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

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

2. Possible policies and interventions for implementation at the national level increasing capacity of health and social welfare systems establishing and maintaining a system of registration and monitoring integration of prevention, treatment and care strategies into those for other mental and behavioural disorders identification of hazardous and harmful drinking in different settings inclusion of alcohol in regular curricula for the training of health and social welfare professionals

3. Possible policies and interventions for implementation at the national level brief intervention with at-risk drinkers safe and effective management of alcohol withdrawal enhanced availability, accessibility and affordability to treatment services for groups of low socioeconomic status support for mutual help or self-help activities and programmes provision of technical guidance and mobilization of support from other sectors

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

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

6. 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.

7. 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.

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

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

10. Conversation is neither desired nor required Does anyone know who said that?

11. The Sheliak: Conversation is neither desired nor required

12. What are the incentives for a good day in the life of a primary health care doctor, and, how can science inform this?

13. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

14. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

15. 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.

16. Volume of consumption effectiveness trials Volume of consumption efficacy trials On average, drinkers reduced their consumption from 320g/week (32 drinks) to 280g/week (28 drinks) Treatment effect No treatment effect Kaner et al 2007

17. Proportion of heavy drinkers

18. 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.

19. Some NICE results The relationship between the level of alcohol dependence and the effectiveness of brief interventions was unclear.

20. But, can we really be confident about global reach? Not really!

21. 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.

22. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

23. 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.

24. 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.

26. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

27. 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.

28. 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)

29. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

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

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

32. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

33. Proportion of cardiovascular diseases due to alcohol (%) by drinks per day, ages 15-60 Hypertension % of hypertension due to alcohol If you have hypertension, and you drink 1 drink a day, there is a 12% chance that your hypertension is due to alcohol Whereas, if you drink 10 drinks a day, there is a 75% chance that your hypertension is due to alcohol

34. 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

35. Population attributable fraction - selected risk factors 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

36. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

37. 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).

38. 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.

39. 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.

40. 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.

41. 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.

42. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

43. 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).

44. 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.

45. 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.

46. 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.

47. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance

48. 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

49. Impact Worth Length Content Style Complexity Occurrence Cost Commonality Resonance