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A high-‐risk approach: screening and brief interven6ons in primary care
Dr Antoni Gual [email protected]
POLICY DISCUSSION: ADDRESSING HARMFUL ALCOHOL USE.
OECD -‐ HEALTH COMMITTEE. 16th Session. PARIS, DECEMBER 9th, 2014
Conflicts of interest
Interest Name of organisa/on
Current roles and affilia/ons
Addic6ons Unit, Psychiatry Dept, Neurosciences Ins6tute, Hospital Clinic, University of Barcelona; IDIBAPS; RTA; Vice President of INEBRIA, President of EUFAS
Grants Lundbeck, D&A Pharma, FP7, SANCO
Honoraria Lundbeck, D&A Pharma, Servier, Lilly, Abbvie
Advisory board/consultant
Lundbeck, D&A Pharma, Socidrogalcohol (Alcohol Clinical Guidelines) 2013
Screening or early iden6fica6on?
• Screening: Strategy used in a popula6on to iden6fy an unrecognised disease in individuals without signs or symptoms.
• Targeted screening: Screening limited to selected popula6on (because of high risk or high vulnerability)
• Early iden/fica/on: Evalua6on of pa6ents in whom signs of alcohol playing a nega6ve role in a case history are present
The AUDIT-‐C
1. How oaen do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
3. How oaen do you have six or more drinks on one occasion 0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or almost daily
The AUDIT-‐C
1. How oaen do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
3. How oaen do you have six or more drinks on one occasion 0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or almost daily
Cut off point for Hazardous drinking:
• 4 or more in women • 5 or more in men
Prevalence of Alcohol Dependence (AD) and access to treatment. Data from the APC study
AD diagnosis by GP
Pa6ents visited by the GP 13,003
Pa6ents iden6fied as alcohol dependent 5.1% (663)
Pa/ents who received professional help 21.8% (n=145)
• Six EU countries • GPs interviewed about
pa6ents seen in a given day • Pa6ents interviewed with
standardized ques6onnaires when they exit consulta6on
Rehm J, et al. Ann Fam Med. 2014. In press.
What is a Brief Intervention?
It usually consists of a package involving: • informa6on on drinking risk levels, • the status of the pa6ent’s own drinking in rela6on to
those levels, • encouragement to cut down and set a date for doing so • and perhaps a few simple hints on how cujng down
might best be achieved
Heather, N., 2010
What is the evidence ?
1. Do brief interven6ons work? Efficacy studies. 2. Do brief interven6ons work in the real world of primary
care? Effec/veness trials. 3. Are they cost-‐effec6ve? Cost-‐effec/veness studies. 4. What factors promote widespread adop6on of brief
interven6ons into rou6ne prac6ce? Implementa/on trials.
5. Wider roll-‐out work: Demonstra/on studies.
O’Donnell et al, 2014
1. Efficacy studies
• 23 trials • Best evidence for 10-‐15 min BIs and mul6contacts • Compared to controls:
• Consump6on decreased by 3,6 drinks per week from baseline
• Heavy drinking episodes reduced by 12% • 11% reported drinking below recommended limits
Jonas et al, 2012
2. Effec6veness trials
• 24 systema6c reviews • Brief alcohol interven6ons are effec6ve when delivered in
primary healthcare • Brief alcohol interven6on equally effec6ve across different
countries and different health care systems • Insuficient evidence in young and older adults • Op6mum length, frequency and content unknown
O’Donnell et al, 2013
3. Cost-‐effec6veness studies
Agnus et al, 2014, Unpublished
3. Cost-‐effec6veness studies Cost-‐effec/ve Highly cost-‐effec/ve Cost-‐saving
Bulgaria Estonia Romania
Croa6a Latvia Lithuania Hungary Slovakia Poland Czech Republic Germany Italy Finland
Portugal Malta Cyprus Greece Spain France Austria Belgium Ireland Luxembourg Sweden Netherlands Denmark United Kingdom
Agnus et al, 2014, Unpublished
4. Implementa6on trials
• Cluster randomized factorial trial • 120 PHC prac6ces in 5 countries • Objec6ve: to test three strategies that might increase implementa6on of EIBI for excessive alcohol consump6on in PHC: – Training and support (Educa/on) – Financial incen6ves (Money) – E-‐Brief Interven6on (Time)
Keurhorst et al, 2013
4
8
12
16
20
24
28
Baseline Week 1-‐4 Week 5-‐8 Week 9-‐12 Follow-‐up
TS-‐ TS+ FR-‐ FR+ eBI-‐ eBI+
125%*** > FR-‐
69%*** > TS-‐
Anderson et al, 2014, Submired
4
8
12
16
20
24
28
32
Baseline Week 1-‐4 Week 5-‐8 Week 9-‐12 Follow-‐up
TSFR-‐ TSFR+ TSeBI-‐ TSeBI+ FReBI-‐ FReBI+ TSFReBI-‐ TSFReBI+
280%*** > TSFR-‐
Anderson et al, 2014, Submired
Implementa6on trials
1. Two hours of training led to more interven6ons being delivered.
2. Modest financial reimbursement led to more interven6ons being delivered. Work op6mally when fine-‐tuned to country-‐specific contexts
3. A combina6on of training and support and financial reimbursement led to more interven6ons being delivered than either strategy alone
Anderson et al, 2014, Submired
5. Demonstra6on studies: screening in PHC in Catalonia
Colom et al, 2014. Data on file
0"
10"
20"
30"
40"
50"
60"
70"
2005" 2006" 2007" 2008" 2009" 2010" 2011"
Lleida""
Tarragona"
Barcelona"
Girona"
Metropolitana"Sud"
Metropolitana"Nord"
Caralunya"central"
Alt"Pirineu"
Terres"de"l'Ebre"
Total"
Health areas in Catalonia
• Double gap: iden6fica6on and treatment rates are very low
• BIs efficacy and effec6veness established. • Implementa6on is difficult • Dissemina6on is feasible
Final remarks
A high-‐risk approach: screening and brief interven6ons in primary care
Dr Antoni Gual [email protected]
POLICY DISCUSSION: ADDRESSING HARMFUL ALCOHOL USE.
OECD -‐ HEALTH COMMITTEE. 16th Session. PARIS, DECEMBER 9th, 2014
THANKS FOR YOUR ATTENTION !!!
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