Referral for alcohol misuse in an emergency department: Results of a randomised trial

Alcohol Insight Number 20

Research and Development Grant

Introduction

More than 14 million people are treated in Accident and Emergency departments (AED) in England each year. As many as one in three have consumed alcohol prior to their presentation and over two-thirds of attendances after midnight may be alcohol related. Despite the scale of the problem, high patient turnover, clinical inertia, and other pressures mean that identification and management of alcohol problems in AEDs is a challenging task.

Over the last 16 years methods for identifying and treating patients with alcohol problems in the AED of St Mary’s Hospital London have been developed which are acceptable to patients and staff. The Paddington Alcohol Test (PAT) is a four-item questionnaire that identifies alcohol misuse by establishing if the person is cur­rently drinking over recommended limits, or if they feel their attendance in the AED could be related to their use of alcohol. Doctors working at St Mary’s AED are trained in the use of the PAT and are encouraged to screen all patients who present with one of ten presenting problems, such as falls, collapse, head injury, assaults, and other medical conditions, which are most often associated with alcohol misuse. Those found to be misusing alcohol are then offered an appointment with an alco­hol health worker who is able to meet the patient in the AED. Alcohol health work­ers provide a patient-centred assessment of alcohol problems, discuss the impact of alcohol use with the patient and provide further information or referral aimed at encouraging the patient to reduce their consumption.

In this study we set out to examine the effects and cost effectiveness of referral to an alcohol health worker by randomising patients who consented to take part in the study to either an appointment with an alcohol health worker or an information leaflet on alcohol and health. We set out to measure the level of alcohol consump­tion, use of services and service and other costs among patients randomised to one of these two interventions at over the following year.

Findings

  • During the study period 22% of all those who were screened were found to be misusing alcohol. Of these two-thirds were willing to accept brief
    advice.
  • 599 patients were recruited to the study, of whom 384 (64%) completed fol­low-up interviews at one year ..
  • 29% of those offered an appointment with an alcohol health worker attend­ed the appointment. Patients were almost three times more likely to keep the appointment if they thought their attendance in the AED was related to alcohol, and 6 times more likely to attend if the appointment was on the same day as their initial attendance in the AED
  • At six months, those referred to the alcohol health worker were drinking 23 units of alcohol a week less than those given an information leaflet, at twelve months the difference was 14 units.
    Levels of alcohol consumption were lower in people referred to an alcohol health worker whether or not they actually attended the appointment. Those referred to the alcohol health worker had on average Oe5 fewer visits to the AED over the following 12 months.
  • Differences in quality of life between those referred to the alcohol health worker and those given the information leaflet were not seen.
  • Total direct and indirect costs were not significantly different in each arm of the trial.
  • A decision-making approach revealed that there was at least a 70% prob­ability that referral to an alcohol health worker is more cost-effective than provision of an information leaflet in reducing alcohol consumption

Implications

  • Attendance at an AED provides a ‘teachable moment’ in which opportunistic identification of alcohol misuse can potentially help patients develop insight into the consequences of their drinking and promote improved health. Short-term reductions in alcohol consumption associated with referral to an alcohol health worker benefits patients and may reduce demand for AED services.
  • Referral to an alcohol health worker does not generate a significant increase in cost and is likely to be cost-effective.

Further Information

  • Further details of the Paddington Alcohol Test can be found in: Alcohol and Alcoholism 2004;39:266-8. The Paddington Alcohol Test: A short report.
  • Further details of the development and use of ‘selective screening’ in AEDs can be found in: Emergency Medicine Journal 2001 ;18:99-104. Improving detection of alcohol misuse in patients presenting to an accident and emergency department.
  • Further information about the characteristics of AED patients who are willing to accept brief advice can be found in: Emergency Medicine Journal 2004; 21 :491-492. Hazardous drinking in the AED: Who accepts brief advice? Information about how to improve levels of patient acceptance of advice are reported in: Journal of Accident and Emergency Medicine 2003 ;20:451- 52. The effect of health consequences feedback on patients’ acceptance of advice about alcohol consumption.
  • Further details of the study methods and findings can be found in: The Lancet 2004; 364: 1334-1340. Screening and referral for brief intervention of alcohol misusing patients in an Accident and Emergency Department: A pragmatic randomised controlled trial.

Acknowledgements

The study was entirely funded by Alcohol and Education Research Council. We are also grateful to patients who participated in the study, for the help of Alcohol Health Workers, and to doctors (in Teams 30 to 32) and other staff in AED for recruiting study patients.

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