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ORIGINAL CONTRIBUTION |
From the Department of Emergency Medicine at Lehigh Valley Hospital in Bethlehem, Pa.
Address correspondence to Aaron Craig Love, DO, 7437 Beaver Valley Rd, Prescott Valley, AZ 86314-1412. E-mail: alove1{at}mac.com
Context: Physicians in emergency departments (EDs) treat more patients with alcohol-related disorders than do those in primary care settings.
Objectives: To implement an effective screening, brief intervention, and referral (SBIR) program for use in EDs. Further, to evaluate the impact of the program on alcohol-consumption levels.
Methods: A prospective cohort pilot study was conducted at a suburban community teaching hospital using a convenience sample of ED patients and an original seven-question screening tool based on well-known guidelines. Subjects screening positive for possible alcohol abuse were given treatment referrals. Follow-up telephone interviews were conducted 6 months later.
Results: Of the 1556 enrolled subjects, 251 (16%) were classified as at-risk drinkers. Seventy-nine at-risk subjects (32% [95% CI, 26%-37%]) screened positive on CAGE-based questions (Cut down, Annoyed, Guilty, Eye opener). At follow-up, 20 (25% [95% CI, 16%-35%]) were successfully contacted. Of these 20 subjects, 5 (25%) refused to participate in follow-up screening. For the remaining 15 individuals, follow-up screening indicated that the mean (SD) number of drinks consumed per week decreased from 28 (14) on study enrollment to 10 (10) at 6-month follow-up (P<.001). Maximum number of drinks per occasion decreased from 12 (8) at enrollment to 6 (7) on follow-up (P=.008). Subject scores on the CAGE-based questions decreased from pre- to postintervention, though not significantly, with an average of 2.1 (1) affirmative answers on enrollment and 1.5 (1.4) at follow-up (P=.108).
Conclusion: Implementation of an effective SBIR program for alcohol-related disorders can be accomplished in the ED.
Based on probability sample comparisons of noninjured patients seen in emergency departments (EDs) versus noninjured patients in primary care settings, it was found that physicians in EDs treat a larger percentage of patients who misuse alcohol.3 Thus, there exists great potential for physicians in EDs to have a beneficial impact on intervention efforts.
The US Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration (NHTSA), and the American College of Emergency Physicians (ACEP) have spearheaded a nationwide effort to incorporate patient screening for alcohol misuse into a broad-based program of injury prevention.4 In addition, the ACEP has received an NHTSA grant to develop an alcohol-screening and brief intervention tool to help ED physicians address alcohol-related injuries.4 A randomized controlled trial by Crawford et al5 found reduced alcohol-consumption levels and ED visits in alcohol-misusing patients who were screened and referred to follow-up care with alcohol-abuse treatment specialists. Nevertheless, there remain considerable barriers to establishing and evaluating the effectiveness of alcohol-screening programs.
Although there have been more than 30 studies revealing the beneficial impact of brief intervention in various clinical settings for patients with alcohol-related disorders, there have been few studies on the effectiveness of brief intervention under conditions commonly encountered in an ED.6 The goals of the present pilot study were to develop a brief alcohol-screening and referral program for this patient population, to investigate the feasibility of telephone follow-up after intervention, and to determine the 6-month self-reported change in patients' alcohol-consumption levels and CAGE scores. The CAGE questionnaire is an internationally used assessment instrument for identifying people who misuse alcohol. The letters in the acronym represent the standard four questions used in the test7:
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Methods |
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The present project was referred to the institutional review board at Lehigh Valley Hospital. The board deemed the project to be exempt from full review because it was designated a quality-improvement initiative. Because of the social nuances of alcohol abuse, there was considerable concern that requiring written consent from the patients would diminish participation. Therefore, verbal consent was obtained from patients for ED screening and postintervention telephone follow-up. Verbal consent was logged for subjects who could be contacted for follow-up.
Study Participants and Setting
Patients were eligible for and included in the present pilot study if they
were cognitively alert, cooperative, medically stable, at least 14 years of
age, and presented with a condition that did not result in hospital admission.
Subjects were enrolled in the study at the hospital's ED during a 6-month
period, from April 2004 to October 2004. Patients who were excluded from study
participation were customarily cared for at the discretion of physicians and
nurses. Physicians, nurses, and physician assistants in the ED performed the
initial patient screening for alcohol misuse. A research assistant conducted
the telephone follow-up of subjects 6 months after intervention.
Lehigh Valley Hospital is a suburban community teaching hospital with approximately 30,000 visits to its ED every year. The hospital is part of a three-site, tertiary care network that has a total ED patient volume of more than 100,000 individuals per year.
