Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial.

0.61 MB·English

by  Kaner, Eileen

BMJ2013;346:e8501doi:10.1136/bmj.e8501(Published9January2013) Page1of14
Research
RESEARCH
Effectiveness of screening and brief alcohol
intervention in primary care (SIPS trial): pragmatic
cluster randomised controlled trial
OPENACCESS
EileenKanerprofessorofpublichealthresearch1,MartinBlandprofessorofhealthstatistics2,Paul
Cassidygeneralpractitioner3,SimonCoultonprofessorofhealthservicesresearch4,VeronicaDale
trial statistician2, Paolo Deluca trial manager5, Eilish Gilvarry consultant psychiatrist and honorary
professorofaddictionpsychiatry6,ChristineGodfreyemeritusprofessorofhealtheconomics2,Nick
Heather emeritus professor of drug and alcohol studies7, Judy Myles consultant psychiatrist8,
DorothyNewbury-Birchlecturerinpublichealth1,AdenekanOyefesohonoraryreaderandconsultant
clinical psychologist8, Steve Parrott health economics2, Katherine Perryman PhD student9, Tom
Phillips clinical doctoral research fellow10, Jonathan Shepherd professor of oral and maxillofacial
surgery11, Colin Drummond professor of addiction psychiatry5
1InstituteofHealthandSociety,NewcastleUniversity,NewcastleNE24AX,UK;2DepartmentofHealthSciences,UniversityofYork,UK;3Teams
FamilyPractice,Gateshead,UK;4CentreforHealthServiceStudies,UniversityofKent,Canterbury,UK;5NationalAddictionCentre,Instituteof
Psychiatry,King’sCollegeLondon,UK;6Northumberland,TyneandWearNHSFoundationTrust,Newcastle,UK;7DepartmentofPsychology,
FacultyofHealthandLifeSciences,NorthumbriaUniversity,UK;8DivisionofPublicHealthScienceandEducation,StGeorge’sUniversityofLondon,
UK;9GreaterManchesterCLAHRCPractitionertheme,UniversityofManchester,UK;10HumberMentalHealthandTeachingNHSTrust,Willerby,
UK;11ViolenceResearchGroup,CardiffUniversity,UK
Abstract lifestylecounselling.Deliveryofthepatientleafletandbriefadvice
ObjectiveToevaluatetheeffectivenessofdifferentbriefintervention occurreddirectlyafterscreeningandbrieflifestylecounsellingina
strategiesatreducinghazardousorharmfuldrinkinginprimarycare. subsequentconsultation.
Thehypothesiswasthatmoreintensiveinterventionwouldresultina MainoutcomemeasuresTheprimaryoutcomewaspatients’self
greaterreductioninhazardousorharmfuldrinking. reportedhazardousorharmfuldrinkingstatusasmeasuredbythealcohol
DesignPragmaticclusterrandomisedcontrolledtrial. usedisordersidentificationtest(AUDIT)atsixmonths.AnegativeAUDIT
result(score<8)indicatednon-hazardousornon-harmfuldrinking.
SettingPrimarycarepracticesinthenortheastandsoutheastof
SecondaryoutcomeswereanegativeAUDITresultat12months,
EnglandandinLondon.
experienceofalcoholrelatedproblems(alcoholproblemsquestionnaire),
Participants3562patientsaged18ormoreroutinelypresentingin
healthutility(EQ-5D),serviceutilisation,andpatients’motivationto
primarycare,ofwhom2991(84.0%)wereeligibletoenterthetrial:900
changedrinkingbehaviour(readinesstochange)asmeasuredbya
(30.1%)screenedpositiveforhazardousorharmfuldrinkingand756
modifiedreadinessruler.
(84.0%)receivedabriefintervention.Thesamplewaspredominantly
ResultsPatientfollow-uprateswere83%atsixmonths(n=644)and
male(62%)andwhite(92%),and34%werecurrentsmokers.
79%at12months(n=617).Atbothtimepointsanintentiontotreat
InterventionsPracticeswererandomisedtothreeinterventions,each
analysisfoundnosignificantdifferencesinAUDITnegativestatus
ofwhichbuiltonthepreviousone:apatientinformationleafletcontrol
betweenthethreeinterventions.Comparedwiththepatientinformation
group,fiveminutesofstructuredbriefadvice,and20minutesofbrief
Correspondence to: E Kaner [email protected]
Extra material supplied by the author (see http://www.bmj.com/content/346/bmj.e8501?tab=related#webextra)
PaT plot of procedures
Results of interaction tests
Mean alcohol problems questionnaire (APQ) score by intervention group
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RESEARCH
leafletgroup,theoddsratioofhavinganegativeAUDITresultforbrief screeningtest19oramodifiedsinglealcoholscreening
advicewas0.85(95%confidenceinterval0.52to1.39)andforbrief questionnaire),20andthreeinterventions(patientinformation
lifestylecounsellingwas0.78(0.48to1.25).Aperprotocolanalysis leaflet,fiveminutesofbriefadvice,and20minutesofbrief
confirmedthesefindings. lifestylecounselling).Targetedscreeningfocusedon
ConclusionsAllpatientsreceivedsimplefeedbackontheirscreening presentationslinkedtomentalhealth,gastrointestinalproblems,
hypertension,minorinjuries,andnewpatientregistrations.The
outcome.Beyondthisinput,however,evidencethatbriefadviceorbrief
screeningresultsarereportedindetailelsewhere.21Thispaper
lifestylecounsellingprovidedimportantadditionalbenefitinreducing
focusesonpatientleveloutcomesafterbriefalcoholintervention
hazardousorharmfuldrinkingcomparedwiththepatientinformation
ratherthantrialprocessmeasures.
leafletwaslacking.
TrialregistrationCurrentControlledTrialsISRCTN06145674.
Settings
Introduction
Weinitiallyrecruited24practicesacrossLondonandthesouth
eastandnortheastofEngland,plusfivestandbysitesincase
Internationalstudieshaveshownthat20-30%ofpatientswho
ofdropouts.Allpracticesdeliveredthefullrangeofgeneral
routinelypresentinprimarycarearehazardousorharmful
drinkers.1Hazardousdrinkingisarepeatedpatternofdrinking medicalservicesandcoveredarangeofurbanandruralareas,
thatincreasestheriskofphysicalorpsychologicalproblems,2 sociallydeprivedandaffluentcommunities,andculturally
diversepopulations.Recruitmentspanned15monthsfromMay
whereasharmfuldrinkingisdefinedbythepresenceofthese
problems.3Severalmeta-analyseshaveshownthatscreening 2008toJuly2009.Fifteenpracticescompletedtheirtarget
recruitmentof31patientsbutninepractices(sixinLondonand
usingshortquestionnairesfollowedbybriefintervention
threeinthenortheast)onlypartiallyrecruitedthistarget(three
(comprisingsimpleadviceorpsychologicalcounselling)
patientinformationleaflet,onebriefadvice,andfivebrief
significantlyreducesalcoholconsumptioninprimarycare
populations.4-8ACochraneCollaborationsystematicreviewof lifestylecounselling).Thuswesubsequentlyutilisedthefive
standbypractices.Inaddition,fivepracticesthathadcompleted
29primarycaretrialsreportedthatbriefinterventioninpatients
thefullrecruitmentagreedtobereallocatedtoamoreintensive
wasassociatedwithastatisticallysignificantreducedalcohol
interventionthantheiroriginalallocation.Thusweincluded34
consumptionof38gaweek(95%confidenceinterval23gto
practiceclustersinthefinalanalysis.
