Original ResearchEvaluation of a Brief Intervention in an Inner-City Emergency Department
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
References (57)
- et al.
Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial
Ann Emerg Med
(2002) - et al.
Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system
Ann Emerg Med
(1997) - et al.
Major injury as a unique opportunity to initiate treatment in the alcoholic
Am J Surg
(1988) - et al.
Alcohol use and readiness to change after spinal cord injury
Arch Phys Med Rehabil
(1998) - et al.
Readiness to change alcohol drinking habits after traumatic brain injury
Arch Phys Med Rehabil
(1997) The effectiveness of treatment for substance abuse: reasons for optimism
J Substance Abuse Treat
(1992)- et al.
Screening for alcohol problems: comparison of the audit, RAPS4 and RAPS4-QF among African American and Hispanic patients in an inner city emergency department
Drug Alcohol Depend
(2003) - et al.
Physician-patient communication: a descriptive summary of the literature
Patient Educ Counsel
(1988) - et al.
National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary
Adv Data
(2004) - et al.
Alcoholism in the emergency department: an epidemiologic study
Acad Emerg Med
(2000)
US Emergency Department visits for alcohol-related diseases and injuries between 1992 and 2000
Arch Intern Med
Brief physician advice for problem alcohol drinkers
JAMA
Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department
J Consult Clin Psychol
Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence
Ann Surg
Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings
Med Care
Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department
J Stud Alcohol
Problem drinking in emergency department patients: the scope for early intervention
Med J Aust
Brief physician advice for alcohol problems in older adults: a randomized community-based trial
J Fam Pract
Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption
BMJ
Patients with alcohol problems in the emergency department, part 2: intervention and referral. SAEM Substance Abuse Task Force: Society for Academic Emergency Medicine
Acad Emerg Med
Hazardous and harmful alcohol consumption in primary care
Arch Intern Med
Broadening the Base of Treatment for Alcohol Problems
Brief interventions for alcohol problems: a review
Addiction
Managing alcohol problems and risky drinking
Am J Health Promot
Reasons why trauma surgeons fail to screen for alcohol problems
Arch Surg
Analysis of alcohol use clusters among subcritically injured emergency department patients
Acad Emerg Med
Emergency department detection and referral rates for patients with problem drinking
Substance Abuse
Detecting alcoholism: the CAGE questionnaire
JAMA
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).