Nick Heather PhD

1
IMPLEMENTING BRIEF INTERVENTIONS IN PRACTICE
RECENT DEVELOPMENTS FROM SOUTH OF THE BORDER

• Nick Heather PhD
• Division of Psychology, Northumbria University
• Presentation at SHAAP One-day Conference,
• Edinburgh, 7/2/08

2
DEVELOPMENTS TO BE COVERED

• Cochrane Review of effectiveness of BI
• DH SIPS (Trailblazer) project
• Safe, Sensible, Social (renewed alcohol strategy)
  and other DH publications
• Roll-out of SBI across England
• NICE project
• National Audit Office review of treatment
  (including SBI)
• Social marketing campaign to reduce regular
  excessive drinking
• Inclusion of SBI in Quality and Outcomes
  Framework (QoF)?

3
COCHRANE REVIEW

• Effectiveness of brief alcohol interventions in
  primary care populations
• Eileen Kaner et al.
• http//www.mrw.interscience.wiley.com/cochrane/cls
  ysrev/articles/CD004148/frame.html

4
Has SBI been evaluated in ideal-world scenarios?

• Over recent years, there has been a growing view
  that most of the BI trials have been tightly
  controlled efficacy studies and not particularly
  representative of routine clinical practice

5
Is the evidence relevant to real world practice?

• Babor et al. 2006 There has been little
  systematic research to evaluate the effectiveness
  and cost of SBI under conditions approaching
  typical clinical conditions

6
Thus we decided to conduct a Cochrane
Collaboration review
7
Aim

• To assess the effectiveness of brief
  intervention, delivered in primary care (general
  practice or accident emergency settings), at
  reducing excessive alcohol consumption

8
Efficacy-Effectiveness

• Efficacy studies
• Tightly controlled protocols
• Ideal world atypical practice
• High internal validity limited applicability
• Effectiveness studies
• Pragmatic trial reflect the noise in practice
• Closer to the real world routine practice
• High external validity broader applicability

9
Conclusions

• In risky drinkers, BI reduces average weekly
  drinking by 41g (about 4-5 units per week)
  compared to controls
• As little as 5 minutes of structured advice
  enough
• No significant benefit of longer BI or EI
• BI is highly effective in men, we need more
  evidence in women
• There is no significant difference in outcomes
  between efficacy and effectiveness trials
• Most of the evidence is skewed to the
  effectiveness domain
• BI evidence is highly relevant to routine PHC

10
Screening and Interventions programme for
Sensible drinking (SIPS)

• Aka The Trailblazer project
• Alcohol Harm Reduction Strategy for England
  (2004) The DH will set up a number of pilot
  schemes by Q1/2005 to test how best to use a
  variety of models of targeted screening and brief
  intervention in primary and secondary healthcare
  settings, focusing particularly on value for
  money and mainstreaming (p.37)
• National research consortium with expertise in
  screening and brief interventions in the alcohol
  field
• Three different settings and three different
  regions of England as different tools may be
  necessary in different settings
• Funded by DH 3.2 million,

11
Research Project Group

• IOP
• Prof C Drummond (CI)
• Dr P Deluca
• Ms K Perryman
• St Georges
• Dr J Myles
• Dr A Oyefeso
• Mr T Phillips
• York
• Prof M Bland
• Mr S Coulton
• Prof C Godfrey
• Mr S Parrott

• Newcastle
• Prof E Kaner (DCI)
• Prof C Day
• Dr E Gilvarry
• Dr P Cassidy
• Dr D Newbury-Birch
• Prof Nick Heather
• Imperial College and St Marys Hospital
• Dr M Crawford
• Prof R Touquet
• Alcohol Concern
• Mr D Shenker

12
Aims

• To identify the most appropriate, acceptable and
  cost-effective
• screening methods for AUD
• brief intervention techniques for AUD
• methods of implementation
• Across 3 health and social care settings
• Primary Health Care (PHC)
• Accident Emergency Departments (AED)
• Criminal Justice Services (CJS)

13
Research Programme Design

• Three cluster randomised clinical trials (PHC,
  AED, CJS)
• Each with a purpose-designed project to assess
• Identification of the most effective screening
  approach (universal vs targeted and 2/3 screening
  tools)
• Identification of the most effective and
  cost-effective intervention approach
• Barriers and facilitators to implementation
• 6 month follow-up

14
Research Programme Design (cont.)

• To recruit patients from 24 PHC practices
• 9 AEDs
• 24 CJS
• Across North East, London, and South East Regions
  
