Original Research
Evaluation of a Brief Intervention in an Inner-City Emergency Department

https://doi.org/10.1016/j.annemergmed.2004.10.014Get rights and content

Study objective

This study tests the effect of a brief intervention with emergency department (ED) patients to reduce at-risk drinking.

Methods

We enrolled patients aged 18 years or older who screened positive for at-risk drinking in an urban academic ED and used alternative allocation to assign them to control or intervention status. A 20-minute, semiscripted, negotiated interview was conducted with the intervention group in English and Spanish by 3 health promotion advocates (peer educators). The Alcohol Use Identification Test (AUDIT) was administered at baseline and 3 months after enrollment.

Results

Among 1,036 patients screened for at-risk drinking, 295 with CAGE questionnaire score greater than 1 and no alcohol treatment in the past year enrolled in the study and were randomly assigned to the control arm (n=151) or the intervention arm (n=144). Follow-up was achieved with 88 patients in the intervention group and 97 patients in the control group (63% of enrollees). Among the 185 patients followed up, 64% of the intervention group versus 80% of the control group scored greater than 7 on the follow-up AUDIT (scored on a scale of 1 to 40; P<.05, odds ratio [OR] 2.35, 95% confidence interval [CI] 1.21 to 4.55). Multinomial logistic regression analysis demonstrates, after controlling for demographic characteristics and other independent variables, that assignment to intervention status decreased the odds of at-risk (moderate) drinking as defined by AUDIT scores of 7 to 18 (OR 0.42, P<.05, 95% CI 0.19 to 0.91) but did not affect patients with AUDIT scores in the 19 to 40 range.

Conclusion

Brief motivational intervention administered by peer educators to ED patients appears to reduce moderately risky drinking and associated problems.

Introduction

A large number of the many patients who visit the nation's emergency departments (ED) each year present with alcohol-related problems.1, 2 According to the National Hospital Ambulatory Medical Care Survey for 1992 to 2000, there was an average of 7.6 million ED visits per year attributable to alcohol.3 The detection and early treatment of patients with alcohol problems may reduce alcohol-related injuries and other associated consequences,4, 5, 6 improve the health of individuals, and save unnecessary costs to the health care system.7

During the past decade, brief intervention for reducing alcohol consumption has been tested empirically, with favorable results in general settings and in the ED.8, 9, 10, 11, 12, 13 The ED visit provides a chance to reach patients who might not otherwise be identified, at a time when an injury or illness may make them more receptive to changing risky behaviors.12 Because ED providers often lack time to do more than address the acute presenting problem, alcohol interventions must be brief to be acceptable and effective in the emergency setting. Although evaluations of ED screening and brief intervention have suggested that it may be an effective modality for eliminating or reducing harmful health behaviors related to alcohol abuse, the current study is the first controlled trial testing the effectiveness of a brief negotiated interview by peer educators with patients who screen positive for at-risk drinking. Bernstein et al13 describe a follow-up study for a similar intervention with a small convenience sample that included a subgroup of Spanish-speaking patients, but there was no control group for comparison.

The goal of this brief intervention is to identify at-risk drinkers and address problem drinking early. At-risk drinking describes the behavior of those whose drinking is likely to lead to adverse health, social, and economic consequences over time.14 Epidemiologic studies suggest that for every 4 at-risk drinkers, there is 1 dependent drinker.15 These drinkers constitute the largest proportion of society's alcohol-related problem.16 Brief intervention trials conducted in primary care settings demonstrate benefit to at-risk drinkers without prolonged or intensive counseling.17, 18, 19, 20, 21, 22, 23, 24

At present, many at-risk drinkers who utilize EDs receive no recommendation or advice from their providers about their alcohol use.25, 26 If providers are to institute universal screening, brief intervention, and referral practices as is suggested in Healthy People 2010 Objective number 26-22, they will need an evidence base for adopting new practices and a feasible method for interacting effectively with patients in this busiest of medical settings. The goal of this study is therefore to test the behavioral impact of peer educators (physician extenders) conducting an intervention to reduce at-risk drinking in an inner-city ED.

Section snippets

Setting

King/Drew Medical Center ED, the site for this study, serves a mostly minority population of 1.7 million individuals in South Central Los Angeles, with an annual census of 50,000 to 60,000 ED visits. The racial/ethnic composition is 60% Hispanic, 23% black, 12% non-Hispanic white, and 5% Asian American. The area has a high level of poverty (nearly 32% of the population below the federal poverty level), low educational attainment, and a high age-adjusted mortality rate. A study conducted in the

Results

Enrollment of the subjects in the study was voluntary and based on ability to meet eligibility criteria. Among 1,058 subjects who were approached in the King/Drew Medical Center ED, 22 (2.1%) refused to be screened (Figure). Of the 1,036 patients screened, 488 met eligibility requirements. Among them, 295 patients enrolled in the study and 193 (39.5%) patients refused. Enrollees were alternatively allocated into the intervention arm (n=144) or control arm (n=151), as described above. All

Limitations

Our study has several limitations. The allocation of alternate patients to intervention and control condition is not accepted as a method of randomization by the CONSORT statement.45 Alternate allocation thus limits the generalizability of our findings, and the unequal number of subjects in the control and intervention groups is a concern. Although it is conceivable that the health promotion advocate might have consciously or unconsciously influenced the subject allocation to the control or

Discussion

This study was designed to test the effectiveness of a 15- to 20-minute brief negotiated interview intervention in reducing alcohol consumption of at-risk drinkers who used an inner-city ED to receive health care. Our results provide evidence of the effectiveness of brief intervention conducted by health promotion advocates as a model for providing screening and counseling to ED patients who might otherwise not receive such services. It demonstrates that a 15- to 20-minute structured

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  • Cited by (0)

    Supervising editor: Judith E. Tintinalli, MD, MS

    Author contributions: SB-H, MB, and EB submitted the grant proposal, conceived the study, and designed the intervention. SB-H and EH supervised the implementation of the intervention and data collection. CD-M was responsible for analyzing the data, and MB provided statistical advice on data analysis. JB and EB participated in the design of intervention and writing the discussion. SB-H takes responsibility for the paper as a whole.

    Funding and support: Supported by grants from the Center for Minority HEALTH and Health Disparities, National Institute on Alcohol Abuse and Alcoholism (U24AA11899-05) and the National Institutes of Health, National Center for Research Resources and Research Centers in Minority Institutions (G12-RR03026-16).

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