Transcript Slide 1

Conversation is neither desired nor required
Peter Anderson
Newcastle
8 October 2009
Possible policies and interventions for implementation at
the national level
1. increasing capacity of health and social welfare systems
2. establishing and maintaining a system of registration
and monitoring
3. integration of prevention, treatment and care strategies
into those for other mental and behavioural disorders
4. 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 withdrawal
8. 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.
Conversation is neither desired nor required
Does anyone know who said that?
The Sheliak:
Conversation is neither desired nor required
What are the incentives for a good day in the life
of a primary health care doctor,
and, how can science inform this?
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. 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 consumption
efficacy trials
Volume of consumption
effectiveness trials
On average, drinkers
reduced their consumption
from 320g/week (32 drinks)
to 280g/week (28 drinks)
No treatment effect
Treatment effect
Kaner et al 2007
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,
Zimbabwe
As 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.
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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.
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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)
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
% of hypertension due to alcohol
Proportion of cardiovascular diseases due
to alcohol (%) by drinks per day, ages 15-60
100
80
60
If you have hypertension, and you drink 1 drink
a day, there is a 12% chance that your
Whereas, if you drink 10 drinks a day, there is a
hypertension is due to alcohol
75% chance that your hypertension is due to
alcohol
40
20
0
1
2
3
4
5
6
7
8
Drinks per day (10g/drink)
9
10
Crampin
Tocque
Hemilä
Results
Kolappan
Kim
Dong
Lienhardt
Brown II
Buskin
Thomas
Shetty
Low exposure: cut-off for intake
set at <40 g alcohol / day
Schluger
Coker
Lewis
Moran
High exposure: cut off for intake
set at >=40g/day, or diagnosed
alcohol disorder (dependence,
abuse, or "heavy drinking")
Rosenman
Mori
Selassie
Spletter
Brown I
Tekkel
Exposure not clearly defined
Riekstina
0.1
10
1
Odds Ratio
100
Population attributable fraction
- selected risk factors
PAF 
P   RR  1
P   RR  1  1
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%
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
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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.
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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.
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
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
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
Expansion Path
3,000,000,000
Current taxation
Increased taxation (Current + 25%)
Intervention cost over 10 years (£)
2,500,000,000
Increased taxation (Current + 50%)
Reduced access to retail outlets (50% coverage)
2,000,000,000
Comprehensive advertising ban (80% coverage)
Brief advice in primary care (30% coverage)
1,500,000,000
Roadside breath-testing (RBT; 80% coverage)
Current Scenario - combination of interventions
Combination 1: Increased tax and RBT
1,000,000,000
Combination 2: Increased tax and Advertising Ban
Combination 3: Increased tax and Brief advice
500,000,000
Combination 4: Increased tax + Ad Ban + Reduced access
Combination 5: Increased tax + Brief Advice + Ad ban +
Reduced access
0
0
1,000,000
2,000,000
3,000,000
4,000,000
Healthy years of life gained over 10 years
5,000,000
Combination 6: Increased tax + Brief Advice + Ad ban +
Reduced access + RBT
1. Impact
2. Worth
3. Length
4. Content
5. Style
6. Complexity
7. Occurrence
8. Cost
9. Commonality
10. Resonance
The Sheliak:
Conversation is neither desired nor required