54g)atoneyearcomparedwithcontrolstypicallyreceiving
assessmentonly,treatmentasusual,orwritteninformation.8
Inclusion and exclusion criteria
GiventhatastandarddrinkunitintheUnitedKingdomcontains
8gofethanol,9thisisequivalenttoareductionof4or5units Weincludedpatientswhoscreenedpositiveforanalcoholuse
aweek.Nevertheless,briefalcoholinterventionisrarely disorderandwhowerealertandoriented,aged18ormore,
deliveredinpractice10andthisgapinimplementationhasbeen residentwithin20milesofthepractice,andabletounderstand
ascribedtoseverallimitationsinthecurrentevidence. Englishsufficientlytocompletestudyquestionnaires.We
Briefinterventiontrialshavebeencriticisedforbeingefficacy excludedpatientsalreadyinvolvedinanalcoholresearchstudy
studies(optimisinginternalvalidity)ratherthanpragmatic orwhowerespecificallyseekinghelpforalcoholproblemsand
trials.11Mosttrialshavealsofocusedonmiddleagedmale thosewhowereseverelyinjuredorunwell,hadaseriousmental
drinkers,withothergroupsunder-represented.812Moreover,the healthproblem,weregrosslyintoxicated,orhadnofixedabode.
optimalintensityofbriefinterventioniscurrentlyunclear.One
study8reportednosignificantadditionalbenefitoflonger Randomisation
interventionscomparedwithbriefones.However,although Asecureremoterandomisationservicecarriedout
threesystematicreviewsfoundabenefitofmotivational randomisation.Twentyfourallocationswereinitiallygenerated
interviewingcomparedwithnoinput(controls)inreducing foreachofthepossiblefactorialcombinationsofscreening
alcoholconsumption,theirconclusionsonitsimpactcompared approach,screeningtool,andintervention.Randomisationwas
withotheractiveinterventions,includinggivingadvice, stratifiedbygeographicalarea(northversussouth).Thestandby
differed.13-15Thusthepresenttrialoccurredinacontextwhere andreallocatedpracticesweresubsequentlyrandomlyallocated
briefinterventionwaswidelyregardedasbeingeffectiveat inasimilarmanner.
reducinghazardousandharmfuldrinking.Nevertheless,the
necessarylengthormodalityinputofbriefinterventionhasyet Consent
tobedetermined.Wecarriedoutapragmatictrialofthe
effectivenessofthreedifferentbriefinterventionstrategiesat Primarycarestaffinitiallyestablishedverbalconsentwith
reducinghazardousandharmfuldrinkinginprimarycare.This patientstocheckeligibilityforthetrial.Atthisstagethey
studywasoneofthreetrialsintheScreeningandIntervention collectedbasicpersonalinformationandscreenedthepatient
ProgrammeforSensibledrinking(SIPS)study.Thetwolinked usingthefastalcoholscreeningtest19ormodifiedsinglealcohol
trialswerebasedinemergencydepartments16andprobation screeningquestionnaire.20Patientswhoscreenedpositivewere
offices.17 theninvitedtoprovidewrittenconsentforthetrial.All
consentingpatientsenteredtheinterventionpartofthetrial.
Methods
Interventions
Detailsofthistrialprotocolhavebeenpublished.18Thetrial
Immediatelyafterthescreeningprocess(inthesame
incorporatedclusterrandomisationofpracticestoavoidtherisk
consultation),trialparticipantsreceivedashortassessmentof
ofcontaminationbetweenthetrialarms.Theoveralltrialhad
theirdrinkingbehaviour,andbriefinterventionwasdelivered
a2×2×2×3nestedfactorialdesignencompassinggeographical
accordingtotheinterventiontowhichthepracticehadbeen
area(northeastandsoutheastofEnglandandLondon),
randomised.Allinterventionmaterialsareavailablefromthe
screeningapproach(universalscreeningofallpatientsversus
studywebsite(www.sips.iop.kcl.ac.uk/pil.php).
targetedscreeningfocusedonpresentationswherealcoholwas
mostlikelytoberelevant),screeningtool(eitherthefastalcohol
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RESEARCH
Patientinformationleaflet—Patientsreceivedsimplefeedback providedtoclarifythesequenceandtimingofscreening,
ontheirscreeningoutcomeandapatientinformationleafletthat assessment,briefintervention,andfollow-upactivity(see
hadbeendevelopedbytheDepartmentofHealthinEngland supplementarydiagram1,PaTplot).Seventypercentoftarget
calledHowmuchistoomuch?(www.sips.iop.kcl.ac.uk/pil.php). patientrecruitmentoccurredwithinsixmonths,withthe
This16pageleafletdescribestheeffectsofalcoholonhealth remaining30%overninemonths.Owingtothisslow
andwellbeingandshowsthenumberofunitscontainedin recruitment,researchstaffwhohaddeliveredtraininginstudy
popularalcoholicdrinkstohelpthereaderunderstandhowmuch proceduressupportedscreeningandbriefinterventiondelivery
theyaredrinking.Thebackpageliststwointernethelpsites in10practicesandrecruited152patients,whichwas5%ofthe
plusdetailsofanationalDrinklinenumber.Theonly totalnumberoftrialparticipants.
modificationtothisleafletwastheadditionofanadhesivelabel
onthebackpagewithcontactdetailsoflocalalcoholtreatment Measures
agenciesrelevanttothepracticesetting.
Baseline
Briefadvice—Patientsreceivedfeedbackonscreeningandthe
Theprimaryoutcomewasdrinkingstatusatsixmonthsas
patientinformationleafletplusfiveminutesofstructuredbrief
measuredbythealcoholusedisordersidentificationtest
advicefrompracticestaffbasedontheHowmuchistoomuch?
