Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol Screening for problem drinking and counseling by the primary care physician-nurse team. Brief intervention content matters Addressing Alcohol Problems in Primary Care: A Cluster Randomized, Controlled Trial of a Systems Intervention: The Screening and Intervention in Primary Care (SIP) Study Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial Opportunistic screening and clinician-delivered brief intervention for high-risk alcohol use among emergency department attendees: a randomized controlled trial. Alcohol screening and brief interventions for offenders in the probation setting (SIPS Trial): a pragmatic multicentre cluster randomized controlled trial. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial Screening and brief intervention targeting risky drinkers in Danish general practice--a pragmatic controlled trial. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial. Brief physician and nurse practitioner-delivered counseling for high-risk drinking Screening for Family and Intimate Partner Violence: Recommendation Statement Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes. Nurse-provided screening and brief intervention for risky alcohol consumption by sexual health clinic patients
Background There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical , psychological and social health of the population . There also exists a substantial evidence base for the efficacy of brief interventions aim ed at reducing alcohol consumption across a range of healthcare setting s. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness . Within this body of evidence there is marked variation in the intensity of brief intervention delivered , from very minimal interventions to more intensive behavioural or lifestyle counselling approaches . Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments . Methods / design The study design is a prospect i ve pragmatic factorial cluster r and omised controlled trial . Individual Emergency Departments ( ED ) ( n = 9 ) are r and omised with equal probability to a combination of screening tool ( M-SASQ vs FAST vs SIPS-PAT ) and an intervention ( Minimal intervention vs Brief advice vs Brief lifestyle counselling ) . The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker ( AHW ) is more effective than Brief Advice or a minimal intervention delivered by ED staff . Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED . Individual participants will be followed up at 6 and 12 months after consent . The primary outcome measure is performance using a gold-st and ard screening test ( AUDIT ) . Secondary outcomes include ; quantity and frequency of alcohol consumed , alcohol-related problems , motivation to change , health related quality of life and service utilisation . Discussion This paper presents a protocol for a large multi-centre pragmatic factorial cluster r and omised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments . Trial Registration IS RCT N Present methods to screen for alcohol abuse are generally obtrusive and result in referral to services that deal mainly with alcoholics . These factors deter physicians from identifying alcohol abuse patients at an early stage . In the present study , 81 % of all primary care physicians of a single city evaluated ( i ) the efficiency and the acceptability of a nonobtrusive screening method for the identification of problem drinkers and ( ii ) the effectiveness of brief cognitive behavioral counseling given by a nurse in a lifestyle context . Patients ( n = 15,686 ) attending the private practice s of 42 primary -care physicians were asked four alcohol-neutral trauma questions in the reception area . Physicians asked about alcohol use and alcohol-related problems only to patients with previous trauma . Problem drinkers by defined criteria were offered an appointment with a nurse who , by r and om assignment , gave either 3-hr of cognitive behavioral counseling over 1 year or simply advised patients to reduce their alcohol intake . The screening method identified 62 - 85 % of expected number of problem drinkers in this population . Following the application of exclusion criteria , 105 problem drinkers were entered in the intervention part of the study . After 1 year , patients who received counseling showed significant reductions in reported alcohol consumption ( -70 % ; p < 0.001 ) , psychosocial problems ( -85 % ; p < 0.001 ) and serum gamma glutamyl transferase ( -32 % to -58 % ; p < 0.02 ) . Physician visits were reduced ( -34 % ; p < 0.02 ) following counseling . Patients receiving only advice showed neither reductions in psychosocial problems nor in serum gamma glutamyl transferase or physician visits , but reported a 46 % reduction ( p < 0.01 ) in alcohol consumption . Data indicate that asking patients about recent trauma is efficient and is well accepted as the first screening instrument in the identification of the problem drinker . Cost of screening per patient is under one dollar . Counseling of 3 hr given by a nurse is markedly superior ( p < 0.05 ) to simple advice in reducing alcohol consumption , objective indicators of alcohol-related morbidity , and the frequency of physician visits For more than 30 years , there have been concerted efforts internationally to develop the evidence base for brief interventions in general practice 1 . The choice of this setting reflected strategic judgements about where in health systems heavy drinking and alcohol problems were likely to be most encountered and thus where these interventions may be optimally delivered . This literature is usually interpreted along the lines that efficacy is now well established in general practice and that there is a need to extend study to new setting s 2,3 . This year has seen the publication of two large general practice cluster r and omised effectiveness trials that in different ways draw attention to a crucial limitation of the evidence base in this setting ; the lack of well-developed study of intervention content . Although both undertaken in the UK , they are likely to be seen internationally as important studies . The three-arm Screening and Intervention Programme for Sensible drinking ( SIPS ) trial compared a leaflet control condition against the same leaflet plus five minutes advice and the addition subsequently of 20 minutes counselling 4 . Preventing disease through opportunistic , rapid engagement by primary care teams using behaviour change counselling ( PRE-EMPT ) compared training practitioners to address behaviour change for the big four key lifestyle risk factors ( diet , exercise , smoking and alcohol ) versus delayed training , thus entailing a non-intervention control condition 5 . Both trials found no differences in alcohol outcomes for