to do to peer pressure to do). Concurrent validity was also good. Each behavior or attitude was significantly associated with peer pressure.

CONCLUSION

Peer pressure seems to be a multidimensional concept. In this study, peer pressure to do showed the strongest influence on participants. Indeed, peer pressure not to do did not add anything useful. Only peer pressure to do affected young Swiss men's behaviors and attitudes and was reliable.

[The spirit of community medicine: students learning from students]

At the University of Lausanne third-year medical students are given the task of spending a month investigating a question of community medicine. In 2009, four students evaluated the legitimacy of health insurers intervening in the management of depression. They found that health insurers put pressure on public authorities during the development of legislation governing the health system and reimbursement for treatment. This fact emerged during the scientific investigation led jointly by the team in the course of the "module of immersion in community medicine." This paper presents each step of their study. The example chosen illustrates the learning objectives covered by the module.

[Medical students and community health care centers: preparing the future]

Since 2011, second year medical students from Lausanne University follow a single day course in the community health care centers of the Canton of Vaud. They discover the medico-social network and attend to patients' visits at home. They experience the importance of the information transmission and the partnership between informal caregivers, professional caregivers, general practitioner and hospital units. The goal of this course is to help the future physicians to collaborate with the community health care centers teams. This will be particularly important in the future with an aging and more dependant population.

[Learning motivational interviewing to help patients change their health-related behaviors: medical students confirm it]

At the Lausanne University, 5th year medical students were trained in Motivational interviewing (MI). Eight hours of training improved their competence in the use of this approach. This experience supports the implementation of MI training in medical schools. Motivational interviewing allows the health professional to actively involve the patient in this behavior change process (drinking, smoking, diet, exercise, medication adherence, etc.), by encouraging reflection and reinforcing personal motivation and resources.

Alcohol drinking, the metabolic syndrome and diabetes in a population with high mean alcohol consumption

AIMS

To investigate the relationship of alcohol consumption with the metabolic syndrome and diabetes in a population-based study with high mean alcohol consumption. Few data exist on these conditions in high-risk drinkers.

METHODS

In 6172 adults aged 35-75 years, alcohol consumption was categorized as 0, 1-6, 7-13, 14-20, 21-27, 28-34 and ≥ 35 drinks/week or as non-drinkers (0), low-risk (1-13), medium-to-high-risk (14-34) and very-high-risk (≥ 35) drinkers. Alcohol consumption was objectively confirmed by biochemical tests. In multivariate analysis, we assessed the relationship of alcohol consumption with adjusted prevalence of the metabolic syndrome, diabetes and insulin resistance, determined with the homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

Seventy-three per cent of participants consumed alcohol, 16% were medium-to-high-risk drinkers and 2% very-high-risk drinkers. In multivariate analysis, the prevalence of the metabolic syndrome, diabetes and mean HOMA-IR decreased with low-risk drinking and increased with high-risk drinking. Adjusted prevalence of the metabolic syndrome was 24% in non-drinkers, 19% in low-risk (P<0.001 vs. non-drinkers), 20% in medium-to-high-risk and 29% in very-high-risk drinkers (P=0.005 vs. low-risk). Adjusted prevalence of diabetes was 6.0% in non-drinkers, 3.6% in low-risk (P<0.001 vs. non-drinkers), 3.8% in medium-to-high-risk and 6.7% in very-high-risk drinkers (P=0.046 vs. low-risk). Adjusted HOMA-IR was 2.47 in non-drinkers, 2.14 in low-risk (P<0.001 vs. non-drinkers), 2.27 in medium-to-high-risk and 2.53 in very-high-risk drinkers (P=0.04 vs. low-risk). These relationships did not differ according to beverage types.

CONCLUSIONS

Alcohol has a U-shaped relationship with the metabolic syndrome, diabetes and HOMA-IR, without differences between beverage types.

Neuropathie optique lors d’un traitement par disulfirame

INTRODUCTION

Disulfiram has been used since the late 1940s to treat chronic alcoholism. This drug interferes with alcohol metabolism resulting in an acetaldehyde increase. This causes painful symptoms, encouraging abstinence. Side effects include rare cases of bilateral optic neuropathies. Visual recovery occurs frequently upon cessation of therapy.