(AUDIT,scorerange0-40),25whichhasbeenvalidatedforuse
briefinterventionprogramme.22Inadditiontoprovidingspecific
asanoutcomemeasureinprimarycare.26Ascoreof≥8onthis
detailsaboutthehealthandsocialconsequencesofhazardous
testindicateshazardousorharmfuldrinkingorthelikelihood
andharmfuldrinking,patientswereshownasexspecificgraph,
ofdependentdrinking,withasensitivityof92%andspecificity
whichindicatedthattheirdrinkingexceededthatofmostofthe
of94%.25Sincebriefinterventionsaimtoreducehazardousor
population,andalistofbenefitsthatwouldresultfromreduced
harmfuldrinking,theprimaryoutcomemeasurewasnegative
drinking.Thereafterpatientsweretakenthroughamenuof
statusonthetest(proportionofparticipantsscoring<8)atsix
techniquestohelpreducedrinkingandaskedtoconsidera
months.
personaltargetforanachievablereductionindrinking.
ParticipantsalsocompletedtheEuroQoltomeasurequalityof
Brieflifestylecounselling—Patientsreceivedfeedbackon
life,27ashortserviceusequestionnaire,28andamodified
screeningplusthepatientinformationleafletandstructured
readinessrulerwithonequestion(andfourresponsecategories)
briefadviceintheinitialconsultation.Theywerethenaskedto
tomeasurepatients’motivationor“readinesstochange”their
makeanappointmentforafollow-upconsultationwithintwo
drinkingbehaviour.29Theuseofsuchreadinesstochange
weeksfora20minutesessionofbrieflifestylecounselling.22
measureshasbeenrecommendedinclinicalpracticetohelp
Thecounsellingwasbasedonacondensedformofmotivational
tailorbriefinterventionsandalsopredictsubsequentdrinking
interviewingcalledhealthbehaviourchange.23Thepatientsfirst
outcomes.30
describedtheirtypicaldrinkingdayandthenratedthe
importanceofchangingtheirdrinkingandtheirconfidence
Follow-up
aboutchangingtheirdrinkingona10pointscale(whereahigher
numberindicatedgreaterimportanceorconfidenceandvice Atsixand12monthsafterrandomisationresearcherswhowere
versa).Thepractitionerthenworkedwiththeseratingsto blindedtotheallocatedinterventioncontactedtheparticipants
establishwhytheywereatthecurrentlevelandhowtheymight bytelephoneorpost.Researchersadministeredthesame
beincreasedtoahigherpoint,beforeelicitingbothprosand instrumentsasatbaselineplusthealcoholproblems
consofdrinkingandfinallyworkingthroughasixstepplanto questionnaire.31Ashortpatientsatisfactionquestionnaire32was
helpreducedrinkinglevels. alsoadministeredat12months.
Training and support Financial incentives
Implementationoftheprotocolinthispragmatictrialvaried Eachpracticereceived£3000tocoverstafftimeanddisruption.
acrosspracticesaccordingtotheirsize,levelofinterest,and Paymentswerestagedandoccurredaftertraining,oncompletion
availableresources.Practicebasedtrainingwasdeliveredto ofparticipantrecruitment,andattheendofdatacollection.
195people(includingallparticipatingclinicians)indesignated ModelledonsmokingcessationpaymentsintheQualityand
teammeetings.Thetrainingincludedgeneralinformationon OutcomesFramework,33screeningandbriefinterventionwas
alcoholepidemiologyandUKstandarddrinks,anintroduction incentivisedas£1perpatientscreened(€1.26or$1.85,all
tothetrialprotocol,demonstrationoftherelevantscreening conversionsat2008exchangerates),£8perbriefadvice,and
andbriefinterventionapproaches,androleplaytopractise £32perbrieflifestylecounselling.Eachpatientparticipant
delivery.Researchassociatesdeliveredtraininginthepatient receiveda£10vouchershortlyaftercompletingthebaseline
informationleafletandbriefadvicegroup.Analcoholhealth assessmentandateachfollow-upinterview.
workerwhowasexperiencedinalcoholcounsellingdelivered
thetraininginbrieflifestylecounselling.Inthisgroupbrief Sample size calculation
lifestylecounsellingwaspractisedwithtrainedactorsandtape
Acomprehensivemeta-analysis4suggestedaclinicallyimportant
recorded.Thecompetencyofcounsellingwascheckedusing
differenceinnegativestatusonAUDITbetweenbrief
thebehaviourchangecounsellingindex.24Onlypractitioners
interventionandcontrolsof13%(5%reductionincontrolsand
whoreachedarequiredstandard(agreedbyinter-raterconsensus
18%inbriefinterventionrecipients).Detectingthisdifference
betweenthreeindependentclinicalassessors)wereapproved
atthe5%significancelevelwith80%power(withatwosided
todeliverbrieflifestylecounsellinginthetrial.
test),required109patientspergroup(total327).Assuminga
losstofollow-upof25%,thesamplesizewasinflatedto145
Implementation
pergroup(total435).Toaccountforpotentialclustereffects
Amixtureofgeneralpractitionersandpracticecarenurses weusedanintraclasscorrelationcoefficientof0.04basedon
delivered95%ofscreeningandbriefinterventionactivityin ourexperienceofprimarycaretrials.34Assumingaclustersize
thistrial.Agraphicalsummaryofthetrialprocedureshasbeen of31patientsperpractice,thisinflatedthecalculationbya
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RESEARCH
factorof1.7.Hencewerequired248patientspergroup(total patientsreportedneveroronlysometimesthinkingabout
744),withanexpectationthatatleast558wouldbefollowed drinkingless.
upatsixmonths.
Primary outcome
Statistical analysis
TheproportionsofpatientswithanegativeAUDITstatus
Analysiswasbyintentiontotreat,withpatientsanalysedinthe increasedatsixmonthsinallthreeinterventions(fig2⇓).The
grouptowhichtheyhadbeenrandomised.Weusedlogistic differencesbetweentheinterventionswerenot,however,
regressiontoanalysetheprimaryoutcome,negativestatuson significant(table2⇓).Noneoftheinteractionstestedwere
AUDITatsixmonths.Includedinthemodelwerescreening significant(seesupplementarytableS1)sothemodelwithout
approach,screeningtool,andintervention,andthemodelwas interactionswasusedtoestimatethedifferencesbetween
adjustedforage,sex,andbaselineAUDITscore.Totake interventions.TheoddsratiosofhavinganegativeAUDIT
accountoftheclusterstudydesignweusedthe statusforbriefadvicecomparedwiththepatientinformation
Huber-White-sandwichestimator,robuststandarderrorsmethod. leafletwas0.85(95%confidenceinterval0.52to1.39)andfor
Asafactorialstudy,interactioneffectswereconsidered.Tothe brieflifestylecounsellingcomparedwiththepatientinformation
modelweindividuallyaddedthreetwo-wayinteractions, leafletwas0.78(0.48to1.25).Theprimaryoutcomewasnot
screeningapproach*tool,screeningapproach*intervention,and affectedbymissingdata(table3⇓).
screeningtool*interventionandcomparedtheresultwitha
modelwithoutinteractions.Iftheinteractionwasfoundtobe Secondary analyses
significantweincludeditinthefinalmodel.
