Alcohol screening and brief intervention: new evidence Colin - PowerPoint PPT Presentation

Alcohol screening and brief intervention: new evidence Colin Drummond

Evidence base for SBI  Freemantle 1993 - 6 trials in primary care – 24% drop in consumption (95% CI 18 to 31%)  Moyer 2002 – 56 trials, 34 relevant to PHC – Consistent positive effect, NNT 8-12 (smoking=20) – Cost savings found at 4 years in the USA  Kaner 2007 – 29 trials in PHC & A&E – Consistent positive effects ~7 drinks less/week – Evidence strongest for men, less work on women – No significant benefit of longer versus shorter BI  National Institute for Healthcare and Clinical Excellence 2010 • Public health guidelines recommend implementation

SBI primary care 6 months (n=14) Brief Intervention Control Std. Mean Difference Std. Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI 1.1.1 Europe Altisent et al., 1997 168 167.2 34 280 174.4 30 3.2% -0.65 [-1.15, -0.14] Diez Manrique et al.,2002 293.74 186.21 206 302.74 163.01 186 9.9% -0.05 [-0.25, 0.15] Fernandez et al., 1997 -107.4 370.4 38 -64.6 278.3 50 4.2% -0.13 [-0.55, 0.29] Heather et al., 1987 252.55 156.37 29 317.76 246.68 62 3.9% -0.29 [-0.73, 0.15] Huas et al., 2002 -109 164.73 270 -92 190.35 149 9.8% -0.10 [-0.30, 0.10] Kaner et al., 2013 140 81.73 213 134.4 105.25 209 10.2% 0.06 [-0.13, 0.25] Lock et al., 2006 126.4 98.48 39 199.68 320.8 32 3.5% -0.32 [-0.79, 0.15] Romelsjo et al., 1989 -34.86 209.04 35 42.64 202.26 36 3.6% -0.37 [-0.84, 0.10] Subtotal (95% CI) 864 754 48.3% -0.13 [-0.27, -0.00] Heterogeneity: Tau² = 0.01; Chi² = 10.32, df = 7 (P = 0.17); I² = 32% Test for overall effect: Z = 2.00 (P = 0.05) 1.1.2 Rest of the World Chang et al., 1997 130.7 191 11 109.71 191 8 1.1% 0.10 [-0.81, 1.02] Fleming et al., 1997 135.03 127.68 337 174.83 129.78 366 11.9% -0.31 [-0.46, -0.16] Fleming et al., 1999 120.6 89.88 76 193.08 152.52 68 5.8% -0.58 [-0.92, -0.25] Maisto et al., 2001 138.97 143.62 74 147.05 164.69 85 6.3% -0.05 [-0.36, 0.26] Ockene et al., 1999 161.28 181.76 233 170.24 162.56 248 10.7% -0.05 [-0.23, 0.13] Richmond et al., 1995 310 241 70 276 267 66 5.7% 0.13 [-0.20, 0.47] Senft et al., 1997 140.95 177.31 196 160.7 177.31 215 10.1% -0.11 [-0.30, 0.08] Subtotal (95% CI) 997 1056 51.7% -0.16 [-0.31, -0.00] Heterogeneity: Tau² = 0.02; Chi² = 15.27, df = 6 (P = 0.02); I² = 61% Test for overall effect: Z = 1.96 (P = 0.05) Total (95% CI) 1861 1810 100.0% -0.15 [-0.25, -0.05] Heterogeneity: Tau² = 0.02; Chi² = 26.83, df = 14 (P = 0.02); I² = 48% -1 -0.5 0 0.5 1 Test for overall effect: Z = 2.98 (P = 0.003) Favours BI Favours Control Test for subgroup differences: Chi² = 0.04, df = 1 (P = 0.84), I² = 0%

