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A	
  high-­‐risk	
  approach:	
  screening	
  and	
  
brief	
  interven6ons	
  in	
  primary	
  care	
  	
  
Dr	
  Antoni	...
Conflicts	
  of	
  interest	
  
Interest	
   Name	
  of	
  organisa/on	
  
Current	
  roles	
  and	
  
affilia/ons	
  
Addic6...
Screening	
  or	
  early	
  iden6fica6on?	
  
•  Screening:	
  Strategy	
  used	
  in	
  a	
  popula6on	
  to	
  iden6fy	
 ...
The	
  AUDIT-­‐C	
  
1.	
  How	
  oaen	
  do	
  you	
  have	
  a	
  drink	
  containing	
  
alcohol?	
  
2.	
  How	
  many...
The	
  AUDIT-­‐C	
  
1.	
  How	
  oaen	
  do	
  you	
  have	
  a	
  drink	
  containing	
  
alcohol?	
  
2.	
  How	
  many...
Prevalence	
  of	
  Alcohol	
  Dependence	
  (AD)	
  and	
  
access	
  to	
  treatment.	
  Data	
  from	
  the	
  APC	
  s...
What is a Brief Intervention?
It	
  usually	
  consists	
  of	
  a	
  package	
  involving:	
  
	
  
•  informa6on	
  on	
...
What	
  is	
  the	
  evidence	
  ?	
  
1.  Do	
  brief	
  interven6ons	
  work?	
  Efficacy	
  studies.	
  
2.  Do	
  brief	...
1.	
  Efficacy	
  studies	
  
•  23	
  trials	
  
•  Best	
  evidence	
  for	
  10-­‐15	
  min	
  BIs	
  and	
  mul6contacts...
2.	
  Effec6veness	
  trials	
  
•  24	
  systema6c	
  reviews	
  
•  Brief	
  	
  alcohol	
  interven6ons	
  are	
  effec6v...
3.	
  Cost-­‐effec6veness	
  studies	
  
Agnus	
  et	
  al,	
  2014,	
  Unpublished	
  
3.	
  Cost-­‐effec6veness	
  studies	
  
	
  Cost-­‐effec/ve	
   Highly	
  cost-­‐effec/ve	
   Cost-­‐saving	
  
Bulgaria	
  ...
4.	
  Implementa6on	
  trials	
  
•  Cluster	
  randomized	
  factorial	
  trial	
  
•  120	
  PHC	
  prac6ces	
  in	
  5	...
4	
  
8	
  
12	
  
16	
  
20	
  
24	
  
28	
  
Baseline	
   Week	
  1-­‐4	
   Week	
  5-­‐8	
   Week	
  9-­‐12	
   Follow-...
4	
  
8	
  
12	
  
16	
  
20	
  
24	
  
28	
  
32	
  
Baseline	
   Week	
  1-­‐4	
   Week	
  5-­‐8	
   Week	
  9-­‐12	
   ...
Implementa6on	
  trials	
  
1.  Two	
  hours	
  of	
  training	
  led	
  to	
  more	
  interven6ons	
  being	
  
delivered...
5.	
  Demonstra6on	
  studies:	
  	
  
screening	
  in	
  PHC	
  in	
  Catalonia	
  
Colom et al, 2014. Data on file
0"
10...
•  Double	
  gap:	
  iden6fica6on	
  and	
  treatment	
  rates	
  
are	
  very	
  low	
  
•  BIs	
  efficacy	
  and	
  effec6v...
A	
  high-­‐risk	
  approach:	
  screening	
  and	
  
brief	
  interven6ons	
  in	
  primary	
  care	
  	
  
Dr	
  Antoni	...
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Brief Interventions for alcohol problems. OECD meeting.

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Lecture on efficacy & effectiveness of Brief Interventions for Alcohol problems, given in to the OECD - HEALTH COMMITTEE, 16th Session.PARIS, DECEMBER 9th, 2014

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Brief Interventions for alcohol problems. OECD meeting.