hazardous and harmful drinkers over a 12-month study period following interventions delivery by general practitioners and practice nurses . The authors of these studies identify contrary implication s for practice from these null findings . The SIPS authors conclude that the control condition : ‘ screening followed by simple feedback and written information may be the most appropriate strategy to reduce hazardous and harmful drinking in primary care ’ 4 . One commentator , however , is concerned that this provides : ‘ false reassurance that we have taken care of unhealthy alcohol use and will waste time and money ’ 6 by delivering more time consuming interventions . In contrast , the PRE-EMPT authors , including myself , conclude that : ‘ enduring behaviour change and improvements on biochemical and biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling , without additional intervention ’ 5 . Attention to the detailed content of the evaluated interventions and consideration of their relationship to the existing general practice literature is necessary for interpreting study findings . Following screening in SIPS , leaflet delivery was accompanied by the st and ard script reproduced in Box 1 ( interested readers are strongly encouraged to examine the study website 7 for detailed information on all interventions ) . It will be seen that the feedback is very brief . The leaflet comprises content on health and social consequences , awareness of units ( st and ard drinks ) , recommendations on daily consumption and where to get help . The advice intervention covers similar material providing additional tips on planning and the benefits of cutting down after being shown that drinking exceeded the majority of the population , without having further dedicated content on decision making , i.e. whether one should cut down 7 . This was based on the Drink-Less material developed approximately 20 years ago , and in SIPS one hour training in delivery was given 7 . The counselling intervention provides quite different material , being influenced by motivational interviewing , and requiring some underst and ing of this approach , though not proficiency in it 7 . Counselling required a return visit to general practice , and just over half took this up 4 . Box 1 . The SIPS control condition ‘ Thank you for taking part in this project . Your screening test result shows that you 're drinking alcohol above safe levels , which may be harmful to you . This leaflet describes the recommended levels for sensible drinking and the consequences for excessive drinking . Take time to read the leaflet . There are contact details on the back [ Indicate where these are ] should you need further help or advice ’ . [ http://www.sips.iop.kcl.ac.uk/pil.php ] PRE-EMPT is a training trial that examined the effects of the ‘ Talking Lifestyle ’ training program on outcomes following a routine practice consultation . This program aims to enhance skills in undertaking behaviour change discussion s 5 . This intervention was thus not specific to alcohol , which may have been discussed only for those screening positive , most likely for those for whom this was their only positive screen . To see the detailed content of the training program visit http://www.3trials.net : login = ku.ca.fc@01tseug , password = guest10 , and then click on the Talking Lifestyles icon . Although there were good levels of engagement with the training program , skill acquisition was sub-optimal even though it was not design ed for advanced practice . The listening skills that are a key feature of motivational interviewing were not included within the training program 5 . Approximately one-third of the trials included within the Cochrane primary care review compared a brief intervention with no intervention ( as in PRE-EMPT ) , and in the other two-thirds the control conditions were the provision of leaflets or usual care in the form of general practitioner ( GP ) advice to cut down ( as in SIPS ) 8 . This review incorporates some emergency room studies as well as those conducted in general practice . Overall evaluated brief interventions were found to be effective in reducing drinking by approximately 38 grams of alcohol per week more than the control conditions 8 . This means that the findings from both SIPS and PRE-EMPT differ from previous studies in ways that remains to be explained , though the existing literature is not straightforward to interpret 9 . Both trials were pragmatic , intended by design to measure real world effectiveness , for which detailed investigation of intervention conduct could have interfered . The slow development of process study 10,11 has previously been widely recognised as a key weakness of this literature ( see , e.g. 2 ) and the corollary to this is that we do not know as much about effective content as we should . As a result , there has been little or no evidence -based innovation in the design of advice interventions . In SIPS , there appears little difference in content between the evaluated leaflet and advice interventions other than in the extent of verbal interaction . Providing relatively patient-centred counselling after this type of advice 7 may not be optimal . As a training trial , the detailed content of the intervention was not the object of evaluation in PRE-EMPT , making it impossible to know how exactly these discussion s were conducted 5 . Counselling that simply calls upon the perspective of motivational interviewing , though does not implement it , as is the case in both trials , may simply not be helpful enough ; non-specific forms of counselling do not have a good track record in this field ( e.g. 12 ) . Brief intervention content research questions are difficult to answer rigorously in pragmatic trials where effects may not survive well the translation into routine practice 6 . This would be true even if the specific content has previously been established as efficacious , which it has not been for brief interventions . It is an interesting possibility that leaflets with SIPS content accompanied by minimal verbal interaction can be effective in their own right and as effective as lengthier discussion s , however unlikely this appears . Brief interventions in routine practice can be very brief 13 , and this SIPS intervention deserves to be evaluated in well- design ed r and omised controlled trials that overcome barriers to interpretation cited by the SIPS authors , such as assessment effects 14 . Saitz 6 suggests that the SIPS trial results are vulnerable to unhelpful interpretations and I suggest this is true of PRE-EMPT too . Applying findings from these studies directly to influence policy and practice is misguided , as they conflict with what was previously known in ways which call for better underst and