METHOD AND OBSERVATION

We retrospectively studied patients referred for visual loss while treated with disulfiram between 1987 and 2005. Fourteen patients (three females, 11 males; aged 35-62 years) complained of visual loss, but a toxic, disulfiram-related, optic neuropathy was diagnosed in only five patients. Following cessation of disulfiram therapy, visual acuity and field improved in all five patients.

DISCUSSION

and conclusion: When disulfiram toxicity is suspected with optic neuropathy, cessation of treatment is mandatory. Visual prognosis is good in the majority of cases, as illustrated by our series. Disulfiram toxicity can be diagnosed only after excluding all other possible causes of visual loss.

[Helping patients with risky health behaviors: some suggestions for motivational interviewing]

Helping patients modify risky health behaviors, including cigarette smoking, at-risk alcohol use, sedentary lifestyle and unhealthy diet, is a common and sometimes frustrating task. Motivational interviewing was developed from the notion that simple advice usually does not lead to behavioral change and may be even misperceived by patients. Based on active listening and an empathic attitude, some principles of motivational interviewing may be easily adapted to a primary care consultation. These principles facilitate positive, relaxed and constructive atmosphere for behavior change discussions and have been associated with promising results. This article presents key concepts of motivational interviewing such as ambivalence, resistance and stages of change, illustrated with practical examples.

[Content and efficacy of remedial interventions with drinking and driving offenders]

In Switzerland, 20% adults drove under the influence of alcohol over the last 12 month, 30% motor vehicle crashes are related to alcohol and over 18,000 people were sentenced for driving under the influence in 2001, 15-25% for repeated offence. This article reviews the scientific literature about the current prevention measures in Europe and North America, assessing the effectiveness of prevention measures. On average, prevention programs reduce repeated offence of 40%. The effectiveness of such programs appears superior for programs combining various measures, educational and behavioral, matched with repression measures, i.e., probation and driving license suspension. Efforts should be undertaken to pursue research and development in this major domain of public health concern.

[Does disulfiram still have a role in alcoholism treatment?]

What is the place of disulfiram in the treatment of alcohol dependence since anti-craving pharmacological molecules (acamprosate, naltrexone) were launched on the market? Considering methodological limitations, available studies do not allow to conclude about disulfiram's efficacy. Clinical observations indicate however that disulfiram should keep a place in the treatment of alcohol-dependence considering favourable outcome for some patients. Disulfiram implants have however to be avoided. Side effects and possible adverse reactions should not be a barrier to its use. Disulfiram shouldn't be given during pregnancy and to patients with instable cardio-vascular disease. Its prescription justifies a close monitoring of liver tests for patients with abnormal hepatic function.

[Assessment and treatment of coexisting mental illness or dual diagnosis]

Substance abuse touches around a quarter of psychiatric patients, which brings up various therapeutic problems. Literature shows us that between the "parallel", "series" and "integrated" approaches, it is the integrated approach which proves to be the most effective in terms of reducing symptoms, hospitalisations and criminality. An improvement in the patients' quality of life can also be observed. The integrated approach is developed by a team of in-patient and out-patient workers, whose job is to identify and evaluate clinically the motivation and the psychological and social functioning of the patients, and to propose suitable treatments according to the pathology and context of each case. A designated "case manager" guarantees the long term therapeutic project for each patient.

[Prevalence, prophylaxis and treatment of Wernicke encephalopathy. Thiamine, how much and how do we give it?]

Wernicke's encephalopathy (WE) is an acute neuropsychiatric condition due to thiamine deficiency (vitamin B1) most commonly associated with chronic alcohol abuse. WE is difficult to diagnose because the classical triad of signs (confusion, ataxia and ophthalmoplegia) occurs in only 10% of cases. The presentation is often one of a non-specific confusional state which may easily be attributed to intoxication, alcohol withdrawal or to a concurrent morbidity such as head injury. To improve the outcome, it is important to make a presumptive diagnosis of WE and treat the patients as soon as possible with high-dose parenteral thiamine. Patients with an alcohol problem associated with malnutrition should all be offered a preventive treatment with parenteral thiamine in view of the impaired oral thiamine absorption.

