Presentation to Imperial College London Wednesday 10 th December 2014 Screening and brief intervention for alcohol use in general practice and the potential role of digital technologies in optimising delivery Paul Wallace Theme Director Primary Care, NIHR Clinical Research Networks Professor Primary Health Care (emeritus) General Practitioner (retired)
Professor of Primary Care (emeritus) GP Principal and Partner (retired) Director, NIHR Primary Care Research Network
Scope of the presentation To consider the scale of the problems due to alcohol misuse To review the role of alcohol screening and brief intervention (SBI) in general practice To consider the role of digital technologies is delivering SBI To present the international EFAR trials programme
Size of the problem The EU is the heaviest drinking region in the World Average per capita consumption of 12.5 litres per annum Average 3 drinks per day, and double the world average In the EU in 2004 ~ 95,000 men and ~ 25,000 women aged 15 and 64 years died of alcohol-attributable causes (11.8% of all deaths in this age category) Alcohol in EU consumption, harm and policy approaches. WHO Europe 2012
Alcohol is the leading risk factor for overall burden of disease among men aged 15 59 DALYs lost attributable to 10 leading risk factors, for the age group 15 59 years (2004) In 2004, 4.5% of the global burden of disease and injury was attributable to alcohol: 7.4% for men and 1.4% for women DALY=disability-adjusted life year WHO. Global status report on alcohol and health, 2011
Proportion of deaths within major disease categories attributable to alcohol in the EU for the group aged 15 64 years, 2004 Alcohol in EU consumption, harm and policy approaches. WHO Europe 2012
Current epidemic of liver disease in the UK
Clinician advice for behavioural change Clinicians are well placed to provide opportunistic counselling Patients consult their GP several times each year (in UK 5) Behavioural counselling by GPs demonstrated to be cost effective for and alcohol
Screening and Brief Intervention (SBI) in primary care settings Largest evidence base relates to preventive interventions Mainly use of brief alcohol interventions in primary care with hazardous and harmful drinkers who are not seeking treatment (generally because they are unaware of their alcohol-related risk or harm) Delivery by a range of practitioners has beneficial effectseffect size is greater when doctors are the deliverers Comprehensive reviews conducted for the NICE concluded that alcohol SBI is a highly cost-effective strategy for health sector organisations, especially primary care NICE=National Institute of Health and Clinical Excellence Alcohol in EU consumption, harm and policy approaches. WHO Europe 2012
Categories of alcohol use / misuse Alcohol Harmful*/ dependence Higher risk** Hazardous* / Increasing risk** Lower risk /abstinence WHO* / DH**
Standard drinks (units) Medium glass of wine, 175 ml @ 12% ABV = 2 250ml glass = 3 Small glass fortified wine 50ml = 1 Half pint ordinary strength beer - 3.5%. = 1 (Most lagers are 5% and = 1.5 A single measure of spirits 25ml = 1 (35ml also exists and = 1.5)
Screening instruments Bio-markers Questionnaires
Screening the AUDIT-C Questions Scoring system 0 1 2 3 4 Your score How often do you have a drink containing alcohol? Never Monthly or less 2 4 times per month 2 3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1 2 3 4 5 6 7 9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily Score of 3 OR More detailed assessment of drinking and related problems 6 or more drinks on one occasion Bush et al. Arch Intern Med 1998;158(16):1789 1795 Bradley et al. Alcohol Clin Exp Res 2007;31(7):1208 1217
AUDIT questionnaire (Alcohol Use Disorders Test) Designed to detect harmful/hazardous drinking 10 items on consumption, symptoms and consequences of alcohol use 92% sensitivity in primary care 94% specificity in primary care Saunders JB, Aasland OG, Babor TF et Al. Addiction 1993
Domains and item content AUDIT Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Scoring system 0 1 2 3 4 Never Monthly or less 2 4 times per month 2 3 times per week 4+ times per week 1 2 3 4 5 6 7 9 10+ Never Never Never Never Alcohol consumption Less than monthly Less than monthly Less than monthly Less than monthly Frequency Typical quantity Frequency of heavy drinking Monthly Monthly Monthly Weekly Dependence symptoms Weekly Impaired control Monthly Increased salience Weekly Morning drinking Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Your score How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor, or other health worker been concerned about your drinking or suggested that you cut down? Never Never No No Less than Daily or Monthly Weekly monthly almost daily Alcohol-related problems Less than monthly Monthly Guilt after drinking Weekly Blackouts Yes, Alcohol-related but not in injuries Other last concern year about drinking Yes, but not in the last year Daily or almost daily Yes, during the last year Yes, during the last year WHO (Babor et al. AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for use in primary health care.1989; Saunders et al. Addiction1993; 88(6):791 804)
Delivering brief advice: NICE guidance Brief advice to be given to everyone who scores as a risky or harmful drinker: Offer a session of structured brief advice on alcohol. If this cannot be offered immediately, offer an appointment as soon as possible thereafter NICE. Alcohol-use disorders preventing the development of hazardous and harmful drinking. Public health guidance, PH24. Issued: June 2010
What does brief advice look like? Brief advice should take 5 15 minutes and should: Use a recognised, evidence-based resource that is based on FRAMES principles F Feedback R A M E Responsibility Advice Menu Empathy S Self-efficacy Lead to a set of goals Review and extend, if necessary Miller and Sanchez 1993
The Stages of Change Model Precontemplation Relapse Change maintenance Contemplation Change instigation after Prochaska and Di Clemente 1994
Brief advice: decisional balance sheet Positives of reducing my drinking.. Less good things about reducing my drinking Positives of not reducing. Less good things about not reducing.