ing of the literature as a whole . A leaflet and a few words about drinking may well be enough for some , though we have no idea who they are and this is not what the wider literature indicates . It would be inadvisable to expect that anything delivered briefly as an intervention should be effective . There is reason to be concerned that many who might value the opportunity to talk about their drinking , and benefit from so doing , should not be denied that opportunity . It remains to be established which skills practitioners need to have , or how they need to be applied and for how long , in order to be able to discuss drinking or other behaviours in ways which do help people . Brief intervention content matters and we should study it Context Brief interventions can reduce problem drinking , but physicians infrequently use them . Contribution This r and omized trial , from an academic primary care setting , tested whether prompting  physicians with positive alcohol screening results that are linked to specific management recommendations works . Prompted faculty , but not residents , tended to discuss alcohol problems and counsel patients more often than did their counterparts who were not prompted . At 6 months , however , only patients of prompted residents had reduced their drinking . Implication s Prompting physicians with positive alcohol screening results and recommendations for action may or may not be effective , depending on patient , physician , and setting characteristics . The Editors Alcohol use disorders are a leading cause of disability and are as common and costly as coronary artery disease and depression ( 1 - 6 ) . Primary care setting s are ideal for alcohol screening and intervention ( 7 ) . Valid , brief , practical screening tools exist , and brief interventions can reduce drinking and improve health when delivered to primary care patients with alcohol problems ( 8 - 11 ) . However , alcohol problems are often unrecognized and untreated in primary care setting s ( 12 - 16 ) . Barriers to screening and intervention include issues related specifically to addictions ( such as patient readiness and physician discomfort , frustration , lack of confidence or skills , or pessimism about efficacy of intervention ) and issues related to the delivery of preventive services in general ( such as cost , acceptability , priorities , and time ) ( 17 , 18 ) . Physician prompting can improve the likelihood of cancer screening , administration of immunizations , and smoking cessation interventions ( 19 - 21 ) . Screening and intervention for alcohol problems , however , involve more complex assessment and intervention . The effectiveness of providing physicians with screening results and a prompt without training is unknown . Such a systems intervention would be easier and less costly to implement than training all physicians about addressing alcohol problems . We tested the hypotheses that providing physicians with patients ' alcohol screening results and simple individualized recommendations would increase physician alcohol counseling and decrease patient drinking . Methods Study Description The study was a cluster r and omized trial at the physician level because r and omization at the patient level would have risked contamination . The institutional review board of the Boston University Medical Center in Boston , Massachusetts , approved the study . Patients gave informed consent and were told that the physician may be given the results of alcohol screening questions . We obtained a Certificate of Confidentiality from the federal government . Participants Physicians were recruited , enrolled , and r and omly assigned before patients were enrolled . All faculty and resident primary care physicians in an urban academic practice ( excluding the authors ) were eligible . Physicians who had seen fewer than 80 patients in the previous 3 years or who anticipated leaving the practice within 6 months were excluded . We informed physicians that we would conduct a health screening study . We used a self-administered question naire to screen and enroll patients who spoke English or Spanish ( staff were available to assist ) ( 22 ) . This was done before a visit with one of the enrolled physicians . Eligible patients were current hazardous drinkers [ 23 ] , which was defined as having consumed alcohol in the past month and either 1 ) answered yes to one or more of the CAGE ( 24 - 26 ) alcohol screening questions  ( modified to refer to the past year rather than lifetime ) [ 27 ] or 2 ) drank hazardous amounts in the past month ( 28 , 29 ) . Hazardous amounts for men and women , respectively , were defined as more than 4 st and ard drinks per occasion or 14 drinks per week and as more than 3 st and ard drinks per occasion or 7 drinks per week in the past 30 days ( 26 , 30 ) . Assessment s Before patients were enrolled , physicians completed a confidential written survey ( July 1997 ) . They were asked about their attitudes toward patients with addictions ; their professional satisfaction when caring for patients with alcohol problems ; whether they or someone they knew had an alcohol or drug problem ; and other issues related to alcohol and physicians , including the physician 's usual practice s ( 18 ) . A trained staff research er interviewed enrolled patients before and after their visits with a physician ( between February 1998 and August 1999 ) . All questions not available in Spanish ( 31 ) were translated , back-translated , and checked for accuracy . The assessment visit that occurred before the physician visit addressed demographic characteristics , previous counseling for alcohol problems , and readiness to change ( 32 , 33 ) . Patients were also asked about medication use , medical comorbidity ( 34 , 35 ) , psychiatric comorbidity ( 36 , 37 ) , and tobacco and other drug use . Immediately after the physician visit , patients were interviewed to determine whether counseling had occurred , drinking amounts ( 38 , 39 ) , the quality of communication with the physician ( 40 ) , alcohol dependence symptoms ( 41 ) , and alcohol problems ( Short Inventory of Problems [ SIP-2R ] ) ( 42 ) . Six months later , patients were interviewed by telephone to determine alcohol consumption in the past 30 days ; the vali date d Timeline Followback method was used ( 43 ) . Patients and staff research ers were not blinded to group assignment ( in addition , patients were not necessarily given this information ) ; at follow-up , interviews were done without knowledge of group assignment . R and omization and Intervention Physicians were stratified by level of training ( resident or faculty ) and were r and omly assigned to the intervention or control group at the start of the study . The computer-generated r and omization