Ultra-rapid opiate detoxification using deep sedation and prior oral buprenorphine preparation: long-term results

BACKGROUND

New methods of ultra-rapid opiate detoxification (URD) under intravenous sedation have been criticized because of limited data on safety and long-term follow-up. Premedication with buprenorphine has been advocated to improve safety by decreasing vomiting. Prior research has not explored URD in socially impaired patients.

METHOD

Sixteen patients were detoxified with URD and prospectively evaluated over at least 30 months. Data of this procedure were compared with those of our previous study without buprenorphine preparation (Drug Alcohol Depend. 52(3) (1998) 243). The 16 patients were followed up by a general practitioner (GP) before and after URD. The GPs also supervised the 7-day course of buprenorphine treatment prescribed for the 16 patients prior to URD.

RESULTS

During the procedure, only one episode of vomiting occurred instead of 13 out of 20 in our previous study. Post-procedure, only two patients experienced moderate withdrawal symptoms, such as persistent nausea, abdominal cramps and vomiting lasting from 24 to 48 h, in comparison with most patients in the previous study without buprenorphine. After a period of at least 30 months (36.0+/-6.38), the 16 patients were still alive and were regularly monitored by their GP. Only two of the 16 never relapsed after URD and reported total opiate abstinence. Fourteen patients relapsed; 12 of these were prescribed a licensed methadone substitution program and two were still using heroin.

CONCLUSION

In this small sample, the data indicated that URD with buprenorphine preparation was safe and that it markedly decreased post-procedure morbidity. No patient died over a minimum 30-month follow-up period. Furthermore, the procedure was employed with socially impaired patients. In the long term, a few patients were still free of opiates, while the majority opted for a methadone maintenance program, showing that URD can serve as one possible step in a long-term treatment program.

[High risk alcohol consumption in a sample of patients of the Lausanne University Medical Polyclinic]

OBJECTIVES AND METHODS

This study indicates the prevalence, the characteristics, and the screening methods of patients with at risk alcohol drinking at the University Medical Clinic of Lausanne.

RESULTS

The results reported demonstrate that one patient out of six is a drinker at risk without criteria for alcohol-dependance. The questionnaire AUDIT (Alcohol Use Disorders Identification Test) with a cut-off of five points seems to be the best screening test for at risk alcohol consumption.

CONCLUSIONS

The high prevalence of at risk drinking in this study, combined with scientific evidence of the efficiency of brief interventions in changing drinking habits, emphasises the importance of alcohol screening for all patients attending outpatient medical settings.

[Management of patients with alcohol problems: how effective? Several response factors based on a review of the literature]

What do we know about the effectiveness of various treatments of alcoholism? This review of literature shows that lack--or weaknesses--of published studies make it impossible to draw definite conclusions. Rigorous controlled studies show high rates of spontaneous remission and important uncertainties about specialised treatments of alcoholism. However, except for severe dependence that may well require a different approach, brief interventions conducted by non-specialists have proved highly effective for at-risk alcohol drinkers: based on minimal medical advice, they increase the chances of lowering alcohol consumption. General practitioners may thus represent on important link in the therapeutic chain.

A measure of the intensity of response to alcohol to screen for alcohol use disorders in primary care

Alcohol-dependent subjects tend to report lower level of response to alcohol (LR) in the years before the disorder developed, compared to control subjects. The Self-Rating of the Effects of alcohol (SRE) score is a quick and valid retrospective estimate of LR. This study examined the associations between alcohol abuse or dependence and early experience of alcohol as measured on retrospective SRE score (relating to the first five times alcohol was imbibed), and the presence of alcohol abuse or dependence, in patients attending primary care. Higher Early SRE score (i.e. greater early tolerance of alcohol) was obtained in patients with an alcohol-related diagnosis than in patients without those diagnoses. Using a cut-off of 2 on the Early SRE score, the Early SRE score could discriminate between patients with and without an alcohol diagnosis with moderate to high sensitivity (84%) and modest specificity (57%).

Reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) imbedded within a general health risk screening questionnaire: results of a survey in 332 primary care patients

BACKGROUND

Self-administered, general health risk screening questionnaires that are administered while patients wait in the doctor's office may be a reasonable and timesaving approach to address the requirements of preventive medicine in a typical 10-min medical visit. The psychometric characteristics of the Alcohol Use Disorders Identification Test (AUDIT) incorporated within a health questionnaire (H-AUDIT) have not been examined.

METHODS

The reliability and validity of the self-administered AUDIT were compared between the H-AUDIT and the AUDIT used as a single scale (S-AUDIT) in 332 primary care patients.

RESULTS

No major demographic or alcohol use characteristics were found between the 166 subjects who completed the H-AUDIT and the 166 individuals who completed the S-AUDIT. The test-retest reliability of the 166 subjects who completed the H-AUDIT [estimated by Spearman correlation coefficient at a 6-week interval (0.88), internal consistency (total correlation coefficients for all items ranged from 0.38 to 0.69; Cronbach alpha index 0.85), and the sensitivity and specificity of the H-AUDIT were used to identify at-risk drinkers' areas under receiver operating characteristic (0.77) and alcohol-dependent subjects' areas under receiver operating characteristic (0.89)] was similar to the same measurements obtained with the 166 individuals who completed the S-AUDIT.

CONCLUSIONS

The AUDIT incorporated in a health risk screening questionnaire is a reliable and valid self-administered instrument to identify at-risk drinkers and alcohol-dependent individuals in primary care settings.

Clinical correlates of cigarette smoking and nicotine dependence in alcohol-dependent men and women. The Collaborative Study Group on the Genetics of Alcoholism

This paper examines the clinical characteristics associated with tobacco use and nicotine dependence in a large sample of alcohol-dependent subjects. The goal was to determine if the characteristics of the alcohol use history were associated with the smoking status, even after controlling for additional characteristics, such as the antisocial personality disorder, other drug dependence and gender. As part of the Collaborative Study on the Genetics of Alcoholism, a semi-structured interview, including a detailed history of alcohol and tobacco use, was administered to 1005 alcohol-dependent men and women, made up of 658 (65.5%) current smokers, 167 (16.6%) former smokers, and 180 (17.9%) non-smokers. Among former smokers, 50.3%, and among current smokers, 72.8% had ever been nicotine-dependent (DSM-III-R). Current smokers and nicotine-dependent subjects had a greater severity of alcohol dependence, even as evaluated through logistic regression analyses in which gender and associated diagnoses were considered. The data also enabled us to study the relationships among depression, nicotine dependence, and alcohol dependence, with most of the correlation occurring for substance-induced, not independent, mood disorders.

[Brief intervention: specific counseling of patients with problem alcohol consumption]

This article describes brief interventions for individuals with levels of alcohol consumption associated with increased morbidity and mortality but without severe dependence on alcohol. Brief interventions are described and the results of major studies evaluating their efficacy are reported. Data from the medical literature offer convincing evidence on the efficacy of these interventions to reduce alcohol consumption. Consecutive to a reduction of the level of alcohol consumption, further research also demonstrated a beneficial effect of brief interventions in terms of absenteeism at work, days hospitalized, and mortality. Evidence of the efficacy of brief interventions for "high-risk drinkers" justify their implementation in medical practice. In Switzerland, the national programme on handling alcohol "handle with care?" will offer workshops to primary care physicians about the practice of brief interventions.

