Journal Club Alcohol, Other Drugs, and Health: Current Evidence May–June 2014

Featured Article Implementation of Screening and Brief Intervention with Fidelity in Trauma Centers: Challenging but Not Impossible Zatzick D, et al. Addiction. 2014;109:754–765.

Study Objective To determine whether a patient and provider targeted intervention would lead to higher quality alcohol screening and brief intervention (SBI) at a trauma center than routine mandated SBI. To determine whether patients who receive the intervention SBI experienced a reduction in their alcohol consumption compared to those who receive the routine mandated SBI.

4 Study Design Cluster randomized trial. Providers at the intervention site trauma centers (site n = 10, patient n = 409) received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions. Providers at the control sites (site n = 10, patient n = 469) implemented the SBI mandate without training enhancements. All providers’ MI skills were assessed at 6 and 12-month follow-up via SBI sessions with patient-actors. Patients (total n = 878): in-patients at trauma centers with and without traumatic brain injury (TBI) and positive blood-alcohol tests. All patients’ alcohol consumption was assessed at follow-up via the AUDIT.

5 Assessing Validity of an Article about Therapy Are the results valid? What are the results? How can I apply the results to patient care?

Are the Results Valid? Were patients randomized? Was randomization concealed? Were patients analyzed in the groups to which they were randomized? Were patients in the treatment and control groups similar with respect to known prognostic variables?

Are the Results Valid? (cont‘d) Were patients aware of group allocation? Were clinicians aware of group allocation? Were outcome assessors aware of group allocation? Was follow-up complete?

Were patients randomized? Yes. –Sites were randomized in a 1:1 ratio using a random number generator and were assigned by a blinded research coordinator. –Patients were blinded to site intervention or control group status.

Was randomization concealed? Yes. –The random number generation was performed by the investigation’s statistician and site group allocation was performed by a blinded research coordinator.

Were patients analyzed in the groups to which they were randomized? Yes. Providers and patients were analyzed in the groups to which they were randomized.

Were the patients in the treatment and control groups similar? Yes. –The sites were all teaching hospitals, had similar mean numbers of annual injury admissions, and of similar size. –Across groups, patients were an average age of 37 years; 62% were white; and 76% were men.

Were patients aware of group allocation? No. –Patients were blinded to whether they received SBI from a provider who had received the additional training or from one who did not.

Were clinicians aware of group allocation? Not stated.

Were outcome assessors aware of group allocation? No. Research assistants who performed follow-up patient interviews and coded interviews were blinded to group allocation.

Was follow-up complete? No. Approximately 72% of patients were assessed at 12 months.

What Are the Results? How large was the treatment effect? How precise was the estimate of the treatment effect?

How large was the treatment effect? Providers in the intervention group demonstrated significantly better MI skills than those in the control group based on their performance on the following domains of the motivational interviewing treatment integrity scale (MITI): –‘Global spirit’ (P = 0.03) –MI ‘adherent behaviors’ (P = ) –‘percentage open-ended questions’ (P = 0.006) –‘reflection-to-question ratio’ (P = 0.002) –‘complex reflections’ (P = ) Patients in the intervention group demonstrated an 8% reduction in the percentage of patients who met AUDIT criteria for hazardous drinking compared with controls over the course of a year.

How Can I Apply the Results to Patient Care? Were the study patients similar to the patients in my practice? Were all clinically important outcomes considered? Are the likely treatment benefits worth the potential harm and costs?

Were the study patients similar to those in my practice? Patients were English-speaking men and women ≥18 years old with intentional or unintentional injuries who had a positive blood alcohol test upon admission to the trauma center.

Were all clinically important outcomes considered? Yes.

Are the likely treatment benefits worth the potential harm and costs? Possibly. –Patients who received SBI from providers in the intervention group experienced a small but statistically significant reduction in alcohol consumption, particularly those without traumatic brain injury. –No harms were reported. –Costs were not assessed.