At12monthstherewerenostatisticallysignificantdifferences
Datawerepresentedasoddsratiosandcorresponding95% betweenthethreeinterventionsintheproportionsofpatients
confidenceintervals.Wecarriedoutsecondaryanalysesusing withanegativeAUDITresult(table2).Comparedwiththe
appropriatemethodsfortheoutcomes(linear,logistic,orordinal patientinformationleafletintervention,at12monthstheodds
regression)controllingforthesamecovariatesastheprimary ratioofhavinganegativeAUDITresultwas0.91(0.53to1.56)
outcomeandadjustingfortheclusterednatureofthestudy. forbriefadviceand0.99(0.60to1.62)forbrieflifestyle
Interventionefficacywasalsoexploredinaperprotocol counselling.Aperprotocolanalysis,includingjustthosewho
analysis. receivedtheirallocatedtreatment,andananalysiscombining
Toassesstheimpactofmissingdataontheprimaryoutcome, themoreintensiveinterventions(briefadviceplusbrieflifestyle
wecarriedoutmultipleimputationusingtheICEprocedurein counsellingversuspatientinformationleaflet)alsoindicated
STATA.Wetestedseveralmodelsfortheprediction;thefinal nosignificantdifferencesbetweentheinterventionsatsixor12
modelusedAUDITnegativestatusatsixmonthsasthe months.
dependentvariable,baselineAUDITscore,screeningapproach, Inaddition,therewerenostatisticallysignificantdifferencesin
screeningtool,intervention,sex,andage.Aseriesof10 meanAUDITscorebyinterventionorovertime(table4⇓).At
imputationswasdone.WecombinedtheseusingtheMIcombine sixmonths,themeandifferencebetweenbriefadviceandthe
commandinSTATA.Theimputationconfirmedtheinitial patientinformationleafletwas0.06(−0.70to0.83)andbetween
analysiswhereonlythoseactuallyfollowedupwereincluded. brieflifestylecounsellingandthepatientinformationleaflet
was−0.38(−1.51to0.75).At12monthsthesemeandifferences
Results werelargerbutnotstatisticallysignificant.Comparedwiththe
patientinformationleaflet,themeandifferenceforbriefadvice
Of3562presentingpatients,2991(84.0%)wereeligiblefor
was−0.20(−0.83to0.43)andforbrieflifestylecounselling
screening;900(30.1%)ofthesepatientswereidentifiedas
was−0.25(−1.19to0.68).Theestimateswerederivedfrom
hazardousorharmfuldrinkers.Overall,756(84.0%)consented
modelswithoutinteractions.
toparticipateinthetrial;consentratesweresimilarbetween
Atsixmonthsthereweredifferencesinreportedreadinessto
thethreeinterventions(fig1⇓).Allparticipantsreceiveda
change(table5⇓),with32%(n=65)ofpatientsinthepatient
patientinformationleaflet,whereas99%(n=250)ofthose
informationleafletgroupreporting“tryingtocutdown”
allocatedtotheothertwointerventionsreceivedbriefadvice.
comparedwith34%(n=69)receivingbriefadviceand45%
However,just57%(n=143)ofrelevantpatientsreturnedand
(n=93)receivingbrieflifestylecounselling.Theexpected
receivedthebrieflifestylecounsellingintervention.
orderedoddsforbrieflifestylecounsellingcomparedwiththe
Atsixmonthsthefollow-uprateswere85%(patientinformation
patientinformationleafletincreasedby1.74(95%confidence
leaflet85%(n=212),briefadvice86%(n=215),andbrief
interval1.27to2.39,P=0.001)withashifttothenexthigher
lifestylecounselling85%(n=217))andat12months82%
category—thatis,agreaterreadinesstochange.Forbriefadvice
(patientinformationleaflet79%(n=197),briefadvice83%
comparedwiththepatientinformationleaflet,theexpected
(n=209),brieflifestylecounselling83%(n=211)).Follow-up
orderedoddsincreasedby1.37(0.95to1.98,P=0.095).A
ratesbetweentheinterventionsdidnotdiffersignificantly.
similarfindingoccurredat12months,with32%(n=61)ofthose
However,thosefollowedupatsixmonthshadlowermean
inthepatientinformationleafletgrouptryingtocutdown
baselineAUDITscoresthanthosenotfollowedup:12.4(SE
comparedwith37%(n=74)receivingbriefadviceand48%
0.25)v14.3(SE0.66).
(n=95)receivingbrieflifestylecounselling.Forbrieflifestyle
Theaverageageofparticipantswas45years,62%(n=756)of counsellingcomparedwiththepatientinformationleaflet,the
participantsweremen,92%(n=755)werewhite,34%(n=253) expectedorderedoddsincreasedby1.86(1.31to2.65,P=0.001).
hadattainedhigherdegreelevel,and34%(n=258)weresmokers Forbriefadvicecomparedwiththepatientinformationleaflet,
(table1⇓).Atbaseline82%(n=611)ofparticipantswere theexpectedorderedoddsincreasedby1.24(0.83to1.87,
identifiedashazardousorharmfuldrinkersbytheAUDIT,with P=0.293).
anaveragescoreof12.7(SD6.4).Reportedreadinesstochange
Participantswhoreceivedbrieflifestylecounsellingalso
variedacrossthethreeinterventions,although62%(n=465)of
reportedgreatersatisfactionthanthosewhoreceivedthepatient
informationleaflet(table6⇓)basedongeneralcommunication
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(meandifference0.13,95%confidenceinterval0.01to0.26) Intermsofpotentialweaknesses,sincedirectmonitoringofthe
andtheinterpersonalmannerofthecliniciandeliveringthe consultationswouldhaveunderminedthepragmaticnatureof
intervention(meandifference0.10,0.002to0.19).These thestudy,itwasdifficulttoascertaintheextenttowhichthe
differenceswerenotobservedbetweenbriefadviceandthe interventionsweredeliveredasintended.Moreover,trialstaff
patientinformationleafletinterventions. deliveredscreeningandbriefinterventiontoasmallproportion
ofpatients(5%)owingtoflaggingrecruitment.Itispossible
Interaction with earlier screening activity thatthelackofinterventiondifferencesmayhavebeendueto
unsuccessfulimplementationofthebriefinterventionprotocols
Atsixmonthstherewasasignificantinteractionbetweenbrief
bytheprimarycareclinicians.Thesecliniciansoftengiveadvice
interventionandearlierscreeningapproach,thereforetheresults
andlifestylecounsellinginotherareasofpracticeandthere
arepresentedassixseparategroups(seesupplementarytable
mayhavebeenunconscioususeoftheseskillswithpatients
2).Eachgroupwascomparedwiththereferencegroupofpatient
whowerenotintendedtoreceivetheminthistrial.Theissue
informationleaflet/universalscreening.Attheinitialfollow-up
ofinterventionfidelitywillbeexploredinanindepthqualitative
point,patientsinthebrieflifestylecounselling/universal
(interviewbased)processstudywithcliniciansfromthistrial,
screeninggroup(meandifference−0.78,95%confidence
whichoccurredafterpatientfollow-upwascompleted.