Clinical characteristics of alcoholism in alcohol-dependent subjects with and without a history of alcohol treatment

BACKGROUND

Most clinical alcohol research is carried out on alcoholics who are in treatment, usually inpatients. However, most alcohol-dependent men and women never enter treatment, and even fewer ever receive inpatient care. Thus, some generally accepted data on the clinical course of alcoholism, derived from treatment samples, might not generalize to the entire population of alcohol-dependent individuals. This article characterizes the clinical characteristics of alcohol dependence in three groups of alcoholics, based on their histories of treatment for alcohol problems: those without prior rehabilitation; those with only outpatient approaches or Alcoholics Anonymous (AA); and subjects with an inpatient experience.

METHODS

Semistructured interviews were administered to 3572 DSM-III-R-defined alcohol-dependent subjects from the Collaborative Study on the Genetics of Alcoholism. The clinical patterns were compared across the three groups of alcoholics: Group 1, never-treated (n = 1582; 44%); Group 2, histories of outpatient or AA only (n = 399; 11%); and Group 3, at least one inpatient experience (n = 1591; 45%).

RESULTS

A progression was shown from Groups 1 to 3 for more general life problems (e.g., unemployment, marital instability); higher rates of additional drug dependencies and psychiatric disorders; and more alcohol-related adverse events. Logistic regression analyses revealed that those with no prior treatment were more likely to be women, Caucasian, and employed, and to report a lower rate of divorce/separation, lower levels of alcohol intake, and fewer alcohol problems. Among those who received help, inpatient care was predicted by an opposite profile.

CONCLUSIONS

These results indicate that studies using data from inpatient populations may give a skewed picture of the clinical characteristics of alcohol dependence.

How would you label your own drinking pattern overall? An evaluation of answers provided by 181 high functioning middle-aged men

The self-rating of drinking habits was compared to DSM-III-R diagnoses of alcohol abuse and dependence in 181 men with an average age (+/- SD) of 38.7 +/- 1.91 years. Results indicate that the 150 subjects without alcohol-related diagnosis (Group 1) rated themselves as 'non-problem drinker', in categories from 'non-drinker' to 'heavy drinker'. Among the 15 individuals with alcohol abuse (Group 2), none rated their drinking pattern as 'problem drinker'. Two (12.5%) subjects in the group of 16 individuals with alcohol dependence (Group 3) rated themselves as 'problem drinker', while most did not consider their drinking patterns as problematic. Within subjects who identified themselves as the same type of drinker (e.g. 'infrequent drinker', 'moderate drinker', etc ...), the quantity, frequency, and number of alcohol-related problems were higher in Groups 2 and 3, compared to Group 1. The self-rating of drinking habits using a single question failed to identify over 90% of the subjects diagnosed with alcohol use disorder (100% of those with alcohol abuse and 87.5% of those with alcohol dependence), and did not differentiate between levels of alcohol intake and number of alcohol-related problems for subjects who identified as a particular drinking type.

Characteristics of alcohol dependent subjects with very elevated levels of Gamma-Glutamyltransferase (GGT)

OBJECTIVE

This article examines characteristics of a subgroup of alcohol dependent men with very elevated serum Gamma-Glutamyltransferase (GGT) activity.

METHOD

GGT was measured in 196 men soon after admission to an inpatient alcohol and drug treatment program. Subjects were split into two groups based on the a priori GGT value of > or =150 U/L for Group 1 (n = 20), and <150 U/L for Group 2 (n = 176). Serum aspartate amino-transferase (AST), serum alanine amino-transferase (ALT) and mean corpuscular volume (MCV), as well as several aspects of the drinking history, were compared cross-sectionally between the two groups. The stability of GGT in the context of drinking was evaluated prospectively over 12 months in a subsample of 35 individuals.

RESULTS

Most measures of the drinking pattern and severity of dependence were similar between the two groups, although subjects in Group 1 demonstrated higher levels for AST (p < .01), MCV (p < .01) and ALT (p < .01). Subjects in Group 1 reported more drinking days per month (23.8 +/- 3.98 vs 17.8 +/- 8.71, t = 5.43, p < .001), and more related history of alcoholic liver disease (30.0% vs 8.5%, chi2 = 8.66, p < .01). In the presence of the variables significantly different between the two groups, AST, the number of drinking days per month and the proportion with alcoholic liver disease predicted membership to Group 1, although their influence was moderate (pseudo R between 0.16 and 0.20). The correlation between GGT at intake and follow-up in 35 individuals who returned to drinking was r = .56, p < .001, while two out of three subjects with high GGT at intake were also high at follow-up.