Intervention
Prior to the data-collection phase of the present pilot study, ED hospital
staff (eg, resident and attending physicians, physician assistants, and triage
and bedside nurses) were given a 1-hour training session on the importance of
screening patients for alcohol-related disorders and on the use of our
original screening
tool.7 A nationally
renowned expert in alcohol-use disorders conducted the training session.
Pocket reference cards were developed and distributed to ED staff. An
incentive program offering retail gift cards was used to increase staff
participation. Local newspapers were contacted and encouraged to publish
articles about the SBIR program, further contributing to staff interest and
participation.
Staff determined which patients to screen, being encouraged to perform screening on any patient who answered "yes" or "yes, socially" to the question, "Do you drink alcohol?" This question is part of the standard social history obtained at triage in the ED of our hospital. Subjects who answered with either affirmative response to this question were screened—regardless of whether their presenting complaints were related to alcohol consumption. We adopted this strategy because other researchers have recommended similar screening for any ED patient who consumes alcohol.8,9 In addition, it has been shown that self-reporting of recent drinking is not a good indicator of alcohol abuse in ED populations.10 Subject screening was conducted by ED staff, depending on the available time and resources, workload, and staff motivation.
We developed our SBIR tool (Appendix) based on the NIAAA at-risk
drinking guidelines ("at-risk drinking" defined as >14
drinks/wk or >4 drinks per occasion for men age 
65 years; >7
drinks/wk or >3 drinks per occasion for women of all ages and men older
than 65 years) and the CAGE
questionnaire.7 One
standard drink was defined as 142 mL (5 oz) of wine; 43 mL (1.5 oz), spirits;
or 341 mL (12 oz), regular beer. The NIAAA at-risk drinking guidelines have
previously been shown to result in the best balance of sensitivity and
specificity for screening patients with alcohol-related
disorders.10,11
To increase the selectivity for subjects' current drinking patterns, we added
the phrase, "Within the past year..." to the beginning of each of
the four standard CAGE questions. During the study period, the SBIR tool was
placed on each new ED patient record.
Subjects who answered "yes" or "yes, socially" to the question, "Do you drink alcohol?" were screened first with the three NIAAA at-risk questions evaluating current drinking habits. Subjects who screened positive according to these guidelines were then screened with the four-question CAGE-based portion of our SBIR tool. A positive result on this section of the SBIR was defined as one affirmative answer to any of the four questions. The total length of this screening process can be less than 1 minute, though we did not evaluate screening time in this pilot study. The questions used in the screening process have been validated previously with high sensitivity and specificity in EDs.10,11
Subjects who screened positive in both portions of the SBIR were given copies of the NIAAA recommendations for safe drinking habits and a list of local treatment facilities and Alcoholics Anonymous resources. Each of these subjects were also given a motivational interview by his or her ED staff member. In this interview, the subject was encouraged to pursue follow-up treatment with a primary care physician. Each practitioner determined the length and nature of the motivational interview, but subjects were generally told that consuming large amounts of alcohol could be detrimental to their health and that they should strongly consider seeking follow-up consultation about their drinking. In addition, each subject's readiness to change was determined by the screener based on the general concept of different stages of change: precontemplation, contemplation, preparation and action, or maintenance. Clinicians were asked to document intervention results on the back of each subject's SBIR form for later reference by the research assistant during follow-up.
6-Month Follow-Up
Approximately 6 months after ED intervention, a nonblinded research
assistant conducted follow-up telephone interviews with those subjects who
screened positive for any of the CAGE-based questions. Subjects' telephone
numbers were obtained through ED records.
Subjects were then grouped by availability for follow-up: (1) entirely lost to follow-up, (2) lost to follow-up through attrition, and (3) successfully reached.
Subjects in the first group consisted of individuals with disconnected or incorrect telephone numbers.
Telephone contact information for subjects in the second group was valid, but the research assistant remained unable to contact these individuals after two telephone calls. These telephone calls were separated by at least 1 week and both attempts resulted in either an unanswered line or a message left with another person.
The third group was composed of subjects who the research assistant spoke to within two telephone calls. Contacted subjects were asked the same series of questions on the SBIR tool.
Primary Data Analysis
The percentage of drinkers who were determined to be at-risk based on their
responses to the first three questions of the SBIR tool and the percentage of
at-risk drinkers who screened positive on the CAGE-based questions were
calculated. Percentages of subjects in each follow-up availability category
were also calculated.