interval−1.53to−0.03)andthepatientinformation
leaflet/targetedscreeninggroup(meandifference−0.77,−1.42 Only57%ofpatientsinthebrieflifestylecounsellinggroup
to−0.12)hadsignificantlylowerscoresonthealcoholproblems actuallyreceivedtheintervention,whichcouldhavereduced
questionnaire.Buttheotherfourcombinationsofbrief itspotentialimpact.But,asthiswasapragmaticstudythislevel
interventionandscreeningapproachdidnotdiffersignificantly. ofreturntoasubsequentcounsellingsessionprobablyreflects
Furthermore,outcomesmeasuredbythealcoholproblems whatwouldhappeninusualpractice.Afurtherissueof
questionnaireat12monthsdidnotdiffersignificantly(see pragmatismwasourattempttomakebaselineassessmentas
supplementarytableS2). shortaspossible.Wewereawarethatextensivequestioning
aboutalcoholcouldhaveactedasaninterventioninitsown
Discussion right.Henceweusedthe10itemAUDIT(alcoholusedisorders
identificationtest)questionnairetoprovideourprimaryoutcome
Allpatientsinthistrialreceivedfeedbackontheirhazardous measure.26Althoughthistooldidnotallowdetailedmeasurement
orharmfuldrinkingstatusimmediatelyafterthescreening ofactualconsumptionlevels(intermsofstandarddrinkunits
process.Attwofollow-uppoints,however,briefadviceand dailyorweekly),itcapturedwideraspectsofalcoholrelated
brieflifestylecounsellingdidnotprovideastatistically riskandharmthroughitemsondrinkingquantity,frequency,
significantadditionalbenefitinreducinghazardousorharmful intensity,andnegativebehaviouralconsequences.
drinkingcomparedwiththeprovisionofapatientinformation
leaflet.Brieflifestylecounsellingsignificantlyincreased Relevance of the findings to the discipline
patients’motivationtoreducetheirdrinkingthroughapositive
Numeroussystematicreviewsandmeta-analyseshavenow
shiftinreadinesstochangecomparedwiththosereceivingthe
shownbenefitsofscreeningandbriefalcoholinterventionin
patientinformationleaflet.Moreover,thesepatientsalso
primarycarecomparedwitharangeofcontrolconditions
reportedgreatersatisfactionwiththebriefinterventionprocess
(typicallyassessmentonly,treatmentasusual,orwritten
thanthoseinthepatientinformationleafletgroup.However,
information).However,aconsistentfindinginthisdiscipline
nosignificantdifferencesbetweenthebriefinterventionswere
issignificantlyreducedalcoholconsumptioninbothintervention
foundforalcoholrelatedproblemsorhealthrelatedqualityof
andcontrolsgroups.36-38Oneexplanationforreduceddrinking
life.Thisstudythereforedoesnotsupporttheadditionaldelivery
inbothinterventionandcontrolgroupsisregressiontothemean,
offiveminutesofbriefadviceor20minutesofbrieflifestyle
inwhichextrememeasuresofbehaviourtendtoshifttoless
counsellingoverandabovethedeliveryoffeedbackon
extremepositionsfromonetimepointtoanother.39Wecannot
screeningplusapatientinformationleaflet.
fullydiscountthisexplanationforourfindings.However,we
thinkitunlikelysincelevelsofdrinkinginthistrial,asshown
Strengths and weaknesses of the study
bymeanAUDITscores,werenotparticularlyextreme.Indeed,
Thistrialwasalargepragmaticmulticentreevaluationof somepatientswereclosetothethresholdforhazardousdrinking.
screeningandbriefinterventionintypicalprimarycare Inaddition,thechangesovertimeinourcontrolconditionwere
conditions.Clusterrandomisationavoidedthepotentialproblems similartomeaneffectsizesreportedforbriefintervention.837
ofcontaminationbetweenthetrialarmsandthussubversionof Analternativeexplanationisthatourcontrolcondition,
thestudyprotocol.Fivepracticesdeliveredmorethanonebrief consistingofsimplefeedbackandwritteninformationabout
interventionbutonlyaftertheyhadsuccessfullycompleted alcohol,mayhavecontainedactivefactorsofbehaviour
recruitmentfortheinterventiontowhichtheyhadbeen change.40Indeedtwocontrolledtrialshavereportedsignificant
originallyallocated.Thesereallocatedpracticessubsequently clinicaleffectsofscreening41andassessmentalone42ondrinking
deliveredamoreintensivebriefinterventionapproachafter behaviour.Consequently,itislikelythatthecumulativeimpact
traininginthenewprocedure. ofscreening,assessment,simplefeedback,andthedeliveryof
Othermethodologicalstrengthsofthestudyweretheuseof writteninformationmayhaveoverwhelmedtheadditionalinput
remoterandomisationproceduresandvalidatedoutcome offiveminutesofstructuredbriefadvicebothintermsof
measuresofclinicalrelevance.Ratesofeligibilityandpatient elapsedtimeandthenumberofdistinctbehaviourchange
consenttothetrial(84%)werehigherthaninmostprevious techniquesused.43
similarstudies,35whichaddsweighttothegeneralisabilityof Toconclusivelydemonstratethatprovidingfeedbackplusa
theresearch.Furthermore,thestudyachieveditsexpected patientinformationleafletledtoreducedratesofhazardousand
samplesize,andpatientfollow-uprateswerehigherthan harmfuldrinking,ourtrialwouldideallyhavehadanadditional
anticipated(>80%)withnodifferentiallosstofollow-up nointerventionarm.However,inviewoftheextensiveevidence
betweenthethreeinterventions. supportingbriefinterventioneffectivenessatthetimeofthe
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RESEARCH
trial,ourcontrolconditionwasconsideredtobetheminimal Contributors:Alloftheauthorscontributedtothedesignand
ethicallyacceptableinputafterscreeningactivity. developmentofthistrialprotocol.CDwasthechiefinvestigatorofSIPS
andEKwasdeputychiefinvestigatorandleadfortheprimarycaretrial.