CONCLUSIONS

Subjects with very high GGT seem to demonstrate a more intense vulnerability to alcohol, a characteristic which appears to be stable over time.

Clinical implications for four drugs of the DSM-IV distinction between substance dependence with and without a physiological component

OBJECTIVE

The DSM-IV work group asked researchers and clinicians to subtype substance dependent individuals according to the presence or absence of physiological symptoms. A recent report from the Collaborative Study on the Genetics of Alcoholism demonstrated that among alcohol-dependent men and women, a history of tolerance or withdrawal was associated with a more severe clinical course, especially for individuals with histories of alcohol withdrawal. This article evaluates similar distinctions among subjects in the collaborative study who were dependent on marijuana, cocaine, amphetamines, or opiates.

METHOD

Structured interviews gathered information from 1,457 individuals with a lifetime diagnosis of marijuana dependence, 1,262 with histories of cocaine dependence, 647 with amphetamine dependence, and 368 subjects with opiate dependence. For each drug, the clinical course was compared for subjects whose dependence included a history of withdrawal (group 1), those dependent on each drug who denied withdrawal but reported tolerance (group 2), and those who denied both tolerance and withdrawal (group 3).

RESULTS

The proportion of dependent individuals who denied tolerance or withdrawal (group 3) ranged from 30% for marijuana to 4% for opiates. For each substance, individuals in groups 1 and 2 evidenced more severe substance-related problems and at least a trend for greater intensities of exposure to the drug; those reporting withdrawal (group 1) showed the greatest intensity of problems.

CONCLUSIONS

The designation of dependence in the context of tolerance or withdrawal identifies individuals with more severe clinical histories. These results support the importance of the designation of a physiological component to dependence, especially for people who have experienced a withdrawal syndrome.

MOS-SF-36 in evaluating health-related quality of life in alcohol-dependent patients

Health-related quality of life (HRQoL) was evaluated in a sample of alcohol-dependent patients with the 36-item Medical Outcome Study Short-Form Health Survey (MOS-SF-36). The instrument was administered to 147 patients (77% males), aged 26-78, with a DSM-III-R diagnosis of alcohol dependence. The Hamilton Depression Scale (HDS), the Severity of Alcohol Dependence Questionnaire (SADQ), and the Addiction Severity Index (ASI) were also administered to the first 100 patients included in the study. The reliability and validity of the MOS-SF-36 were evaluated. Test-retest intraclass coefficients for a 10-day interval were in the range .65 to .79, whereas the Cronbach alpha coefficient indicated good internal consistency (range .70 to .89). Compared to scores observed in the general population, MOS-SF-36 scores for alcohol-dependent patients were relatively low (indicating worse perception of HRQoL), especially in the psychological and role dimensions (range 52/100 to 55/100), but were closer to populational values in the physical and functional dimensions (range 61/100 to 75/100)). The highest correlation between MOS-SF-36 dimensions and HDS was found in the MOS-SF-36 "mental health" dimension (r=-.56, p < .001); this dimension was also correlated highly with the psychiatric dimension of the ASI (r=-.73, p < .001). The eight dimensions of the MOS-SF-36 were 21% to 127% lower in patients with HDS greater than or equal to 16 (major depression) compared to those with HDS less than or equal to 7 (absence of depression). The MOS-SF-36 dimensions were 10% to 141% lower in patients with high "ASI alcohol" scores, indicating worse HRQoL profiles with a higher severity of alcohol dependence. The MOS-SF-36 presents good criteria for reliability and validity in alcohol-dependent patients. The results suggested that alcohol-dependent patients perceived their problems more as psychological than physical. The severity of alcohol dependence and depression seemed to influence the perception of HRQoL negatively.

