Family physicians are encouraged strongly to screen patients for excessive use of alcohol and to provide brief interventions to those who give positive answers to standardized questions. Although it is widely believed that brief interventions (i.e., lasting only a few minutes) providing feedback, information, and advice can effectively reduce hazardous drinking, this belief has not been systematically studied in primary care. Beich and colleagues conducted a systematic review and meta-analysis of screening and brief intervention for excessive alcohol use in the primary care setting.
Studies were identified from electronic databases, references lists, and consultation with experts and researchers. Nineteen studies were assessed for internal validity (including several forms of bias) and external validity (including losses from the screenable population). Overall, a high percentage of patients identified by screening did not participate in the intervention because they were excluded by study protocols, refused to participate, or were not included for unspecified reasons. Eleven studies were excluded from the meta-analysis because of serious problems in reporting information on participants or outcomes. The eight studies included in the meta-analysis used health or lifestyle questionnaires and interventions ranging from one 10-minute consultation to five consultations, each lasting five to 20 minutes. All interventions were made by primary care physicians and consisted of feedback on drinking patterns, education on risk, strategies to reduce drinking, and direct advice from the physician to reduce alcohol consumption.
The study populations ranged from 104 to 909 participants and achieved follow-up rates of 65 percent to 97 percent. The pooled absolute risk reduction was 10.5 percent (95 percent confidence interval, 7.1 percent to 13.9 percent), giving a number needed to treat (NNT) of 10 (range: seven to 14).Although all studies reported a positive effect from intervention, the NNT for individual studies ranged from six to 61. The researchers estimate that for every 1,000 patients screened, a family physician will find 90 (9 percent) who test positive for excessive alcohol use. Using current recommendations, 25 of these patients qualify for brief intervention but only two to three patients will reduce their alcohol consumption below recommended levels over the following 12 months. The authors conclude that the net effect of screening is that 2.6 patients per 1,000 screened achieve sensible drinking within 12 months. They caution that the studies contained several sources of bias, all of which would overestimate the effects of screening.
The authors conclude that although brief advice can make a difference in excessive alcohol use, the net effect of screening and brief intervention is likely to cause change in only two to three patients for every 1,000 screened. Because of the many demands on time during office consultations, the authors question the validity and practicality of current advice to screen adult patients for excessive alcohol use.
editor's note: This study vividly illustrates that physicians are chastised frequently for not doing more prevention in primary care but are expected to undertake massive screening and intervention with inappropriate or inadequate tools. Family physicians are only too aware of the total burden of excessive alcohol use on our patients, their families, and society in general. To effectively intervene, we need more discriminating screening tools to narrow the gap between 90 patients per 1,000 being identified and only 25 being eligible for intervention. Interventions with better outcomes than less than three of 25 patients achieving sensible drinking by 12 months are needed as well. An effort to make preventive services more practical and effective in primary care is needed urgently. Too many interventions are recommended by all kinds of groups because they sound worthy or intuitively beneficial. The U.S. Preventive Services Task Force (USPSTF) has gone a long way in trying to provide logical and scientifically sound recommendations, but much more needs to be done to make these recommendations applicable to practice. As the authors of this study point out, a family physician would need an estimated 7.4 hours every working day just to provide all of the preventive services currently recommended by the USPSTF alone.—a.d.w.