Implications for clinicians, service Expertiseonclinicalaspectsoftheresearchwasprovidedforprimary
commissioners, and policymakers carebyPCandJM,fornursingpracticebyTPandforpsychiatryCD
andEG.StatisticalinputwasprovidedbySC,VDandMB.Health
Thehighlevelsofconsenttothistrialandthehighratesof
economicsinputwasprovidedbyCGandSP.Trialconductanddelivery
screeningandimmediatedeliveryofbriefinterventionindicate
expertisewasprovidedbyPD,DNBandKP.Alcoholandpolicyexpertise
thatroutinelypresentingpatientsinprimarycarearewillingto
wasprovidedbyAOandDS.Briefinterventionexpertisewasprovided
receivefeedback,writteninformation,andadviceabouttheir
byCD,EK,NHandJS.EKwrotethefirstdraftofthepaperandall
drinkingbehaviour.Inaddition,thehighlevelsofpatient
authorscontributedtosuccessivedrafts.Allauthorsreadandapproved
satisfactionafterbriefinterventioninallthreeconditionssupport
thefinalmanuscript.
theacceptabilityofthistypeofinput.However,thesignificant
patientattritioninthebrieflifestylecounsellinggroupsuggests Funding:EKwaspartfundedbyFusetheCentreforTranslational
thattheremaybeabenefitofdeliveringbriefintervention ResearchinPublicHealth.FuseisaUKCRCPublicHealthResearch
directlyafterscreeningratherthandelayinguntilasubsequent CentreofExcellence,andfundingcomesfromtheBritishHeart
occasion.Inemergencycare,ithasbeenrecommendedthatthe Foundation,CancerResearchUK,EconomicandSocialResearch
timebetweenscreeningandbriefinterventionisminimisedand Council,MedicalResearchCouncil,andtheNationalInstituteforHealth
ideallyoccursonthesameday.44Indeeditislikelythatthe Research.ThisstudywasfundedbytheDepartmentofHealth.The
processofidentifyingandquantifyingalcoholrelatedriskor viewsexpressedhereindonotnecessarilyreflectthoseofthe
harmmaybea“teachablemoment”wherepatientshavea DepartmentofHealthortheNationalHealthServiceinEnglandand
heightenedreceptivitytotheideaofreducingtheirdrinking.44 Wales.
Competinginterests:AllauthorshavecompletedtheICMJEuniform
Nevertheless,inpatientswhoreturnedtoasubsequent
disclosureformatwww.icmje.org/coi_disclosure.pdf(availableon
consultationforbrieflifestylecounselling,thereweresignificant
requestfromthecorrespondingauthor)anddeclare:allauthorshad
positivechangesinmotivationtoreducedrinkingandinpatient
financialsupportfromtheDepartmentofHealthinEngland(Alcohol
satisfactionlevels.Consequently,itispossiblethatwhereas
PolicyUnit)forthesubmittedwork;nofinancialrelationshipswithany
mosthazardousandharmfuldrinkersinprimarycarerequire
organisationsthatmighthaveaninterestinthesubmittedworkinthe
minimalinputafterscreening,theremaybeagroupofpatients
previousthreeyears;nootherrelationshipsoractivitiesthatcouldappear
whowouldvalueandbenefitfromadditionalsupport.Hencea
tohaveinfluencedthesubmittedwork.
steppedcareapproachmightbehelpfulinthisarea.Herethe
leastintensive(lesscostly)interventionisusedwithmost Ethicalapproval:Thisstudyreceivedmulticentreethicalapproval
patientswhopresentwithalcoholrelatedriskorharm,and (06/MRE02/90)pluslocalagreementfromallrelevantlocalresearch
furtherinterventionisreservedforpatientswhodonotrespond ethicscommittees.Researchgovernanceapprovalwasgrantedbyall
orwhoaskformoresupporttohelpreducetheirdrinking relevantprimarycaretrusts.Theresearchwasdoneinaccordancewith
behaviour.Apreviousstudyfoundthatasteppedcarealcohol theHelsinkideclaration.
interventionwasmorecosteffectivethanaminimalintervention Datasharing:Noadditionaldataavailable.
inprimarycare.34Thisapproachwasalsorecommendedinrecent
NationalInstituteforHealthandClinicalExcellenceguidelines 1 FunkM,WutzkeS,KanerE,AndersonP,PasL,McCormickR,etal.Amulticountry
controlledtrialofstrategiestopromotedisseminationandimplementationofbriefalcohol
onthepreventionofalcoholproblemsinadultsandyoung
interventioninprimaryhealthcare:findingsofaWorldHealthOrganizationcollaborative
people.45 study.JStudAlcohol2005;66:379-88.
2 SaundersJB,LeeNK.Hazardousalcoholuse:itsdelineationasasubthresholddisorder,
Finally,giventheextensivepublishedevidenceonthe andapproachestoitsdiagnosisandmanagement.ComprPsychiatry2000;41:95-103.
effectivenessofscreeningandbriefinterventioninreducing 3 WorldHealthOrganization.Internationalclassificationofdiseases.10threvision.WHO,
1992.
hazardousandharmfuldrinking,thecaseforitswider
4 MoyerA,FinneyJW,SwearingenCE,VergunP.Briefinterventionsforalcoholproblems:
implementationinprimarycareisstrong.Regardingthe ameta-analyticreviewofcontrolledinvestigationsintreatment-seekingand
non-treatment-seekingpopulations.Addiction2002;97:279-92.
necessarylevelofinput,ourfindingsconfirmtheconclusion
5 BallesterosJA,DuffyJC,QuerejetaI,ArinoJ,Gonzalez-PintoA.Efficacyofbrief
ofaCochraneCollaborationsystematicreviewthatlonger(more interventionsforhazardousdrinkersinprimarycare:systematicreviewandmeta-analysis.
intensive)briefinterventionsaddnosignificantadditional Alcohol,ClinExpRes2004;28:608-18.
6 BertholetN,DaeppenJ-B,WietlisbachV,FlemingM,BurnandB.Briefalcoholintervention
benefitovershorterinputinprimarycare.8However,thisreview inprimarycare:systematicreviewandmeta-analysis.ArchInternMed2005;165:986-95.
containedjustonetrial,basedinFinland,whichdirectly 7 WhitlockEP,PolenMR,GreenCA,OrleansT,KleinJ.Behavioralcounselinginterventions
inprimarycaretoreducerisky/harmfulalcoholusebyadults:asummaryoftheevidence
comparedthreedifferingintensitiesofbriefintervention. fortheUSPreventiveServicesTaskForce.AnnInternMed2004;140:557-68.