Influence of age and body mass index on gamma-glutamyltransferase activity: a 15-year follow-up evaluation in a community sample

Most clinicians and researchers view serum gamma-glutamyltransferase (GGT) activity as a measure that can be interpreted equally in patients regardless of their demography. The present study evaluates the concurrent influence of age and body mass index (BMI) on GGT in a sample of 133 high functioning young men, with detailed assessment of the pattern of alcohol use at ages 20 [time 1 (T1)], 30 [time 2 (T2)], and 35 [time 3 (T3)]. GGT increased between T1 and T2 (15.4 +/- 9.65 units/liter vs. 20.1 +/- 12.07 units/liter, t = 4.17, p < 0.001), and between T2 and T3 (20.1 +/- 12.07 units/liter vs. 27.3 +/- 24.69 units/liter, t = 4.11, p < 0.001). Controlling for drinking quantity and frequency did not change the finding. The relationship between GGT and BMI was estimated after splitting the sample into normal (BMI < or = 25 kg/m2) and overweight (BMI > 25 kg/m2) subjects. The correlation between GGT and BMI in normal weight men at T1 was r = 0.15, p = 0.09, at T2 r = 0.00, p = 0.96, and at T3 r = 0.09, p = 0.09. In overweight subjects, correlation at T1 was r = 0.40, p = 0.20, at T2 r = 0.36, p < 0.05, and at T3 r = 0.44, p < 0.001. Controlling for the effect of alcohol consumption and/or age did not alter these conclusions. Testing for the interaction of age, BMI, and alcohol consumption did not yield relevant results. We concluded that GGT is positively related to age in the 20s to late 30s and to BMI in overweight subjects; both relationships of age and BMI were independent of alcohol consumption. The interpretation of GGT should take age and BMI into account when suspecting subclinical alcohol problems in young men.

The clinical course of alcohol-related problems in alcohol dependent and nonalcohol dependent drinking women and men

OBJECTIVE

This article examines the differences in the clinical course of alcohol dependence in men and women, interpreting results in light of the gender differences in nonalcoholics and potential findings from the general population.

METHOD

As part of the Collaborative Study on the Genetics of Alcoholism (COGA) protocol, a detailed semistructured interview was administered to 1,085 alcohol dependent women and 2,120 alcohol dependent men, along with 1,936 women and 1,233 men who were drinkers but not alcoholic. Subjects were alcohol dependent probands, controls, and relatives of each.

RESULTS

The men's and women's rank orders of alcohol-related life events were similar for alcohol dependent subjects, with a rho (rho) of .95, a figure that remained constant even when only primary alcoholics were considered. In general, those items for which the two genders evidenced differences in either the mean age of occurrence or the proportion of people who experienced an event were similar to gender differences in drinking among nonalcoholics or the literature on the general population. These included for women a lower maximum number of drinks per day, a 1- to 2-year later onset of several early alcohol-related problems and fewer years between the onset of problems and seeking help. Female alcoholics also showed a lower proportion with legal, job or personal problems related to alcohol. There were also high levels of similarity (p = .76, p > .001) for 28 life events related to alcohol for 1,936 women and 1,233 men who were drinkers but not alcohol dependent.

CONCLUSIONS

Overall, the time course of alcohol-related problems for men and women were more similar than different. While there was evidence of a "telescoping" of the time between the onset of problems and treatment for women, the gender differences in ages of onset of events were relatively small. These data support the conclusion that, after considering gender differences in drinking in society, there is little evidence that the natural history of alcohol dependence in women is substantially different than in men.

Clinical relevance of the distinction between alcohol dependence with and without a physiological component

OBJECTIVE

DSM-IV indicates that diagnoses of substance dependence should be further characterized with regard to the presence of a physiological component, defined by tolerance or withdrawal. This study evaluated the possible meaning of this distinction in alcohol-dependent men and women.

METHOD

As part of the Collaborative Study on the Genetics of Alcoholism, structured interviews were carried out with 3,395 DSM-III-R-defined alcohol-dependent individuals divided into 2,949 subjects (86.9%) with evidence of tolerance and/or withdrawal (group 1), 51.3% of whom evidenced withdrawal symptoms, and 446 subjects (13.1%) without a physiological component (group 2). Data were evaluated to determine differences between the two groups.