was done by off-site data management personnel who had no patient or physician contact . The staff research er attached the intervention , a sheet of paper , to the encounter record the physician routinely received immediately before each patient visit . One side of the paper provided the patient 's alcohol screening results , a preliminary assessment , and specific recommendations . The screening results included answers to each of the CAGE questions , reports of usual weekly and per occasion maximum drinking amounts , and the patient 's report of readiness to change on a 10-point scale ( 44 ) ( see Appendix Figure ) . For patients reporting hazardous drinking amounts but no affirmative CAGE question naire responses , the assessment was drinking hazardous amounts and the recommendation was consider advising safe drinking limits and consider providing patients with a pamphlet provided by the study titled How to Cut Down on Your Drinking ( 27 ) . For patients reporting any affirmative CAGE responses but no hazardous drinking amounts , the assessment was possible alcohol problems and recommendations were consider advising abstinence , provide the pamphlet , and referral to addiction treatment . For patients reporting affirmative CAGE question naire responses and hazardous drinking amounts , the assessment was both possible alcohol problems and drinking hazardous amounts and recommendations were consider advising abstinence and referral to addiction treatment . The other side of the paper provided the predictive value of CAGE based on the prevalence of alcohol abuse or dependence in the practice ( 26 , 31 ) , definitions of hazardous drinking , an approach for patients who are not ready to change , a list of abuse or dependence symptoms , and referral information . To increase counseling rates ( not for data collection ) , we attached a Post-it note to the encounter form asking physicians to indicate whether alcohol was discussed and , if not , why ( 45 ) . Physicians in the  control  group did not receive any information from the study . Statistical Analysis All analyses were performed by using SAS software , version 8.1 [ SAS Institute , Inc. , Cary , North Carolina ] . The primary prespecified outcomes of the study were the occurrence of physician discussion s regarding alcohol problems during the physicianpatient encounter and a decrease in patient drinking . Patients were asked whether they had 1 ) received alcohol counseling , defined as advice on safe drinking limits , advice to cut down or abstain , or referral to an alcohol specialist or treatment program ; 2 ) received any advice [ including counseling ] ; or 3 ) participated in any discussion about alcohol ( including advice ) . An example question was : Did the doctor give you any advice about your drinking habits ? Drinks per drinking day was the primary drinking outcome . We examined additional measures in secondary analyses : days drinking ( any day on which a drink was taken ) , days binge drinking ( any day on which per occasion amounts noted previously were exceeded ) , proportion drinking hazardous amounts , proportion binge drinking , and proportion abstinent . We compared sociodemographic characteristics , level of training , and mean number of patients enrolled for physicians in the intervention and control groups by using the two independent sample s t-test and the Fisher exact test , as applicable . We then compared patients who were seen by physicians in the intervention and control groups with respect to measured characteristics . We compared patients who were available and unavailable at the 6-month follow-up by r and omized group , physician level of training , and sociodemographic characteristics . Outcomes were compared between physicians in the intervention and control groups by using an intention-to-treat analysis ( physicians were analyzed in the groups to which they were r and omly assigned ) . Generalized estimating equations ( GEE ) were used to adjust for clustering of patients by physician ( PROC GENMOD , SAS software , version 8.1 ) ( 46 ) . For continuous outcomes , we specified the identity link function ; for dichotomous outcomes , we specified the logit link Background The European level of alcohol consumption , and the subsequent burden of disease , is high compared to the rest of the world . While screening and brief interventions in primary healthcare are cost-effective , in most countries they have hardly been implemented in routine primary healthcare . In this study , we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement : training and support to address lack of knowledge and motivation in healthcare providers ; financial reimbursement to compensate the time investment ; and internet-based counselling to reduce workload for primary care providers . Methods / design In a cluster r and omized factorial trial , data from Catalan , English , Netherl and s , Polish , and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption . The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group . Screening and brief intervention activities will be measured at baseline , during 12 weeks and after six months . Process measures include health professionals ’ role security and therapeutic commitment of the participating providers ( SAAPPQ question naire ) . A total of 120 primary healthcare units will be included , equally distributed over the five countries . Both intention to treat and per protocol analyses are planned to determine intervention effectiveness , using r and om coefficient regression modelling . Discussion Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required . This international multi-centre trial will provide evidence to guide decision makers . Trial registration Clinical Trials.gov . Trial identifier : OBJECTIVE To evaluate the feasibility and efficacy of routine opportunistic screening and brief intervention ( BI ) by ED staff to reduce high-risk alcohol consumption . METHODS This was an open , r and omized controlled trial with allocation blinding performed over 12 months . Using the Paddington Alcohol Test , adult patients were screened for high-risk alcohol use . Consenting patients who were screened positive were eligible for r and omization to no counselling ( st and ard care , SC ) , same-day BI by an emergency nurse or doctor or motivational intervention ( MI ) within 1 week by off-site drug and alcohol counsellors . Telephone follow up was performed at 1 and 3 months . The primary outcome was maximum self-reported daily st and ard drinks consumed . Analysis was by intention to treat . RESULTS Of 32,965 eligible patients , 10,274 were screened , 1043 were positive , 468 consented to the study , and 161 , 159 and 148 were allocated to SC , BI and MI , respectively . In the MI