Equivalentoutcomeswerereportedforwomen46andmen47who 8 KanerE,BeyerF,DickinsonH,PienaarE,CampbellF,SchlesingerC,etal.Effectiveness
ofbriefalcoholinterventionsinprimarycarepopulations.CochraneDatabaseSystRev
receivedsimplefeedbackcomparedwiththreeorsevenbrief
2007;(2):CD004148.
interventionsessions.However,thisfindingwasattributedto 9 MillerW,HeatherN,HallW.Calculatingstandarddrinkunits:internationalcomparisons.
BrJAddict1991;86:43-7.
afailuretosuccessfullyimplementthemoreintensivebrief
10 KanerE.Briefalcoholintervention:timefortranslationalresearch.Addiction
interventionsinroutinepracticeratherthanthemeritofsimple 2010;105:960-1.
feedbackinitself.Thecurrentstudystronglysuggeststhat 11 BaborTF,Higgins-BiddleJC,DauserD,BurlesonJA,ZarkinGA,BrayJ.Briefinterventions
forat-riskdrinking:patientoutcomesandcost-effectivenessinmanagedcareorganizations.
screeningfollowedbysimplefeedbackandwritteninformation AlcoholAlcohol2006;41:624-31.
maybethemostappropriatestrategytoreducehazardousand 12 EdwardsAGK,RollnickS.Outcomestudiesofbriefalcoholinterventioningeneralpractice:
theproblemoflostsubjects.Addiction1997;92:1699-704.
harmfuldrinkinginprimarycare.
13 BurkeBL,ArkowitzH,MencholaM.Theefficacyofmotivationalinterviewing:a
meta-analysisofcontrolledclinicaltrials.JConsultClinPsychol2003;71:843-61.
14 LundahlB,KunzC,BrownellC,TollefsonD,BurkeB.Ameta-analysisofmotivational
ThispaperispublishedonbehalfoftheSIPSprogrammeresearch interviewing:twentyfiveyearsofempiricalstudies.ResSocWorkPract2010;20:137-60.
group.Afulllistoftheresearchgroupmembersisavailableathttp:// 15 VasilakiE,HosierS,CoxW.Theefficacyofmotivationalinterviewingasabriefintervention
forexcessivedrinking:ameta-analyticreview.AlcoholAlcohol2006;41:328-35.
sips.iop.kcl.ac.uk/contactus.php.WethankRuthMcGovernandRobert
16 CoultonS,BlandM,CassidyP,DelucaP,DrummondC,GilvarryE,etal.Screeningand
Pattonforrefiningthestudyinterventionsandsupportingthe briefinterventionforhazardousandharmfulalcoholuseinaccidentandemergency
departments:arandomisedcontrolledtrialprotocol.BMCHealthServRes2009;9(14).
implementationofthistrial.
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RESEARCH
Whatisalreadyknownonthistopic
Around20-30%ofpatientswhoroutinelypresentinprimarycarearehazardousorharmfuldrinkers
Briefalcoholinterventioninprimarycarecansignificantlyreducehazardousandharmfuldrinking
However,theoptimalintensityofbriefinterventioninputiscurrentlynotclear
Whatthisstudyadds
Briefadviceandbrieflifestylecounsellingdidnotprovideastatisticallysignificantbenefitinreducinghazardousorharmfuldrinking
comparedwithapatientinformationleaflet
Screeningfollowedbysimplefeedbackandwritteninformationmaybethemostappropriatestrategytoreducehazardousandharmful
drinkinginprimarycare
17 Newbury-BirchD,BlandM,CassidyP,CoultonS,DelucaP,DrummondC,etal.Screening 35 BeichA,ThorsenT,RollnickS.Screeninginbriefinterventiontrialstargetingexcessive
andbriefinterventionsforhazardousandharmfulalcoholuseinprobationservices:a drinkersingeneralpractice:systematicreviewandmeta-analysis.BMJ2003;327:536-40.
clusterrandomisedcontrolledtrialprotocol.BMCPublicHealth2009;9:418. 36 BernsteinJ,BernsteinE,HeerenT.Mechanismsofchangeincontrolgroupdrinkingin
18 KanerE,BlandM,CassidyP,CoultonS,DelucaP,DrummondC,etal.Screeningand clinicaltrialsofbriefalcoholintervention:implicationsforbiastowardsthenull.Drug
briefinterventionsforhazardousandharmfulalcoholuseinprimarycare:acluster AlcoholRev2010;29:498-507.
randomisedcontrolledtrialprotocolBMCPublicHealth2009;9:287. 37 JenkinsRJ,McAlaneyJ,McCambridgeJ.Changeovertimeinalcoholconsumptionin
19 HodgsonR,AlwynT,JohnB,ThomB,SmithA.TheFASTalcoholscreeningtest.Alcohol controlgroupsinbriefinterventionstudies:systematicreviewandmeta-regressionstudy.
Alcohol2002;37:61-6. DrugAlcoholDepend2009;100:107-14.
20 CanagasabyA,VinsonDC.Screeningforhazardousorharmfuldrinkingusingoneor 38 McCambridgeJ,KypriK.Cansimplyansweringresearchquestionschangebehaviour?
twoquantity-frequencyquestions.AlcoholAlcohol2005;40:208-13. systematicreviewandmetaanalysesofbriefalcoholinterventiontrials.PLOSOne
21 CoultonS,DrummondC,DelucaP,KanerE,Newbury-BirchD,PerrymanK,etal.The 2011;6:e23748.doi:10.1371/journal.pone.0023748.
utilityofdifferentscreeningmethodstodetecthazardousdrinkingandalcoholusedisorders 39 BlandJ,AltmanD.Regressiontowardsthemean.BMJ1994;308:1499.
inthescreeningandinterventionprogrammeforSensibledrinking(SIPS)programme. 40 MichieS,PrestwichA,deBruinM.Importanceofthenatureofcomparisonconditionsfor
AddictSciClinPract2012;7(Suppl1):A83. testingtheory-basedinterventions:reply.HealthPsychol2010;29:468-70.
22 HeatherN,GirvanM,KanerE,CassidyP.Implementingscreeningandbriefalcohol 41 McCambridgeJ,DayM.Randomizedcontrolledtrialoftheeffectsofcompletingthe
interventioninpilotgeneralpracticesintheTyneandWearHealthActionZone(final AlcoholUseDisordersIdentificationTestquestionnaireonself-reportedhazardousdrinking.
report).AfinalreportonresearchfundedbytheTyneandWearHealthActionZone. Addiction2007;103:241-8.