  1. 1. A  high-­‐risk  approach:  screening  and   brief  interven6ons  in  primary  care     Dr  Antoni  Gual   tgual@clinic.cat   POLICY  DISCUSSION:     ADDRESSING  HARMFUL  ALCOHOL  USE.   OECD  -­‐  HEALTH  COMMITTEE.  16th  Session.   PARIS,  DECEMBER  9th,  2014    
  2. 2. Conflicts  of  interest   Interest   Name  of  organisa/on   Current  roles  and   affilia/ons   Addic6ons  Unit,  Psychiatry  Dept,   Neurosciences  Ins6tute,  Hospital  Clinic,   University  of  Barcelona;  IDIBAPS;  RTA;  Vice   President  of  INEBRIA,  President  of  EUFAS     Grants     Lundbeck,  D&A  Pharma,  FP7,  SANCO   Honoraria   Lundbeck,  D&A  Pharma,  Servier,  Lilly,  Abbvie   Advisory  board/ consultant   Lundbeck,  D&A  Pharma,  Socidrogalcohol   (Alcohol  Clinical  Guidelines)  2013  
  3. 3. Screening  or  early  iden6fica6on?   •  Screening:  Strategy  used  in  a  popula6on  to  iden6fy   an  unrecognised  disease  in  individuals  without  signs   or  symptoms.   •  Targeted  screening:  Screening  limited  to  selected   popula6on  (because  of  high  risk  or  high  vulnerability)   •  Early  iden/fica/on:  Evalua6on  of  pa6ents  in  whom   signs  of  alcohol  playing  a  nega6ve  role  in  a  case   history  are  present    
  4. 4. The  AUDIT-­‐C   1.  How  oaen  do  you  have  a  drink  containing   alcohol?   2.  How  many  standard  drinks  containing  alcohol   do  you  have  on  a  typical  day  when  drinking?   3.  How  oaen  do  you  have  six  or  more  drinks  on   one  occasion    0)  Never    1)  Less  than  monthly  2)  Monthly      3)  Weekly  4)  Daily  or  almost  daily  
  5. 5. The  AUDIT-­‐C   1.  How  oaen  do  you  have  a  drink  containing   alcohol?   2.  How  many  standard  drinks  containing  alcohol   do  you  have  on  a  typical  day  when  drinking?   3.  How  oaen  do  you  have  six  or  more  drinks  on   one  occasion    0)  Never    1)  Less  than  monthly  2)  Monthly      3)  Weekly  4)  Daily  or  almost  daily   Cut  off  point  for  Hazardous  drinking:       •  4  or  more  in  women   •  5  or  more  in  men  
  6. 6. Prevalence  of  Alcohol  Dependence  (AD)  and   access  to  treatment.  Data  from  the  APC  study   AD  diagnosis  by  GP   Pa6ents  visited  by  the  GP   13,003   Pa6ents  iden6fied  as  alcohol  dependent   5.1%    (663)   Pa/ents  who  received  professional  help   21.8%  (n=145)   •  Six  EU  countries   •  GPs  interviewed  about   pa6ents  seen  in  a  given  day   •  Pa6ents  interviewed  with   standardized  ques6onnaires   when  they  exit  consulta6on   Rehm  J,  et  al.  Ann  Fam  Med.  2014.  In  press.  
  7. 7. What is a Brief Intervention? It  usually  consists  of  a  package  involving:     •  informa6on  on  drinking  risk  levels,     •  the  status  of  the  pa6ent’s  own  drinking  in  rela6on  to   those  levels,     •  encouragement  to  cut  down  and  set  a  date  for  doing  so     •  and  perhaps  a  few  simple  hints  on  how  cujng  down   might  best  be  achieved   Heather,  N.,  2010  
  8. 8. What  is  the  evidence  ?   1.  Do  brief  interven6ons  work?  Efficacy  studies.   2.  Do  brief  interven6ons  work  in  the  real  world  of  primary   care?  Effec/veness  trials.   3.  Are  they  cost-­‐effec6ve?  Cost-­‐effec/veness  studies.   4.  What  factors  promote  widespread  adop6on  of  brief   interven6ons  into  rou6ne  prac6ce?  Implementa/on   trials.     5.  Wider  roll-­‐out  work:  Demonstra/on  studies.     O’Donnell  et  al,  2014  