• Aim to recruit over 2,600 patients across the
  three trials
• All health and CJS staff to receive training and
  support from research team
• Staff attitudes to be assessed to identify
  acceptability of implementing screening and brief
  interventions
• Programme duration 2 years

15
How will we assess implementation?

• Number screened, positives, received intervention
• Factors supporting implementation
• Factors impeding implementation
• Impact individual, service, costs and benefits
• Acceptability patient, practitioner,
  commissioner
• Sustainability

16
How will we assess effectiveness?

• Effectiveness of implementation
• Extent of screening and intervention activity
• Attitudes to SBI implementation
• Patient outcome measures
• Alcohol consumption
• Alcohol-related problems
• Health-related quality of life
• Health-related and wider societal costs

17
Toolkit

• Screening toolkit and practical guidance for each
  setting based on optimal tool/method
  (targeted/universal)/setting combination
• Intervention tools and implementation guidance
  based on findings tailored to each setting
• Training package for professionals in each
  setting
• Guide for commissioners of SBI services
• Resource website for providers

18
Progress

• Recruited 9 AEDs 24 PHC practices
• Ethics and RD approval
• Completed CJS pilot
• Site training in Jan 08
• Pilot study report
• Feasibility, validity of screening tools, staff
  attitudes
• Interim report 2008
• Final report 2009

19
PUBLICATIONS BY DEPARTMENT OF HEALTH

• Safe. Sensible. Social. (2007). Renewed National
  Alcohol Strategy to assess progress since AHRSE
  in 2004
• Strong on SBI (see pp. 36-39)
• Alcohol Misuse Interventions Guidance on
  Developing a Local Programme of Improvement (Nov
  2005)
• Alcohol Needs Assessment Research project (ANARP)
  covered SBI as well as specialist treatment
  (Nov 2005)
• Model of Care for Alcohol Misuse (June 2006)
• Review of Effectiveness of Treatment for Alcohol
  Problems (Raistrick, Heather Godfrey Nov 2006)

20
NATIONAL ROLL-OUT OF SBI

• Safe. Sensible. Social. The next steps in the
  National Alcohol Strategy
• states To support the roll-out and take-up of
  targeted identification and brief advice, a
  healthcare collaboration will be set up to
  disseminate the early results of the trailblazer
  research programmes and share learning on
  implementation.
• The DH will launch this support system by April
  2008. An event has taken place in December 2007
  to discuss the scale, scope and operation of this
  supportive effort.
• The DH brought together a range of PCT
  Commissioners, PCT Public Health officials, GPs,
  Practice Based Commissioners, Alcohol
  Co-ordinators and specialist alcohol treatment
  providers to discuss this effort.
• NB. Public Service Agreement (PSA) on Reduction
  of Alcohol-related Hospital Admissions

21
NICE guidance on brief interventions

• National Institute for Health Clinical
  Excellence is establishing a new Programme
  Development Group (PDG) on The prevention and
  Early identification of Alcohol Use Disorders in
  Adults and Adolescents
• To develop public health guidance in conjunction
  with the Centre for Clinical Practice
• Completion of project expected early 2010

22
NATIONAL AUDIT OFFICE STUDYReducing
alcohol-related harm

• NAO is an independent body that reports to
  Parliament on the economy, efficiency and
  effectiveness with which government departments
  have used their funding
• Current study will include all types of health
  service interventions on alcohol from brief
  advice provided by GPs to rehabilitation and
  detoxification services for dependent drinkers
• It will examine the extent of local service
  provision, access to services and the
  effectiveness of treatment
• Will report to Parliament in summer 2008

23
SOCIAL MARKETING STRATEGY FOR HARMFUL DRINKERS

• DH has commissioned the COI Strategic Consultancy
  to develop this strategy
• Harmful drinkers refers to middle-aged (35)
  regular excessive drinkers NOT young binge
  drinkers
• Hazardous drinkers will also probably be included
  in the strategy
• Likely elements of the strategy
• Attempt to reframe understandings of
  alcohol-related harm
• Provision of assisted self-help by a range of
  media (mail, phone, web-based)
• Encouragement of public to ask advice about
  drinking from primary health care
• Draft strategy to be ready May 2008

24
QUALITY AND OUTCOMES FRAMEWORK

• Is inclusion of alcohol in QoF the key to routine
  implementation of SBI?
• DH full supportive of this development but it is
  not their decision
• Two attempts so far have been unsuccessful
• But remember Robert the Bruce!