group , 133 declined intervention or failed to attend . At 3 months , 96 , 81 and 74 participants in the SC , BI and MI groups , respectively , were contactable and consented to telephone interview . Overall , maximum daily alcohol consumption decreased from a median of 13.5 st and ard drinks at enrolment to 9.25 drinks at 3 months . At 3 months , SC participants reported fewer drinks than those r and omized to MI . CONCLUSION In the present study , neither BI nor MI was better than SC in reducing high-risk alcohol consumption . Uptake of opportunistic screening by ED staff was poor , as was patient compliance with off-site counselling AIM To evaluate the effectiveness of different brief intervention strategies at reducing  hazardous or harmful drinking in the probation setting . Offender managers were r and omized to three interventions , each of which built on the previous one : feedback on screening outcome and a client information leaflet control group , 5 min of structured brief advice and 20 min of brief lifestyle counselling . METHODS A pragmatic multicentre factorial cluster r and omized controlled trial . The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test ( AUDIT ) at 6 months ( negative status was a score of < 8) . Secondary outcomes were AUDIT status at 12 months , experience of alcohol-related problems , health utility , service utilization , readiness to change and reduction in conviction rates . RESULTS Follow-up rates were 68 % at 6 months and 60 % at 12 months . At both time points , there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status . Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend ( 36 and 38 % , respectively ) than those in the client information leaflet group ( 50 % ) in the year following intervention . CONCLUSION Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet . The impact of more intensive brief intervention on reoffending warrants further research Objective To evaluate the effectiveness of different brief intervention strategies at reducing  hazardous or harmful drinking in primary care . The hypothesis was that more intensive intervention would result in a greater reduction in hazardous or harmful drinking . Design Pragmatic cluster r and omised controlled trial . Setting Primary care practice s in the north east and south east of Engl and and in London . Participants 3562 patients aged 18 or more routinely presenting in primary care , of whom 2991 ( 84.0 % ) were eligible to enter the trial : 900 ( 30.1 % ) screened positive for hazardous or harmful drinking and 756 ( 84.0 % ) received a brief  intervention .  The sample was predominantly male ( 62 % ) and white ( 92 % ) , and 34 % were current smokers . Interventions Practice s were r and omised to three interventions , each of which built on the previous one : a patient information leaflet control group , five minutes of structured brief advice , and 20 minutes of brief lifestyle counselling . Delivery of the patient leaflet and brief advice occurred directly after screening and brief lifestyle counselling in a subsequent consultation . Main outcome measures The primary outcome was patients ’ self reported hazardous or harmful drinking status as measured by the alcohol use disorders identification test ( AUDIT ) at six months . A negative AUDIT result ( score < 8) indicated non-hazardous or non-harmful drinking . Secondary outcomes were a negative AUDIT result at 12 months , experience of alcohol related problems ( alcohol problems question naire ) , health utility ( EQ-5D ) , service utilisation , and patients ’ motivation to change drinking behaviour ( readiness to change ) as measured by a modified readiness ruler . Results Patient follow-up rates were 83 % at six months ( n=644 ) and 79 % at 12 months ( n=617 ) . At both time points an intention to treat analysis found no significant differences in AUDIT negative status between the three interventions . Compared with the patient information leaflet group , the odds ratio of having a negative AUDIT result for brief advice was 0.85 ( 95 % confidence interval 0.52 to 1.39 ) and for brief lifestyle counselling was 0.78 ( 0.48 to 1.25 ) . A per protocol analysis confirmed these findings . Conclusions All patients received simple feedback on their screening outcome . Beyond this input , however , evidence that brief advice or brief lifestyle counselling provided important additional benefit in reducing hazardous or harmful drinking compared with the patient information leaflet was lacking . Trial registration Current Controlled Trials IS RCT N06145674 BACKGROUND There is a need for primary care providers to have brief effective methods to intervene with high-risk drinkers during a regular outpatient visit . OBJECTIVE To determine whether brief physician- and nurse practitioner-delivered counseling intervention is efficacious as part of routine primary care in reducing alcohol consumption by high-risk drinkers . METHODS Academic medical center-affiliated primary care practice sites were r and omized to special intervention or to usual care .  From a screened population of 9772 patients seeking routine medical care with their primary care providers , 530 high-risk drinkers were entered into the study . Special intervention included training providers in a brief ( 5- to 10-minute ) patient-centered counseling intervention , and an office support system that screened patients , cued providers to intervene , and made patient education material s available . The primary outcome measures were change in alcohol use from baseline to 6 months as measured by weekly alcohol consumption and frequency of binge drinking episodes . RESULTS Participants in the special intervention and usual care groups were similar on important background variables and potential confounders except that special intervention participants had significantly higher baseline levels of alcohol usage ( P = .01 ) . At 6-month follow-up , in the 91 % of the cohort who provided follow-up information , alcohol consumption was significantly reduced when adjusted for age , sex , and baseline alcohol usage ( special intervention , -5.8 drinks per week ; usual care , -3.4 drinks per week ; P = .001 ) . CONCLUSIONS This study provides evidence that screening and very brief ( 5- to 10-minute ) advice and counseling delivered by a physician or nurse practitioner as part of routine primary care significantly reduces alcohol consumption by high-risk drinkers Background Alcohol misuse is common in people attending emergency departments ( EDs ) and there is some evidence of efficacy of alcohol screening and brief interventions ( SBI ) . This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in Engl and : the SIPS ED trial . Methods and Findings Pragmatic multicentre cluster r and omized controlled