Addressing Alcohol Problems in Primary Care: A Cluster Randomized, Controlled Trial of a Systems Intervention: The Screening and Intervention in Primary Care (SIP) Study

4 March 2003 | Volume 138 Issue 5 | Pages 372-382

Background: Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented.

Objective: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use.

Design: Cluster randomized, controlled trial.

Setting: Urban academic primary care practice.

Participants: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking.

Interventions: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit.

Measurements: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later.

Results: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]).

Conclusions: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

Editors' Notes Context Brief interventions can reduce problem drinking, but physicians infrequently use them. Contribution This randomized trial, from an academic primary care setting, tested whether prompting physicians with positive alcohol screening results that are linked to specific management recommendations works. Prompted faculty, but not residents, tended to discuss alcohol problems and counsel patients more often than did their counterparts who were not prompted. At 6 months, however, only patients of prompted residents had reduced their drinking. Implications Prompting physicians with positive alcohol screening results and recommendations for action may or may not be effective, depending on patient, physician, and setting characteristics. –The Editors

 

Author and Article Information

From Boston University and Boston Medical Center, Boston, Massachusetts.

Deceased.

Preliminary results were presented at the annual national meetings of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program in Tucson, Arizona, on 9 December 1999 and in San Diego, California, on 7 December 2000; the Society of General Internal Medicine in Boston, Massachusetts, on 4 May 2000 and in San Diego, California, on 4 May 2001; the Association for Medical Education and Research on Substance Abuse in Alexandria, Virginia, on 5 November 1999 and 4 November 2000; and the Research Society on Alcoholism in Montreal, Quebec, Canada, on 25 June 2001.

Note: The authors acknowledge the contributions of Dr. Moskowitz, who died in September 2001. Dr. Moskowitz, despite his busy role as chief of a large section of general medicine and busy clinician and health services researcher, always had time, night or day, to provide immediate and critical feedback to mentees who will long remember his insights.

Acknowledgments: The authors thank the Primary Care Clinic staff and the patients and physicians who participated in the Screening and Intervention in Primary Care (SIP) study; staff researchers M. Alexandra Ordoñez, Raymond Quon, and Noelia Kvaternik; medical students participating in the Summer Substance Abuse Research Fellowship; and DM-STAT (Medford, Massachusetts) for their meticulous data management.

Grant Support: By the Robert Wood Johnson Foundation (grant 031489), Princeton, New Jersey. Dr. Saitz previously received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar and currently receives support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) (Clinical Research Curriculum Award grant 1 K30 HL04124); he and Dr. Samet received support from the Center for Substance Abuse Prevention of the Substance Abuse and Mental Health Services Administration (Faculty Development grant T26-SP08355). Drs. Saitz, Samet, and Horton are also supported by the NIH National Institute on Alcohol Abuse and Alcoholism (R01 AA10870, AA12617, AA13216), and the NIH National Institute on Drug Abuse (R01 DA10019).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Richard Saitz, MD, MPH, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118-2393; e-mail, rsaitz{at}bu.edu.

Current Author Addresses: Drs. Saitz, Horton, and Samet: Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118-2393.

Dr. Sullivan: Department of Mathematics and Statistics, Boston University Statistics & Consulting Unit, 111 Cummington Street, Boston, MA 02215.

Author Contributions: Conception and design: R. Saitz, N.J. Horton, L.M. Sullivan, M.A. Moskowitz, J.H. Samet.

Analysis and interpretation of the data: R. Saitz, N.J. Horton, L.M. Sullivan, J.H. Samet.

Drafting of the article: R. Saitz, N.J. Horton, L.M. Sullivan, J.H. Samet.

Critical revision of the article for important intellectual content: R. Saitz, N.J. Horton, L.M. Sullivan, M.A Moskowitz, J.H. Samet.

Final approval of the article: R. Saitz, N.J. Horton, L.M. Sullivan, J.H. Samet.

Provision of study materials or patients: R. Saitz.

Statistical expertise: N.J. Horton, L.M. Sullivan.

Obtaining of funding: R. Saitz.

Administrative, technical, or logistic support: M.A. Moskowitz.

Collection and assembly of data: R. Saitz, N.J. Horton, L.M. Sullivan.