Conversation is neither desired nor required Peter Anderson Newcastle 8 October 2009.

Conversation is neither desired nor required

Peter AndersonNewcastle8 October 2009

Possible policies and interventions for implementation at the national level

1.increasing capacity of health and social welfare systems2.establishing and maintaining a system of registration and monitoring3. integration of prevention, treatment and care strategies into those for other mental and behavioural disorders4.identification of hazardous and harmful drinking in different settings 5.inclusion of alcohol in regular curricula for the training of health and social welfare professionals

Possible policies and interventions for implementation at the national level

6.brief intervention with at-risk drinkers 7.safe and effective management of alcohol withdrawal8.enhanced availability, accessibility and affordability to treatment services for groups of low socioeconomic status 9.support for mutual help or self-help activities and programmes 10.provision of technical guidance and mobilization of support from other sectors

The intellectual concept of a community response to alcohol problems and brief interventions emerged from England and Scotland during the 1970s and 1980s.

Shaw, S., Cartwright, A., Spratley, T. & Harwin, J. 1978. Responding to drinking problems. London, Croom Helm.

Anderson P., Bennison J., Orford J., Spratley T., Tether P., Tomson P. and Wilson D. Alcohol - A balanced view. London: Royal College of General Practitioners, 1986.

Heather, N., Campion, P.D., Neville, R.G. & Macabe, D. (1987) Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme) J Roy Coll Gen Prac 37:358-63.

Despite a long developmental period, conversing about hazardous and harmful alcohol consumption is not the norm in primary health care either locally or globally:

rather, conversation is neither desired nor required is a common response.


Does anyone know who said that?

The Sheliak:


What are the incentives for a good day in the life of a primary health care doctor,

and, how can science inform this?

1. Impact2. Worth3. Length4. Content5. Style6. Complexity7. Occurrence8. Cost9. Commonality10. Resonance

Some NICE results

Twenty seven systematic reviews and meta-analyses have been included in the review of reviews of the effectiveness of brief interventions

Evidence has been identified for the positive impact of brief interventions on alcohol consumption, mortality, morbidity, alcohol-related injuries, alcohol-related social consequences, and healthcare resource use.

Volume of consumptionefficacy trials

Volume of consumption effectiveness trials

Kaner et al 2007

On average, drinkers reduced their consumption from 320g/week (32 drinks) to 280g/week (28 drinks)

Treatment effectNo treatment effect

Proportion of heavy drinkers

Some NICE results

Brief interventions were shown to be effective in both men and women. Study populations were made up primarily of adult populations.

Socioeconomic status was not shown to influence the effectiveness of brief interventions.

Some NICE results

The relationship between the level of alcohol dependence and the effectiveness of brief interventions was unclear.

But, can we really be confident about global reach?

Not really!

Giving brief advice to at risk drinkers in Harare, ZimbabweAs part of the WHO project on identification and management of alcohol problems, 129 at risk drinkers were identified with screening questionnaires from primary health care centres, of whom 113 (92%) were followed up at six months. The 80 drinkers who received simple advice to reduce their drinking reduced their daily alcohol consumption from an average of 70g alcohol/day to 48g/day, whereas the control group who received no advice did not change their consumption (68g/day), anova, F=6.45, p<0.05.

Some NICE results

This review of the economic literature for screening and brief interventions is in line with previous reviews in the area.

That is, screening plus brief intervention is cost effective, but there is a desire for more research because considerable uncertainties exist, particularly regarding the cost effectiveness of specific types of brief intervention.

Some NICE results

All options are considered cost-effective according to NICE rules.

For GP registration, and males, the financial savings (burden of illness) outweigh the costs of delivering BI.

Next doctor’s registration Screens around 39% of the population, with 36% of

hazardous and harmful drinkers receiving a BI over 10 year period.

Next doctor’s appointment:Screens around 96% of the population (most in Year 1),

and 79% of hazardous and harmful drinkers receive a BI.

NICE results

Limited evidence suggests that even very brief interventions may be effective in reducing negative alcohol-related outcomes.

The benefit arising from increased exposure was unclear.

Longer BI did not achieve significant extra benefits in terms of reduced drinking (a small extra reduction of 1.1 grams/week for every extra minute of counselling)

NICE results

The benefit arising from the incorporation of motivational interviewing principles was unclear.

