Design

1. Work in progress Started February 2001 Due to complete August 2003 AERC funded project Reducing alcohol misuse in patients attending an Accident & Emergency department Mr Robert Patton, Dr Mike Crawford, Professor Robin Touquet1 Departments of Psychological Medicine and 1A&E Medicine, St Mary’s Hospital, Paddington There is good evidence to suggest that brief interventions aimed at helping those who misuse alcohol can lead to reduced alcohol consumption (Wilk et al, 1997) and that such interventions are cost effective (Fleming et al, 2000). However this evidence comes mainly from patients treated in primary care and general hospital settings (Chick et al, 1985; Wallace et at, 1988; WHO, 1996). The prevalence of alcohol problems is higher in Accident & Emergency departments than among those in general practice and the majority who attend AED with alcohol related problems are not admitted to hospital (Pirmohamed et al, 2000). Interventions for reducing alcohol misuse may be more successful when they are provided at a time of illness, injury or crisis (Booth and Grosswieler, 1978). The possibility of using an incident that leads to contact with emergency hospital services, together with the high prevalence of alcohol misuse among those attending the AED, may make accident and emergency based interventions particularly effective. Objectives Measures Examination of the effects at one year of referral for brief intervention by an Alcohol Health Worker (AHW) on levels of alcohol consumption, psychiatric morbidity and quality of life among patients attending an Accident & Emergency department (AED). Alcohol consumption PAT, Form 90 AQ Psychiatric morbidity GHQ-12 Quality of life EQ-5D Economic evaluation Health Utilisation Questionnaire Definition of hazardous drinking Paddington Alcohol Test Patients who consumed eight units once a week or more (male) or six units once a week or more (female), or any patient who declared that their attendance in the AED was alcohol-related regardless of the volume / frequency of consumption. • Developed by Smith et al (1996) the PAT has been designed to identify hazardous drinkers presenting to the AED. • Instead of screening all patients, clinicians are asked to assess those who present with one or more of the Top Ten conditions found to be associated with hazardous drinking (Huntley et al, 2001). • It has a sensitivity of 70.0%, a specificity of 84.5% and can be administered in under one minute. Design Randomised controlled trial. Follow-up data collected on a cohort of non treatment-seeking hazardous drinkers at six and twelve months following their initial presentation to the AED. Methods Over a twelve month period three consecutive teams of thirteen Senior House Officers screened patients presenting to the AED of St Mary’s Hospital (London) using the Paddington Alcohol Test (PAT). All those identified as hazardous drinkers were told that they were drinking at a level that might be harmful to their health, and asked if they would accept help aimed at assisting them to reduce their alcohol intake. Patients who met the inclusion criteria and consented to participate were randomised to either the Treatment (ET) or Control (CT) condition. In the ET patients were given a card detailing the time and place of an appointment to discuss their alcohol consumption with an AHW and a copy of the leaflet ‘Think About Drink’. Those randomised to the CT were given the leaflet, but no appointment. At baseline, demographic details were collected together with information about participants’ current levels of alcohol consumption. At six months a telephone interview was conducted to assess alcohol consumption and psychiatric morbidity. At twelve months alcohol consumption, and quality of life were recorded. At both the six and twelve months follow-up, participants completed an economic evaluation that examined their employment / benefits situation, use of health and social services and interaction with the criminal justice system. Results 5250 Patients were screened in the AED with 1160 identified as hazardous drinkers, 753 of whom were willing to accept advice (65%). Of these 659 consented to participate and were randomised. Most participants were male (78%) with an average age of 44 years. At baseline the volume of alcohol consumed in a single session ranged from 3 to 94 units, with a median of 17.5 units. 89% of our sample were consuming twice the DoH recommended limits, with 49% indicating that their visit to the AED was related to alcohol consumption. The six months follow-up has been completed with data collected on 78% of participants. Twelve month data collection is ongoing, with data on 72% of participants having been collected. Overall 13% of participants have been lost to follow-up. Conclusions This pragmatic study should provide evidence of the worth of an opportunistic Screening and Brief Intervention programme applied in the AED and offer guidance on the conduct of psychological research within busy hospital settings. Publications based on this work include: Patton, R., Crawford, M., Touquet, R. (In Press) The effect of health consequences feedback on patients acceptance of advice about alcohol consumption. EMJ. Patton, R., Touquet, R. (2003) General Practitioner screening for excessive alcohol use. BMJ, 326(7384), 336-337. Patton, R., Crawford, M., Touquet, R. (2002) Emergency departments are well placed to identify alcohol misuse problems. BMJ, 324(7332),300-30. Patton, R., Touquet, R. (2002) The Paddington Alcohol Test. British Journal of General Practice, 52(474), 59. Publications that this project builds upon: Huntley, J.S., Blain, C., Hood, S., Touquet, R. (2001) Improving detection of alcohol misuse in patients presenting to an AED. EMJ, 18, 99-104. Wright. S., Moran, L., Meyrick, M. O’Connor, R., Touquet, R. (1998) Intervention by an AHW in an AED, Alcohol & Alcoholism, 33, 651-656. Smith S.G.T., Touquet, R., Wright S., Das Gupta, N. (1996) Detection of alcohol misusing patients in the AED: the Paddington Alcohol Test (PAT). Journal of Accident & Emergency Medicine, 13, 308-312.