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Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse
Comparative Effectiveness Reviews, No. 64
Investigators: Daniel E Jonas, MD, MPH, James C Garbutt, MD, Janice M Brown, PhD, Halle R Amick, MSPH, Kimberly A Brownley, PhD, Carol L Council, MSPH, Anthony J Viera, MD, MPH, Tania M Wilkins, MS, Cody J Schwartz, MPH, Emily M Richmond, MPH, John Yeatts, MPH, Tammeka Swinson Evans, MOP, Sally D Wood, BA, and Russell P Harris, MD, MPH.
Author Information and AffiliationsStructured Abstract
Objectives:
To assess the effectiveness of screening followed by behavioral counseling for adolescents and adults with alcohol misuse in primary care settings.
Data Sources:
MEDLINE®, Embase®, the Cochrane Library, CINAHL®, PsycINFO®. Additional studies were identified from reference lists and technical experts.
Review Methods:
Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews. Quantitative analyses were conducted for outcomes when feasible and used subgroup analyses to explore whether results differed by intensity, sex, country, person delivering the counseling, or setting. Two reviewers graded the strength of evidence (SOE).
Results:
A total of 23 trials and six systematic reviews were included. The trials generally enrolled subjects with risky/hazardous drinking, usually excluding those with alcohol dependence. Among adults receiving interventions, consumption decreased by 3.6 drinks per week (weighted mean difference [WMD], 3.6, 95% confidence interval [CI], 2.4 to 4.8), 12 percent fewer subjects reported heavy drinking episodes (risk difference 0.12, 95% CI, 0.07 to 0.16), and 11 percent more subjects reported drinking beneath recommended limits (risk difference, 0.11, 95% CI, 0.08 to 0.13) over 12 months compared with controls (moderate SOE). Interventions improved some utilization outcomes (e.g., hospital days and costs: low SOE). For most health outcomes, available evidence either demonstrated no difference between interventions and controls (e.g., mortality: low SOE) or was insufficient to draw conclusions (e.g., accidents, injuries, alcohol-related liver problems: insufficient SOE). The best evidence of effectiveness is for brief (generally, 10 to 15 minutes) multicontact interventions.
For older adults, trials provided evidence of effectiveness, but effect sizes were smaller than for all adults. Trials enrolling college students provided evidence of effectiveness for reducing consumption and heavy drinking episodes (moderate SOE) and some accident, utilization, and academic outcomes (low, low, and moderate SOE, respectively). Studies in adults found benefits lasting several years; for college students, some benefits found at 6 months were no longer significantly different for intervention versus control groups at 12 months. The one study enrolling pregnant women did not find a significant difference for reduction in consumption. Evidence was insufficient for adolescent populations.
No studies randomized subjects, practices, or providers to screening and a comparator, and none of the included studies reported followup with referrals as an outcome.
Conclusions:
Behavioral counseling interventions improve behavioral outcomes for adults with risky/hazardous drinking. For most health outcomes, available evidence either found no difference between interventions and controls or was insufficient to draw conclusions. The best evidence of effectiveness is for brief multicontact interventions.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Introduction
- Key Question 1 What is the direct evidence that screening for alcohol misuse followed by a behavioral counseling intervention, with or without referral, leads to reduced morbidity, reduced mortality, or changes in other long-term outcomes?
- Key Question 2 How do specific screening modalities compare with one another for detecting alcohol misuse?
- Key Question 3 What adverse effects are associated with screening for alcohol misuse and screening-related assessment?
- Key Question 4a How do behavioral counseling interventions, with or without referral, compare with usual care for improving intermediate outcomes for people with alcohol misuse as identified by screening?
- Key Question 4b How do specific behavioral counseling approaches, with or without referral, compare with one another for improving intermediate outcomes for people with alcohol misuse as identified by screening?
- Key Question 5 What adverse effects are associated with behavioral counseling interventions, with or without referral, for people with alcohol misuse as identified by screening?
- Key Question 6 How do behavioral counseling interventions, with or without referral, compare with one another and with usual care for reducing morbidity, reducing mortality, or changing other long-term outcomes for people with alcohol misuse as identified by screening?
- Key Question 7 To what extent do health care system influences promote or hinder effective screening and interventions for alcohol misuse?
- Discussion
- References
- Appendix A Search Strategy
- Appendix B List of Excluded Studies
- Appendix C Evidence Tables
- Appendix D Quality Criteria
- Appendix E Quantitative Analysis Results
- Appendix F Screening Instruments
- Appendix G Strength of Evidence Tables
- Appendix H List of Abbreviations
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10056-I. Prepared by: RTI International–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC
Suggested citation:
Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond ER, Yeatts J, Swinson Evans T, Wood SD, Harris RP. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review No. 64. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-EHC055-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the author(s), who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products or actions may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
- Review Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force.[Ann Intern Med. 2012]Review Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force.Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, et al. Ann Intern Med. 2012 Nov 6; 157(9):645-54.
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