This post was written by Matt Field for the Mental Elf website, you can find the original here.
Approximately 15% of adults in Europe drink
alcohol to excess, at levels that are likely to affect their health. Most of
these people are not alcohol dependent and do not require intensive treatment
such as detox and aftercare, but many of them would benefit from a ‘nudge’ to
reduce their drinking to safer levels.
Screening and Brief Interventions for hazardous drinking are a useful
and cost-effective way of doing this. Indeed the Lifestyle Elf has recently
written about screening
and brief interventions in primary care and for general
hospital patients.
This Randomised Controlled Trial, published
in the Journal of the American Board of Family Medicine, describes an
evaluation of an intervention that was delivered through 70 GP practices in the
Netherlands. The headline result is that the group of patients who received the
intervention did show a significant reduction in hazardous drinking when
assessed at two-year follow-up. However, this was no cause for celebration
because a control group of patients also showed a significant reduction in
hazardous drinking at follow-up, and to a greater extent than the group that
received the intervention! Therefore, it
seems that this particular intervention was, unfortunately, counterproductive.
Methods
The research team invited 2758 general
practices to participate, of which 82 practices (3%) agreed to take part. Five
practices dropped out subsequently, and another seven were eliminated because
they did not identify any patients who met the criteria for ‘hazardous
drinking’ (defined as a score of 8 or above on the Alcohol Use Disorders
Identification Test; AUDIT). The final sample comprised 712 patients, who all
scored at least 8 on the AUDIT, recruited from a total of 70 GP practices. Each
practice was then randomly assigned to either the intervention group (346
patients from 36 practices), or the control group (366 patients from 34 practices).
The GP practices in the intervention group received the following:
·
Professional-directed interventions such
as drinking guidelines, reminder cards, and training sessions about hazardous
drinking provided to the GPs themselves.
·
Organization-directed interventions
including feedback from the researchers about their patients’ drinking
characteristics, introductions to local addiction treatment services, and
provision of training in the alcohol intervention by a trained facilitator
·
Patient-delivered interventions including
a poster in the waiting room, personalised feedback on their alcohol
consumption, and leaflets on alcohol consumption and harmful drinking.
The control group were mailed the leaflets
about alcohol consumption and harmful drinking (described above), but did not
receive any personalised feedback on their drinking or any of the other
interventions described above. The primary outcome measure was the proportion
of patients in each group who still met the criteria for hazardous drinking,
which the researchers obtained by mailing the AUDIT to all of the participants
two years after they had originally enrolled in the study.
Results
This is what they found:
·
35.5% of patients from the
intervention group had reduced their alcohol consumption to low-risk levels (a
score of 7 or below on the AUDIT) after two years.
·
47% of patients from the
control group had reduced their alcohol consumption to low-risk levels after
two years.
·
This difference between groups
was statistically significant (Odds Ratio: 0.62, 95% CI: 0.43-0.90).
·
They also found that, across
both groups, females, older participants and non-smokers were more likely to
shift to low-risk drinking across the follow-up period. Other variables,
including beliefs about the effects of alcohol and intentions to reduce
drinking, also predicted outcome.
Conclusions
The authors concluded that their
intervention was counterproductive: although some patients who received the
intervention did reduce their drinking to ‘low risk’ levels, the proportion that
did so was actually significantly lower than the proportion in the control
group, who only received leaflets about alcohol in the post! The research team
discussed several possible explanations for their findings. Firstly, the
participation rate was low (only 3% of practices that were invited actually
took part). Perhaps most importantly, the researchers noted that:
‘our program did
not result in improvements in rates of screening and giving of advice’
In other words, compliance with the intervention among the
GPs was low.
Overall, it is not such a mystery that
patients in both the control and intervention conditions showed a reduction in
hazardous drinking, because factors such as regression to the mean and
‘non-specific effects’ are common with these types of brief interventions, as the
Lifestyle Elf discussed in regards to a different study here.
But it is unusual to demonstrate that a control condition produces better results than a brief
intervention, and the authors were not really able to explain this in their
paper. I cannot explain it either.
Link to paper:
Hilbink M, Voerman G, van Beurden I, Penninx B,
Laurant M. A randomized controlled trial
of a tailored primary care program to reverse excessive alcohol consumption. J Am Board Fam Med. 2012 Sep-Oct;25(5):712-22. doi:
10.3122/jabfm.2012.05.120070.
Matt Field
mfield@liv.ac.uk
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