RESULTS

Group 1 reported greater severity of alcohol dependence as demonstrated by a larger maximum number of drinks in 24 hours, more persons reporting binges, more alcohol-related life problems, more relevant DSM-III-R criteria endorsed, more physiological complications, and more alcohol-related emotional/psychiatric symptoms such as depression and anxiety. Each of these severity indicators for problems in group 1 was significant in the presence of the others in a logistic regression, and similar items remained significant when tolerance alone, withdrawal alone, or their combination was used as the criterion for group 1 membership; however, for withdrawal a larger proportion of the variance was explained by the predictor variables. The regression results were independent of gender, proband status, and history of antisocial personality disorder.

CONCLUSIONS

The results support the clinical relevance of distinguishing between alcohol-dependent patients with and without a physiological component. The data indicate a potential advantage to limiting that definition to withdrawal only.

Validation of the Addiction Severity Index in French-speaking alcoholic patients

OBJECTIVE

Evaluation of a French translation of the Addiction Severity Index (ASI) in 100 (78 male) alcoholic patients.

METHOD

Validity of the instrument was assessed by measuring test-retest and interrater reliability, internal consistency and convergence and discrimination between items and scales. Concurrent validity was assessed by comparing the scores from the ASI with those obtained from three other clinimetric instruments.

RESULTS

Test-retest reliability of ASI scores (after a 10-day interval) was good (r = 0.63 to r = 0.95). Interrater reliability was evaluated using six video recordings of patient interviews. Severity ratings assigned by six rates were significantly different (p < .05), but 72% of the ratings assigned by those who viewed the videos were within two points of the interviewer's severity ratings. Cronbach alpha coefficient of internal consistency varied from 0.58 to 0.81 across scales. The average item-to-scale convergent validity (r value) was 0.49 (range 0.0 to 0.84) for composite scores and 0.35 (range 0.00 to 0.68) for severity ratings, whereas discriminant validity was 0.11 on average (range-0.19 to 0.46) for composite scores and 0.12 (range-0.20 to 0.52) for severity ratings. Finally, concurrent validity with the following instruments was assessed: Severity of Alcoholism Dependence Questionnaire (40% shared variance with ASI alcohol scale), Michigan Alcoholism Screening Test (2% shared variance with ASI alcohol scale) and Hamilton Depression Rating Scale (31% shared variance with ASI psychiatric scale).

CONCLUSIONS

The Addiction Severity Index covers a large scope of problems encountered among alcoholics and quantifies need for treatment. This French version presents acceptable criteria of reliability and validity.

[Current status of cardiovascular rehabilitation and projections for 2010: results of a survey in the Vaud canton]

Compared to the situation in other European countries and the United States, Switzerland chiefly offers inpatient cardiac rehabilitation programmes (CRP). In the opinion of specialists and medical literature, we can expect an increased number of patients with cardiovascular diseases in the next 15 years, as well as a widening of indications for CRP among older patients and those with advanced cardiac conditions. We conducted an inquiry among professionals practising or prescribing CRP in order to estimate population needs and coverage for CRP and to identify the factors that will determine its future. Based on various sources of information, we estimated the incidence of coronary events and demand for CRP in the Canton of Vaud. Cardiac rehabilitation centers provided their occupation statistics for 1993. Simulations were carried out based on the opinion of specialists and expected demographic trends for the next 15 years. In recent years, 600 to 700 patients have been annually enrolled in CRP. Among patients admitted to acute care hospitals after myocardial infarction, 65% of those under 65 years of age and 14% of those between 65 and 74 entered CRP programmes. Most of them followed inpatient programmes in two private clinics which currently cover CRP needs with a capacity of 1500 patients a year. If we expect a 20% increase in the rate of coronary events over the next 15 years, due to demographic trends, without a change in the incidence of coronary disease, the present resources in residential CRP will remain sufficient. However, we can expect that part of the patient surplus will enter outpatient CRP programmes.