Based on studies - but, do we need to go beyond that: probably not really

Proportion of cardiovascular diseases due to alcohol (%) by drinks per day, ages 15-60 Proportion of cardiovascular diseases due

to alcohol (%) by drinks per day, ages 15-60 %

of h

yper

tens

ion

due

to a

lcoh

ol

Hypertension

If you have hypertension, and you drink 1 drink a day, there is a 12% chance that your hypertension is due to alcoholWhereas, if you drink 10 drinks a day, there is

a 75% chance that your hypertension is due to alcohol

Results

Low exposure: cut-off for intake set at <40 g alcohol / day

High exposure: cut off for intake set at >=40g/day, or diagnosed alcohol disorder (dependence, abuse, or "heavy drinking")

Exposure not clearly defined

0.1 1 10 100

Riekstina

Tekkel

Brown I

Spletter

Selassie

Mori

Rosenman

Moran

Lewis

Coker

Schluger

Shetty

Thomas

Buskin

Brown II

Lienhardt

Dong

Kim

Kolappan

Hemilä

Tocque

Crampin

Odds Ratio

Population attributable fraction - selected risk factors

Relative risk for active TB disease

Weighted prevalence (22 HBCs)

Population Attributable

Fraction

HIV infection 20.6/26.7* 1.1% 19%Malnutrition 3.2** 16.5% 27%Diabetes 3.1 3.4% 6%

Alcohol use (>40g / d)

2.9 7.9% 13%

Active smoking 2.6 18.2% 23%Indoor Air Pollution

1.5 71.1% 26%

1

1 1

P RRPAF

P RR

Sources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lönnroth et al. A consistent log-linear relationship between tuberculosis incidence and body-mass index. Submitted, 2009

Audit and feedback has not consistently been found to be effective.

A systematic review of 118 studies found for dichotomous outcomes the adjusted RD of compliance with desired practice varied from -0.16 (a 16% absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, interquartile range = 0.03–0.11).

For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10% absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, interquartile range = 0.05–0.37).

Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

Opinion leaders disseminating and implementing ‘best evidence’ is another potential strategy to bridge evidence–practice gaps.

A systematic review of 12 studies found a median adjusted risk difference (ARD) of 0.10 representing a 10% absolute decrease in noncompliance in the intervention group using the role of opinion leaders.

Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research, there is evidence that these channels of communication might have an important role in influencing the use of health-care interventions for behavioural change.

A systematic review of 20 studies included 15 which evaluated the impact of formal mass media campaigns, and five of media coverage of health-related issues.

Although the overall methodological quality of the individual studies was poor, all of the studies apart from one concluded that mass media was effective in influencing the use of health-care interventions in a positive direction.

One systematic review examined the impact of different payment systems on primary-care physician behaviour

Three payment systems were included: capitation (payment is made for every patient for whom care is provided), salary and fee for service (payment is made for every item of care provided).

There was some evidence that primary-care physicians provide a greater quantity of primary-care services under fee for service payment compared with capitation and salary, although long-term effects are unclear.

There was no evidence, however, concerning other important outcomes, such as patient health status, or comparing the relative impact of salary versus capitation payment.

A second systematic review looked at the effects of target payments on the behaviour of primary-care physicians (e.g. general practitioners and family physicians).

Under a target payments system a lump sum is paid to physicians who provide a certain quantity or level of care.

Two studies assessed the impact of target payments on immunisation rates. There was some evidence that target payments resulted in an increase in immunisations by primary-care physicians.

However, there was insufficient evidence to provide a clear answer as to whether target payments were an effective method of improving quality of care.

3 systematic reviews specifically focusing on the use of brief interventions in emergency care found limited evidence for the effectiveness of brief interventions in emergency care settings.

A further review presented inconclusive evidence of the effectiveness of brief interventions in inpatient and outpatient settings.

A systematic review of brief interventions in the workplace presented limited and inconclusive findings

0

500,000,000

1,000,000,000

1,500,000,000

2,000,000,000

2,500,000,000

3,000,000,000

0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000

Healthy years of life gained over 10 years

Inte

rven

tio

n c

ost

ove

r 10

yea

rs (

£)

Expansion Path

Current taxation

Increased taxation (Current + 25%)

Increased taxation (Current + 50%)

Reduced access to retail outlets (50% coverage)

Comprehensive advertising ban (80% coverage)

Brief advice in primary care (30% coverage)

Roadside breath-testing (RBT; 80% coverage)

Current Scenario - combination of interventions

Combination 1: Increased tax and RBT

Combination 2: Increased tax and Advertising Ban

Combination 3: Increased tax and Brief advice

Combination 4: Increased tax + Ad Ban + Reduced access

Combination 5: Increased tax + Brief Advice + Ad ban +Reduced access

Combination 6: Increased tax + Brief Advice + Ad ban +Reduced access + RBT

The Sheliak:


Conversation is neither desired nor required Peter Anderson Newcastle 8 October 2009.

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