SBI primary care 12 months (n=14) Brief Intervention Control Std. Mean Difference Std. Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI 1.2.1 Europe Aalto et al., 2000 278.3 280.69 82 262.79 299.4 73 5.7% 0.05 [-0.26, 0.37] Beich et al., 2007 168 152.4 224 168 156 288 8.7% 0.00 [-0.17, 0.17] Cordoba et al., 1998 202.4 183.27 104 295.2 215.22 125 6.7% -0.46 [-0.72, -0.20] Huas et al., 2002 -109 164.73 270 -92 190.35 149 8.1% -0.10 [-0.30, 0.10] Kaner et al., 2013 134.4 121.15 208 140 70.2 194 8.2% -0.06 [-0.25, 0.14] Lock et al., 2006 128.64 293.28 36 156.8 293.28 42 3.8% -0.10 [-0.54, 0.35] Rubio et al., 2010 245.76 116.48 371 284.67 116.61 381 9.4% -0.33 [-0.48, -0.19] Wallace et al., 1988 304.34 184.94 363 386.15 230.97 385 9.4% -0.39 [-0.53, -0.24] Subtotal (95% CI) 1658 1637 60.2% -0.19 [-0.32, -0.05] Heterogeneity: Tau² = 0.03; Chi² = 24.23, df = 7 (P = 0.001); I² = 71% Test for overall effect: Z = 2.67 (P = 0.008) 1.2.2 Rest of the World Fleming et al., 1997 137.76 135.72 353 185.52 155.16 370 9.4% -0.33 [-0.47, -0.18] Fleming et al., 1999 119.04 83.64 78 195.24 146.04 67 5.4% -0.65 [-0.98, -0.31] Fleming et al., 2004 57.64 106.39 81 65.99 74.34 70 5.6% -0.09 [-0.41, 0.23] Maisto et al., 2001 133.98 147.52 74 147.33 147.72 85 5.8% -0.09 [-0.40, 0.22] Reiff-Hekking et al, 2005 161.28 190.72 235 170.24 167.68 210 8.5% -0.05 [-0.24, 0.14] Richmond et al., 1995 326 211 70 290 208 61 5.2% 0.17 [-0.17, 0.51] Subtotal (95% CI) 891 863 39.8% -0.18 [-0.37, 0.02] Heterogeneity: Tau² = 0.04; Chi² = 17.69, df = 5 (P = 0.003); I² = 72% Test for overall effect: Z = 1.78 (P = 0.08) Total (95% CI) 2549 2500 100.0% -0.18 [-0.29, -0.08] Heterogeneity: Tau² = 0.03; Chi² = 41.97, df = 13 (P < 0.0001); I² = 69% -1 -0.5 0 0.5 1 Test for overall effect: Z = 3.36 (P = 0.0008) Favours experimental Favours control Test for subgroup differences: Chi² = 0.01, df = 1 (P = 0.94), I² = 0%

Alcohol Screening and Brief Intervention Research Programme SIPS A&E St. Mary ’ s 'Scientia Vincit Timorem'

Programme design • Funded by Department of Health for 3 years • Jointly led by IOP & Newcastle University • 3 cluster randomised clinical trials of alcohol screening and brief intervention (PHC, AED, CJS) to assess: – What are the barriers/facilitators to implementation in a “ typical setting ” ? – What is the most effective screening method? – What is the most effective and cost effective intervention approach? • Total target of 2,403 subjects, completed 2,485 July 2009 • 6 and 12 months follow up, 74% @ 6 months (mainly phone) 69% @ 12 months

Screening tools and methods • Universal versus targeted screening – PHC and ED • Single Alcohol Screening Question (M- SASQ) • Fast Alcohol Screening Questionnaire (FAST) • Paddington Alcohol Test (SIPS-PAT) – ED only • (AUDIT as part of baseline assessment)

Interventions • Patient Information Leaflet (PIL) – DH How much is too much? • Brief Advice (BA) – 5 min of simple structured advice based on WHO Drinkless Programme modified for SIPS • Brief Lifestyle Counselling – 20 min motivational intervention based on WHO Drinkless programme modified for SIPS delivered by a trained Alcohol Health Worker (or Practice Nurse in PHC)

Website www.sips.kcl.ac.uk 9

Training and intervention tools 10

SIPS in numbers Staff Approached Eligible Positive Consent trained (n) (n) (n) % (n) % (n) % ED 278 5,992 3,737 62 1,491 40 1,204 81 PHC 195 3,562 2,991 84 900 30 756 84 CJS 227 967 860 88 574 67 525 91 Totals 700 10,521 7,588 72 2,965 39 2,485 84 �

SIPS results A&E St. Mary ’ s 'Scientia Vincit Timorem'

Primary Health Care

PHC survey results Mean� ratings� and� standard� deviations� for� key� conditions� Key� conditions� N� Mean� SD� Mental� health� problems� 86� 1.60� 1.08� Gastrointestinal� problems� 84� 1.94� 1.08� Hypertension� 82� 2.17� 0.95� Injuries� 85� 2.38� 1.01� � • 68% preferred targeted to universal • 14% preferred universal to targeted • 17% felt both appropriate • New patient registrations and smoking cessation also felt to be important contexts for screening

Proportion screened and positive by targeted condition Targeted� � Screened� Positive� Prevalence� (%)� Condition� n� (%)� n� (%) � � � � � 44� (9.7)� Gastrointestinal� 124� (9.8)� 35.5� 208� (45.9)� Hypertension� 623� (49.4)� 33.4� 30� (6.6)� Injuries� 75� (5.9)� 40.0� 86� (19.0)� Mental� Health� � 167� (13.2)� 51.5� 85� (18.8)� New� Registrations� 273� (21.6)� 31.1� � � � � 421 � Universal� Condition� 1632� 25.8� � � � • Targeted screening results in significantly more screen positives (overall 36.2% versus 25.8%)

Relative Risk of being screen positive for targeted conditions in the targeted group versus the universal screen population Relative� Risk� ç � (95%� CI)� � � Significant� � Mental� Health� � 1.9963� (1.6865;� 2.3630)� Injuries� 1.5506� (1.1613;� 2.0705)� Gastrointestinal� 1.3755� (1.0700;� 1.7683)� Hypertension� 1.2942� (1.2773;� 1.4859)� � � � � Not� significant� � New� Registrations� 1.2079� (0.9935;� 1.4663)� � �