NorthumbriaUniversity,2008. 42 KypriK,LangleyJD,SaundersJB,Cashell-SmithML.Assessmentmayconcealtherapeutic
23 RollnickS,MasonP,ButlerC.Healthbehaviourchange:aguideforpractitioners.Churchill benefit:findingsfromarandomisedcontrolledtrialforhazardousdrinking.Addiction
Livingstone,1999. 2007;102:62-70.
24 LaneC.TheBehaviourChangeCounsellingIndex(BECCI)Scale.UniversityofWales, 43 AbrahamC,MichieS.Ataxonomyofbehavourchangetechniquesusedininterventions.
2002. HealthPsychol2008;27:379-87.
25 SaundersJB,AaslandOG,BaborTF,DeLaFuenteJR,GrantM.Developmentofthe 44 WilliamsS,BrownA,PattonB,CrawfordM,TouquetR.Thehalf-lifeofthe‘teachable
AlcoholUseDisordersIdentificationTest(AUDIT):WHOCollaborativeProjectonEarly moment’foralcoholmisusingpatientsintheemergencydepartment.DrugAlcoholDepend
DetectionofPersonswithHarmfulAlcoholConsumption.Addiction1993;88:791-804. 2005;77:205-8.
26 BradleyKA,McDonellMB,BushK,KivlahanDR,DiehrP,FihnSD.TheAUDITalcohol 45 NationalInstituteforHealthandClinicalExcellence.Alcohol-usedisorders—preventing
consumptionquestions:reliability,validity,andresponsivenesstochangeinoldermale thedevelopmentofhazardousandharmfuldrinking.2010.http://guidance.nice.org.uk/
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27 RabinR,CharroF.EQ-5D:ameasureofhealthstatusfromtheeuroqolgroup.AnnMed 46 AaltoM,SaksanenR,LaineP,ForsstromR,RaikaaM,KivilutoM,etal.Briefintervention
2001;33:337-43. forfemaleheavydrinkersinroutinegeneralpractice:a3-yearrandomizedcontrolled
28 UKATTResearchTeam.Costeffectivenessoftreatmentforalcoholproblems:findings study.AlcoholClinExpRes2000;24:1680-6.
oftherandomisedUKalcoholtreatmenttrial(UKATT).BMJ2005;331:544. 47 AaltoM,SeppaK,MattilaP,MustonenH,RuuthK,HyvarinenH,etal.Briefintervention
29 HeatherN,SmailesD,CassidyP.DevelopmentofaReadinessRulerforusewithalcohol formaleheavydrinkersinroutinegeneralpractice:athreeyearrandomizedcontrolled
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RESEARCH
Tables
Table1|Personalandbaselinevariablesbyinterventionallocation.Valuesarenumbers(percentages)unlessstatedotherwise
Characteristics Patientinformationleaflet Briefadvice Brieflifestylecounselling Total
Percluster: n=14 n=11 n=19 n=44
Median(interquartilerange)Noofpatients 13.5(2-32) 31(3-34) 6(1-47) 12(1-47)
Median(interquartilerange)age(years) 47.4(36.0-60.8) 40.2(31.7-53.6) 42.5(32.0-67.7) 43.4(31.7-67.7)
Median(interquartilerange)%male 61.8(0-100) 70.0(33-75) 55.3(33-100) 61.8(0-100)
Median(interquartilerange)AUDITscore 11.8(8.3-16.1) 13.0(9.4-15.5) 13.0(8.5-24.0) 12.5(8.3-24.0)
Patients: n=251 n=251 n=254 n=756
Mean(SD)age(years) n=251,48.2(17.0) n=251,40.4(16.4) n=253,44.9(14.8) n=755,44.5(16.4)
Mean(SD)EQ-5D* n=243,0.78(0.27) n=247,0.84(0.24) n=246,0.81(0.26) n=736,0.81(0.26)
Mean(SD)AUDITscore n=245,12.3(6.4) n=245,12.6(5.9) n=244,13.1(6.9) n=734,12.7(6.4)
Men 163/251(64.9) 155/251(61.8) 152/254(59.8) 470/756(62.2)
White 215/251(86) 239/251(95) 238/253(94) 697/755(91.7)
Educationafterage16 118/250(47) 159/251(63) 137/251(55) 414/752(55.1)
Degreeorequivalentprofessionalqualification 63/249(25) 111/250(44) 79/249(32) 253/748(33.8)
Single 60/251(24) 98/250(39) 69/252(27) 227/753(30.1)
Smokers 83/251(33) 93/251(37) 82/253(32) 258/755(34.2)
Readinesstochange: n=250 n=248 n=247 n=745
Neverthinkaboutdrinkingless 66(26.4) 67(27.0) 64(25.9) 197(26.4)
Sometimesthinkaboutdrinkingless 89(35.6) 100(40.3) 79(32.0) 268(36.0)
Havedecidedtodrinkless 26(10.4) 34(13.7) 36(14.6) 96(12.9)
Alreadytryingtocutdown 69(27.6) 47(19.0) 68(27.5) 184(24.7)
AUDIT=alcoholusedisordersidentificationtest.
*Measureofhealthutility.
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RESEARCH
Table2|Proportionsofparticipantswithnegativealcoholusedisordersidentificationtestresultatbaselineandsixand12monthfollow-up.
Valuesarenumbers(percentages)unlessstatedotherwise
Oddsratio*(95%CI),Pvalue
Brieflifestyle
Patient Brieflifestyle Briefadvice/patient counselling/patient
Timepoint informationleaflet Briefadvice counselling informationleaflet informationleaflet ICC(SE)
Baseline 50/247(20) 51/249(20) 37/249(15) — — 0.02(0.02)
6months 72/202(36) 61/208(29) 59/205(29) 0.85(0.52to1.39),0.51 0.78(0.48to1.25),0.30 0.03(0.02)
12months 74/190(39) 72/205(35) 72/203(36) 0.91(0.53to1.56),0.73 0.99(0.60to1.62),0.96 0.04(0.02)
ICC=intraclasscorrelationcoefficient.
*Oddsratiofromlogisticregressionmodelsadjustingforscreeningapproach,screeningtool,age,sex,andbaselinealcoholusedisordersidentificationtestscore.
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RESEARCH
Table3|Summaryofsensitivityofprimaryoutcomeresultstomissingdata(statusfromalcoholusedisordersidentificationtestatsix
months)
Oddsratio(95%CI),Pvalue
Analysis Briefadvice/patientinformationleaflet Brieflifestylecounselling/patientinformationleaflet
Completecase 0.85(0.52to1.39),0.51 0.78(0.48to1.25),0.30
Multipleimputationestimate 0.89(0.53to1.50),0.66 0.78(0.50to1.22),0.28
Perprotocolanalysis 0.85(0.52to1.38),0.51 0.93(0.50to1.72),0.81
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