Changes in subjects' alcohol-consumption levels and CAGE scores from pre- to postintervention were determined. Confidence intervals (CI) were calculated for each proportion of data, and paired t tests were computed for pre- and postintervention continuous level data. A P value of less than .05 was considered statistically significant.
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Results |
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Of the 1556 screened subjects, 251 (16% [95% CI, 14%-18%]) were classified as at-risk drinkers based on their responses. Seventy-nine (32% [95% CI, 26%-37%]) of these at-risk subjects also screened positive in the CAGE-based questions.
Of these 79 subjects, at 6-month follow-up, 27 (34% [95% CI, 24%-45%]) were entirely lost to follow-up, most commonly because of an incorrect telephone number. Thirty-two subjects (40% [95% CI, 30%-51%]) could not be reached by the research assistant after two telephone calls and were lost to follow-up through attrition. Twenty subjects (25% [95% CI, 16%-35%]) were successfully contacted by the research assistant within two telephone calls. Of the 20 subjects successfully contacted, 5 (25%) refused to participate in follow-up screening.
Screening of the remaining 15 contacted individuals indicated that the mean (SD) number of drinks they consumed per week decreased from 28 (14) at baseline to 10 (10) at 6-month follow-up (P<.001). The maximum number of drinks consumed by subjects per occasion deceased from 12 (8) at baseline to 6 (7) at follow-up (P=.008).
Mean (SD) subject scores on the CAGE-based questions decreased from pre- to postintervention. However, this decrease was not statistically significant, with an average of 2.1 (1) "yes" answers in the ED and 1.5 (1.4) "yes" answers at follow-up (P=.108).
Figure 1 presents a flowchart overview of the enrollment, intervention, and results of the present pilot study. Figure 2 displays the results in bar-graph format.
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Selection of subjects who were able to be contacted within two telephone calls may have led to bias in favor of individuals who are more likely to have reduced their alcohol consumption (ie, individuals who have reliable contact information may be more likely to reduce their problem drinking).
Self-reporting by patients is not an objective measurement. Nevertheless, it has previously been shown to have overall consistency.12 In the present study and in other alcohol-consumption studies,13-15 self-reporting is a routine method for studying patterns of substance use over time. The only objective measurements available for such purposes are breathalyzer tests and measurements of blood-alcohol level, both of which have the limitation of providing only a single data point. Moreover, it has previously been reported that using a set of closed questions addressing both recent and long-term recall of drinking patterns would capture the most accurate record of self-reported alcohol-consumption levels.16 The SBIR tool used in the present study accomplished this goal.
Although the SBIR tool and ED discharge instructions were the same for all study subjects, there could have been considerable variation in the duration and content of the motivational interviews conducted by ED staff. A scripted motivational interview could assist in controlling for this possibility. This variability could also be corrected by using an alcohol-abuse treatment specialist to perform each intervention in the same manner—a step that might have the added benefit of helping to improve patient follow-up.
Achieving adequate patient follow-up has been challenging to previous researchers, though using an alcohol-treatment specialist has been shown to be an effective measure for ED alcohol-abuse intervention.17 Due to financial constraints, employing a dedicated specialist was not feasible in the present pilot study. Moreover, our aim was to conduct an SBIR program with the resources available in most EDs. Therefore, this limitation can also be viewed as a strength, making our intervention more applicable to most ED settings.
Variation resulting from different practitioners may have been reduced by the fact that intervention results were documented on the back of the original SBIR form, allowing our telephone follow-up research assistant access to each subject's previous SBIR results.
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Comment |
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Findings in the present pilot study reveal that, among heavy drinkers, the SBIR program resulted in significant reductions in alcohol consumption at 6-month follow-up, as measured in the number of drinks consumed per week (P<.001) and maximum number of drinks consumed per occasion (P=.008). These results are comparable to those described in a large meta-analysis conducted by D'Onofrio and Degutis,6 who reported reductions in alcohol consumption 3 to 6 months after brief intervention. However, the studies included in that meta-analysis6 show that significant reductions were found when patients with the most severe alcohol-consumption patterns were excluded. Our results, by contrast, show decreased alcohol use in subjects with the highest consumption rates.
It is difficult to ensure patient compliance with nontreatment follow-up appointments. Encouragingly, however, Crawford et al5 found reduced alcohol-consumption patterns in patients after brief intervention, regardless of whether they kept follow-up appointments. Our pilot study was not designed to investigate whether patients kept their follow-up referrals. Instead, our objective was to investigate change in alcohol-consumption patterns after an ED intervention and referral—perhaps the simplest variable we can affect in the ED.