  9. 9. 1.  Efficacy  studies   •  23  trials   •  Best  evidence  for  10-­‐15  min  BIs  and  mul6contacts   •   Compared  to  controls:   •  Consump6on  decreased  by  3,6  drinks  per  week   from  baseline   •  Heavy  drinking  episodes  reduced  by  12%   •  11%    reported  drinking  below  recommended   limits   Jonas  et  al,  2012  
  10. 10. 2.  Effec6veness  trials   •  24  systema6c  reviews   •  Brief    alcohol  interven6ons  are  effec6ve  when  delivered  in   primary  healthcare   •  Brief  alcohol  interven6on  equally  effec6ve  across  different   countries  and  different  health  care  systems   •  Insuficient  evidence  in  young  and  older  adults   •  Op6mum  length,  frequency  and  content  unknown   O’Donnell  et  al,  2013  
  11. 11. 3.  Cost-­‐effec6veness  studies   Agnus  et  al,  2014,  Unpublished  
  12. 12. 3.  Cost-­‐effec6veness  studies    Cost-­‐effec/ve   Highly  cost-­‐effec/ve   Cost-­‐saving   Bulgaria   Estonia   Romania   Croa6a   Latvia   Lithuania   Hungary   Slovakia   Poland   Czech  Republic   Germany   Italy   Finland   Portugal   Malta   Cyprus   Greece   Spain   France   Austria   Belgium   Ireland   Luxembourg   Sweden   Netherlands   Denmark   United  Kingdom   Agnus  et  al,  2014,  Unpublished  
  13. 13. 4.  Implementa6on  trials   •  Cluster  randomized  factorial  trial   •  120  PHC  prac6ces  in  5  countries   •  Objec6ve:  to  test  three  strategies  that  might   increase  implementa6on  of  EIBI  for  excessive   alcohol  consump6on  in  PHC:   – Training  and  support      (Educa/on)   – Financial  incen6ves      (Money)   – E-­‐Brief  Interven6on      (Time)   Keurhorst  et  al,  2013  
  14. 14. 4   8   12   16   20   24   28   Baseline   Week  1-­‐4   Week  5-­‐8   Week  9-­‐12   Follow-­‐up   TS-­‐   TS+   FR-­‐   FR+   eBI-­‐   eBI+   125%***  >  FR-­‐   69%***  >  TS-­‐   Anderson  et  al,  2014,  Submired  
  15. 15. 4   8   12   16   20   24   28   32   Baseline   Week  1-­‐4   Week  5-­‐8   Week  9-­‐12   Follow-­‐up   TSFR-­‐   TSFR+   TSeBI-­‐   TSeBI+   FReBI-­‐   FReBI+   TSFReBI-­‐   TSFReBI+   280%***  >  TSFR-­‐   Anderson  et  al,  2014,  Submired  
  16. 16. Implementa6on  trials   1.  Two  hours  of  training  led  to  more  interven6ons  being   delivered.     2.  Modest  financial  reimbursement  led  to  more   interven6ons  being  delivered.  Work  op6mally  when   fine-­‐tuned  to  country-­‐specific  contexts   3.  A  combina6on  of  training  and  support  and  financial   reimbursement  led  to  more  interven6ons  being   delivered  than  either  strategy  alone       Anderson  et  al,  2014,  Submired  
  17. 17. 5.  Demonstra6on  studies:     screening  in  PHC  in  Catalonia   Colom et al, 2014. Data on file 0" 10" 20" 30" 40" 50" 60" 70" 2005" 2006" 2007" 2008" 2009" 2010" 2011" Lleida"" Tarragona" Barcelona" Girona" Metropolitana"Sud" Metropolitana"Nord" Caralunya"central" Alt"Pirineu" Terres"de"l'Ebre" Total" Health  areas   in  Catalonia  
  18. 18. •  Double  gap:  iden6fica6on  and  treatment  rates   are  very  low   •  BIs  efficacy  and  effec6veness  established.     •  Implementa6on  is  difficult   •  Dissemina6on  is  feasible   Final  remarks  
  19. 19. A  high-­‐risk  approach:  screening  and   brief  interven6ons  in  primary  care     Dr  Antoni  Gual   tgual@clinic.cat   POLICY  DISCUSSION:     ADDRESSING  HARMFUL  ALCOHOL  USE.   OECD  -­‐  HEALTH  COMMITTEE.  16th  Session.   PARIS,  DECEMBER  9th,  2014     THANKS  FOR  YOUR  ATTENTION  !!!  

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