21 Brief advice: drink diaries
Alcohol Learning Centre The IBA pathway Not all risky drinkers will be suitable for IBA - heavy and dependent drinkers need referral to specialist services
www.healthierdrinkingchoices.org.uk
Conclusions: A significant reduction in weekly alcohol consumption between intervention and control conditions was demonstrated between 3 months and less than 12 months followup indicating esbi is an effective intervention. J Med Internet Res 2014;16(6):e142) doi:10.2196/jmir.3193
Why might digital have a place in the delivery of SBI in general practice? In primary care, <10% at risk drinkers are identified, and < 5% receive brief intervention A combination of factors are responsible for this know / do gap Lack of training and support Fear of compromising therapeutic relationship Time constraints Most people feel more secure interacting with a computer/online
The International EFAR trials programme Effectiveness of facilitated access to alcohol reduction websites Non inferiority RCTs of esbi vs face to face intervention Initial Italian trial developed with Piero Struzzo Subsequent multi-country study application for UK, Australia, Italy, Spain, conditionally funded by BUPA Trials in progress in Italy and Spain and in development in Australia and UK
Rationale for the EFAR trial Providing GP facilitated access to an alcohol reduction website for screening and brief intervention could be a promising alternative to the face-to-face brief intervention. There is growing patient access to the necessary technology by internet and/or mobile phone Evidence regarding the relative effectiveness of this approach limited.
What is GP facilitated access? GP facilitated access is: Active encouragement of patients by their general practitioner to access and engage with digitally mediated health interventions (internet or mobile phone)
GP facilitated access In the UK it is familiar to primary care and mental health professionals through the established model of providing facilitated access to computerised cognitive behavioural therapy programmes such as Beating the Blues and Fear Fighter.* * Department of Health. Improving Access to Psychological Therapies Implementation Plan: National guidelines for regional delivery. London: Department of Health; 2008.
Italy - the EFAR FVG project
EFAR: effectiveness of facilitated access to alcohol reduction websites EFAR FVG non-inferiority RCT of ebi vs face-toface intervention funded by Italian Ministry of Health run by Piero Struzzo in Friuli-Venezia- Giulia, Italy
BMJ Open 2013;3:e002304. doi:10.1136/bmjopen-2012-002304
Aim of the EFAR FVG study Overall: To evaluate whether online GP facilitated access to an alcohol reduction website for at-risk drinkers is as effective as face-to-face brief intervention conducted by GPs
The EFAR FGV trial key features Non-inferiority randomised controlled trial Participating GPs are all in the Italian Region of Friuli Venezia Giulia (FVG) GPs role is to actively promote the use of the alcohol screening component of the health website Ti Vuoi Bene? www.itatvb.it On-line consent, assessment, randomisation and follow-up Comparison is between face to face and online intervention for risky drinkers Effect size to be excluded: 10% difference Required sample size - 1000 patients per country
GP facilitated online recruitment via the Ti Vuoi Bene? brochure and website Active distribution by GPs of brochure with personalised log-in code Code provides access to www.itatvb.it with screening module using the AUDIT-C Cut point of 5 used to identify risky drinkers Those scoring at or above cut point invited to take part in study
Download your Doctor : digital generation of personal physician presence online Tailoring of messages to reflect organisational and personal identity Menu driven facility including: Photograph of GP/Practice Written messages from GP Audio/Video recorded messages option
Digitally mediated GP messaging with video
Stage1: Brochure distribution, online screening, consent, assessment, randomisation
Stage 2: Randomisation, follow-up and analysis
Where are we now? Main trial started 20. 01.2014 Recruitment completed 31.08.2014
EFAR FVG recruitment and follow up spread-sheet* *figures as of 7 th Nov 2014
Key findings from EFAR FVG Trial has recruited 753 patients GP recruitment rates variable (range 1-89 pts) ~ 50% of patients logged on after FA from their GP ~ 18% of patients screened positive ~ 90% of screen +ve patients provided consent & completed baseline assessment Majority of randomized patients either accessed online intervention or received face to face BI ~ 90% follow-up achieved at 3 months
Predictions.. If an appropriate balance can be identified between the use of digital and the personal engagement of the healthcare professional, it is likely that this approach will prove increasingly successful. Success will depend critically on our ability to assess the key elements contributing to both effectiveness and sustainability.
Variability in GP recruitment activity
Overall log-on, screening and randomisation
Online randomisation
Offer and delivery of face to face BI
Engagement with online intervention
3 month follow-up rates