trial of SBI for hazardous and harmful drinkers presenting to ED . Nine EDs were r and omized to three conditions : a patient information leaflet ( PIL ) , 5 minutes of brief advice ( BA ) , and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling ( BLC ) . The primary outcome measure was the Alcohol Use Disorders Identification Test ( AUDIT ) status at 6 months . Of 5899 patients aged 18 or more presenting to EDs , 3737 ( 63·3 % ) were eligible to participate and 1497 ( 40·1 % ) screened positive for hazardous or harmful drinking , of whom 1204 ( 80·4 % ) gave consent to participate in the trial . Follow up rates were 72 % ( n = 863 ) at six , and 67 % ( n = 810 ) at 12 months . There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis . At month 6 , compared to the PIL group , the odds ratio of being AUDIT negative for brief advice was 1·103 ( 95 % CI 0·328 to 3·715 ) . The odds ratio comparing BLC to PIL was 1·247 ( 95 % CI 0·315 to 4·939 ) . A per protocol analysis confirmed these findings . Conclusions SBI is difficult to implement in typical EDs . The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information , which is likely to be easier and less expensive to implement than more complex interventions . Trial Registration Current Controlled Trials IS RCT N AIMS Recommendations for routine alcohol screening and brief counselling intervention in primary health care rest on results from intervention efficacy studies . By conducting a pragmatic controlled trial ( PCT ) , we aim ed at evaluating the effectiveness of the  WHO recommendations for screening and brief intervention ( SBI ) in general practice . METHODS A r and omized PCT ( brief counselling intervention vs no intervention ) involving 39 Danish general practitioners ( GPs ) . Systematic screening of 6897 adults led to inclusion of 906 risky drinkers , and research follow-up on 537 of these after 12 - 14 months . Outcome measures focused on patients ' acceptance of screening and intervention and their self-reported alcohol consumption . RESULTS Patient acceptance of screening and intervention -10.3 % ( N = 794 ) of the target population ( N = 7 , 691 ) explicitly refused screening . All intervention group subjects ( N = 442 ) were exposed to an instant brief counselling session while only 17.9 % of them ( 79/442 ) attended a follow-up consultation that was offered by their GP . Consumption Changes At one-year follow-up , average weekly consumption had increased by 0.7 drinks in both comparison groups . As secondary findings , we observed an indiscriminate absolute risk reduction ( ARR = 0.08 ( 95 % CI : -0.02 ; 0.18 ) ) in male binge drinking , but adverse intervention effects for women on the secondary outcomes ( binge drinking ARR = -0.30 ( 95 % CI : -0.47 ; -0.09 ) ) . CONCLUSIONS The results of brief interventions in everyday general practice performed on the basis of systematic question naire screening may fall short of theoretical expectations . When applied to non-selected groups in everyday general practice SBI may have little effect and engender diverse outcome . Women may be more susceptible to defensive reactions than men Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm . We also examined patient- , physician- , and system-level factors affecting screening rates and , among those who screened positive , rates of brief intervention and referral to treatment . Results Screening rates were highest in the NPP and MA arm ( 51 % ) ; followed by the PCP arm ( 9 % ) and the Control arm ( 3.5 % ) . Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm . The PCP arm had higher brief intervention and referral rates ( 44 % ) among patients screening positive than either the NPP and MA arm ( 3.4 % ) or the Control arm ( 2.7 % ) . Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm . Conclusion Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation . Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models . Trial registration : Clinical Trials This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention ( SBI ) by nurses in primary care . R and omisation was at the level of the practice and the interventions were : written guidelines ( controls , n=76 ) ; outreach training ( n=68 ) ; and training plus telephone-based support ( n=68 ) . After 3 months , just 39 % of controls implemented the SBI programme compared to 74 % of nurses in trained practice s and 71 % in trained and supported practice s. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues . However , there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management . Thus cost-effectiveness ratios ( cost per patient appropriately treated ) were similar between the three strategies . Given the potential for anxiety due to misdirected advice about alcohol-related risk , the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care BACKGROUND : The objective of this study was to determine the effects of a brief primary care provider-delivered counseling intervention on the reduction of alcohol consumption by high-risk drinkers . The intervention was implemented as part of routine primary care medical practice . METHODS : We performed a controlled clinical trial with 6- and 12-month follow-up . Three primary care practice s affiliated with an academic medical center were r and omly assigned to special intervention ( SI ) or usual care ( UC ) . A total of 9,772 primary care patients were screened for high-risk drinking . A fourth site was added later . From the group that was screened , 530 high-risk drinkers entered into the study , with 447 providing follow-up at 12 months . The intervention consisted of brief ( 5–10 minute ) patient-centered counseling plus an office system that cued providers to intervene and provided patient educational material s. RESULTS : At 12-month follow-up , after controlling for baseline differences in alcohol consumption , SI participants had significantly larger changes ( P=.03 ) in weekly alcohol intake compared to UC ( SI=−5.7 drinks per week ; UC=−3.1 drinks per week ) , and of those who changed to safe drinking at 6 months more SI participants maintained that change at 12 months than UC . CONCLUSIONS : Project Health provides evidence that screening and very brief ( 5–10 minute ) advice and counseling delivered by a patient ’s personal physician or nurse practitioner as a routine part of a primary care visit can reduce alcohol consumption by high-risk drinkers Summary of the Recommendation The U.S. Preventive Services Task Force ( USPSTF ) found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children , of women for intimate partner violence , or of older adults or their caregivers for elder abuse . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) Appendix Table 1 . U.S. Preventive Services Task Force Recommendations and Ratings The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death . The USPSTF found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children , women , or older adults in the general population . The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed ( see Clinical Considerations ) . The USPSTF found limited evidence as to whether interventions reduce harm to women and no studies that examined the effectiveness of interventions in older adults . No studies have directly addressed the harms of screening and interventions for family and intimate partner violence . As a result , the USPSTF could not determine the balance between the benefits and harms of screening for family and intimate partner violence among children , women , or older adults . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence Clinical Considerations The USPSTF did not review the evidence for the effectiveness of case-finding tools ; however , all clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse or neglect . Patients in whom abuse is suspected should receive proper documentation of the incident and physical findings ( for example , photographs , body maps ) ; treatment for physical injuries ; arrangements for skilled counseling by a mental health professional ; and the telephone numbers of local crisis centers , shelters , and protective service agencies . Victims of family violence are primarily children , female spouses/intimate partners , and older adults . Numerous risk factors for family violence have been identified , although some may be confounded by socioeconomic factors . Factors associated with child abuse or neglect include low income status , low maternal education , non-white race , large family size , young maternal age , single-parent household , parental psychiatric disturbances , and presence of a stepfather . Factors associated with intimate partner violence include young age , low income status , pregnancy , mental health problems , alcohol or substance use by victims or perpetrators , separated or divorced status , and history of childhood sexual and /or physical abuse . Factors associated with the abuse of older adults include increasing age , non-white race , low income status , functional impairment , cognitive disability , substance use , poor emotional state , low self-esteem , cohabitation , and lack of social support . Several instruments to screen parents for  child abuse have been studied , but their ability to predict child abuse or neglect is limited . Instruments to screen for intimate partner violence have also been developed , and although some have demonstrated good internal consistency ( for example , the HITS [ Hurt , Insulted , Threatened , Screamed at ] instrument , the Partner Abuse Interview , and the Women 's Experience with Battering [ WEB ] Scale ) , none have been vali date d against measurable outcomes . Only a few screening instruments ( for example , the  Caregiver Abuse Screen [ CASE ] and the HwalekSengstock Elder Abuse Screening Test  [ HSEAST ] ) have been developed to identify older potential victims of abuse or their abusive caretakers . Both of these tools correlated well with previously vali date d instruments when administered in the community but have not been tested in the primary care clinical setting ( 1 ) . Home visit programs directed at high-risk mothers ( identified on the basis of sociodemographic risk factors ) have improved developmental outcomes and decreased the incidence of child abuse and neglect , as well as decreased rates of maternal criminal activity and drug use . Discussion Approximately 1 million abused children are identified in the United States each year ( 2 ) . In 1999 , an estimated 1100 children died of abuse and neglect ( 3 ) . It is likely that reported abuse captures only a fraction of all cases . Estimates of the prevalence of intimate partner violence in the United States indicate that 1 to 4 million women are physically , sexually , or emotionally abused by their intimate partners each year ( 4 , 5 ) , with 31 % of all women reporting abuse at some point in their lifetimes ( 6 ) . Although violence by women against men also occurs , women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner ( 7 ) . The National Elder Abuse Incidence Study ( NEAIS ) estimates that approximately 551000 older adults in domestic setting s were abused and /or neglected during 1996 ( 8) . The abuse of older adults takes many forms , including physical , sexual , and psychological abuse ; financial exploitation ; and neglect ( 9 ) . In 90 % of cases , the perpetrator of such abuse is a family member , usually an adult child or spouse ( 8) . Harmful outcomes of family violence may include not only repercussions of acute trauma , including death or unwanted pregnancy , but also long-term physical problems and psychiatric disorders , such as depression , post-traumatic stress disorder , somatization , suicide , and substance abuse ( 10 - 20 ) . In addition , children who witness intimate partner violence are at risk for developmental delay ; school failure ; violent behavior ; and a variety of psychiatric disorders , including depression and oppositional defiant disorder ( 21 - 23 ) . The USPSTF focused this review on children , women , and older adults because they are the largest groups at risk for domestic violence in the general primary care setting and are most likely to have been the subjects of published studies . The USPSTF review ed the evidence for the effectiveness of screening procedures and interventions in the primary care setting in reducing harmful outcomes of domestic violence against children , women , and older adults . Because no studies were found that directly addressed the impact of screening on reducing harmful outcomes , the USPSTF examined the accuracy of clinical screening instruments in identifying risk for current or future abuse and the efficacy of clinic-based interventions in reducing harmful outcomes . Screening for child abuse in the primary care setting can involve a variety of techniques , including physical examination as well as screening question naires . Findings during a routine physical examination suggestive of abuse and /or neglect , such as burns , bruises , and repeated suspicious traumatic injury , have been described ( 24 ) . All instruments design ed to screen for child abuse and neglect were directed at parents , particularly pregnant mothers . Limited evidence suggests that these instruments had fairly high sensitivity but low specificity for identifying future child maltreatment when administered in the study population s , particularly when self-administered question naires were provided to pregnant mothers in a 2-step method , such as the Hawaii Risk Indicators Screening