After a search of the National Library of Medicine's PubMed database using the keywords alcohol abuse, alcohol intervention, and CAGE score for literature published since 1980, we are aware of no prior study that has followed patients' CAGE scores 6 months after an ED SBIR. Nor, to our knowledge, has an SBIR program previously been validated as a useful measure for alcohol-related disorders. The use of the SBIR program allowed us to ascertain subjects' perceptions about the potential harm of their alcohol-consumption patterns. Although these results did not reach statistical significance, a reduction in CAGE scores was seen. Bias in self-reporting due to differences in subject willingness to change at follow-up versus baseline may have also contributed to reduced CAGE scores. In addition, there may have been a Hawthorne effect resulting from the subjects' awareness that they were participating in a study—though the relative anonymity of telephone follow-up should have made answering "yes" to the CAGE-based questions easier.
The difficulties involved in follow-up are of utmost importance in planning future investigations of alcohol-abuse interventions. To date, much of the alcohol-cessation research reported in the literature has been performed outside the ED setting, often consisting of pooled data and meta-analyses.6 However, several studies have demonstrated the efficacy of ED SBIR programs, finding short-term reductions in alcohol consumption and in repeat visits to the ED.5,17
The severe time constraints already faced by overwhelmed ED staff is a considerable barrier to implementing SBIR programs in that setting. The development and evaluation of SBIR programs under actual ED conditions requires researchers to create very time-efficient interventions and minimize the research burden on clinical staff. Patient tolerance is another important consideration. The intervention used in the present study was neither invasive nor time consuming. Therefore, few subjects refused participation. In studies with more extensive intervention, a greater rate of subject refusal can be expected.18
In establishing a SBIR program for the ED, we experienced both successes and barriers. Carrying out SBIR procedures can be a complicated and time-consuming task, especially if study protocols are unclear to clinical staff. The following six intervention elements, known by the acronym FRAMES, have been identified as successfully motivating patients to change their alcohol-consumption patterns19:
Our SBIR program did not strictly adhere to these FRAMES elements. Nevertheless, we experienced successful outcomes by incorporating SBIR into the standard elements that each ED staff member at Lehigh Valley Hospital uses during patient care.
Some researchers have proposed that performing SBIR with a patient can take as little as 5 minutes.8 In addition, previous reviews have found little difference between the impact of brief versus extended intervention.6 We reduced the time element by leaving the extent of SBIR for each patient up to the judgment of the individual ED staff member, as well as by making the discharge-referral process as easy for these individuals as for other ED patients.
Our original SBIR tool has a total of seven questions. We believe that, though some sensitivity and specificity may be lost, a screening questionnaire even shorter than the one used in the present pilot study would still be useful. For example, the Paddington Alcohol Test, also designed to screen patients for alcohol-related disorders in EDs, consists of only three questions.20
We enhanced physician and nurse participation in the present study by placing the SBIR tool on each new patient record, alleviating the logistical paper barrier and providing reference materials at point-of-care. An ongoing incentive program further enhanced staff participation, as did publicity from local media outlets.
Even with the successes of the present pilot study, we had limited subject follow-up, reaching a total of only 15 (0.96%) of the 1556 screened individuals. Larger studies would require substantially more resources and effort in obtaining reliable contact information for subjects to allow better patient follow-up.
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Submitted August 31, 2006; revision received October 30, 2006; accepted November 1, 2006.
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References |
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2. Harwood HJ. Updating estimates of the economic costs of alcohol abuse in the United States: estimates, update methods, and data [National Institute on Alcohol Abuse and Alcoholism Web site]. December 2000. Available at: http://pubs.niaaa.nih.gov/publications/economic-2000/index.htm. Accessed June 12, 2007.
3. Cherpitel CJ. Drinking patterns and problems: a comparison of primary care with the emergency room. Subst Abuse.1999; 20:85 -95.
4. Runge J. Put the brakes on the next drunk driver. Lecture presented at: American College of Emergency Physicians Scientific Assembly 2002; October 6, 2002; Seattle, Wash.
5. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomized controlled trial. Lancet. 2004;364:1334 -1339.[Medline]
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7. Allen JP, Wilson VB, eds; National Institute on Alcohol Abuse and Alcoholism. Assessing Alcohol Problems: A Guide for Clinicians and Researchers. 2nd ed. Washington, DC: US Dept of Health and Human Services, Public Health Service. NIH Pub No. 03-3745. Available at: http://pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/index.htm. Accessed June 13, 2007.
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