Tool followed by the Kempe Family Stress Inventory ( 25 , 26 ) . These question naires have not been widely tested in different population s. Newer brief instruments design ed to identify women who are victims of intimate partner violence in primary care setting s compare well with lengthier , previously vali date d instruments ( 1 ) . Studies indicate that self-administered question naires elicit more positive responses than interviewer-administered question naires in emergency department setting s ( 27 ) , but the opposite was true in a Planned Parenthood clinic ( 28 ) . No studies have evaluated the performance of screening instruments using verified outcomes of reported intimate partner abuse , although self-reported abuse may be a more accurately measured outcome than some verified outcomes ( for example , police or social services reports ) . The USPSTF found few screening instruments for the detection of older adults who are the potential victims of abuse or their caretakers . None of the instruments available have been widely vali date d. The USPSTF review ed the evidence for the efficacy of interventions with children , women , and older adults in reducing harmful outcomes of family and intimate partner violence . The intervention trials identified high-risk women and children on the basis of various inclusion criteria that have not been vali date d , including sociodemographic characteristics , maternal substance use , low infant birthweight , and homelessness . A r and omized , controlled trial with 15 years of follow-up indicated that nurse home visit programs ( for example , the NurseFamily Partnership program ) during the prenatal and 2-year postpartum periods for low-income , first-time mothers can improve the short-term and long-term outcomes of child abuse and neglect ( 29 , 30 ) . When compared with the nonintervention group , the home visit group had improved outcomes , including decreased reports of child maltreatment , child injuries/toxic ingestions and emergency department visits , and maternal criminal activity and drug use . Several trials utilizing nurse home visits for varying lengths of time and with various program components for pregnant and postpartum mothers support these findings , although the outcomes in these studies were short-term measures of child abuse and related factors ( 1 ) . There were 2 studies of interventions to decrease intimate partner violence in women ; both studies , BACKGROUND Alcohol screening , brief intervention , and referral to specialized treatment ( ASBIR ) reduce drinking and related harms . Unanswered questions are how to manage nondependent patients with poor response to brief interventions , how to manage dependent patients who do not obtain treatment , and how to ensure population -wide delivery of ASBIR . Telephone-administered counseling may provide answers . METHODS We conducted a 12-month r and omized controlled trial of a telephone and mail intervention for non-treatment-seeking primary care patients with alcohol use disorders . We enrolled 897 subjects after systematic screening in 18 primary care clinic waiting rooms in and around Madison and Milwaukee , Wisconsin , and subsequent telephone-administered diagnostic interviews .  Experimental subjects received up to six sessions of protocol -driven telephone counseling based on principles of motivational interviewing and stages of readiness to change . Control subjects received a pamphlet on healthy lifestyles . The paper reports on 3-month drinking outcomes for men and women with alcohol abuse and dependence . RESULTS Male experimental subjects ( N=199 ) manifested a 30.6 % decline in risky drinking days , compared with a 8.3 % decline in controls ( N=201 , p<0.001 ) . The total consumption declined by 17.3 % compared with 12.9 % by controls ( p=0.001 ) . Female experimental subjects ( N=246 ) manifested a 17.2 % decrease in risky drinking days compared with an 11.5 % decrease by controls ( N=251 ; p = NS ) and a 13.9 % decline in total consumption compared with 11.0 % by controls ( p = NS ) . Greater numbers of telephone counseling sessions were associated with greater declines in drinking . CONCLUSION Following systematic screening , a six-session telephone and mail intervention is more effective than a pamphlet in reducing drinking at 3 months for non-treatment-seeking men with alcohol abuse and dependence . An intervention effect of the enrollment procedures may have obscured further intervention effectiveness . Telephone counseling shows promise for non-treatment-seeking primary care patients with alcohol use disorders Objectives : Brief intervention for excessive alcohol consumption is effective yet not implemented widely . Alcohol misuse is implicated in unsafe sex and sexually transmitted infections and is common in clients of sexual health services . Our aims were to assess feasibility , acceptability and effectiveness of screening and brief intervention for risky alcohol consumption by a nurse in a sexual health clinic . Methods : Patients completed the AUDIT question naire on h and held computers . Those scoring ⩾8 on AUDIT were asked to participate in the study and the 3 months ’ follow-up and were r and omised to intervention or control groups . The Drink-less package ( based on WHO vali date d methods ) was used to implement the brief intervention by a trained registered nurse . Results : Of 519 ( 87 % ) who completed screening , 204 ( 39 % ) scored ⩾8 on AUDIT ( eligible ) , 184 agreed to follow-up and 133 completed it . At follow-up , both groups showed significant reductions in AUDIT scores . Mean scores decreased from 13.7 to 11.5 ( control group ) and 14.0 to 10.7 ( intervention group ) ; most ( 94 % ) recalled the intervention and 62 % reported reducing drinking compared with 47 % of controls ( p<0.001 ) . The nurse screening and intervention process was reported acceptable by 74 % of patients at follow-up and a majority ( 71 % ) of staff . Conclusions : Screening and brief intervention in a sexual health clinic for risky alcohol consumption is feasible , acceptable and effective in producing significant reductions in drinking as measured by AUDIT . Both intervention and control  groups decreased consumption , suggesting that screening alone is sufficient to influence behaviour . Further study of brief intervention in this setting is appropriate
Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving .
CONCLUSIONS These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using st and ardized methods .
BACKGROUND The U.S. Preventive Services Task Force ( USPSTF ) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse .
This study was design ed to develop a st and ardized rating for the clinical ly preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services .