|Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the US Preventive Services Task Force
|Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Evans TS, Wood SD, Harris RP
This review concluded that behavioural counselling interventions improved behavioural outcomes for adults with risky drinking. This was well-conducted review and although some studies may have been missed the conclusions are likely to be reliable.
To evaluate the benefits and harms of behavioural counselling interventions for adolescents and adults who misuse alcohol.
MEDLINE, EMBASE, The Cochrane Library, CINAHL, PsycINFO and IPA were searched from 1985 to January 2012 for articles in English. The search strategy was reported in the associated full report (see Other Publications of Related Interest).
Randomised controlled trials of at least six months' duration conducted in adults or adolescents with alcohol misuse identified by screening in primary care settings and that evaluated the impact of a counselling intervention on behavioural or health outcomes were eligible for inclusion.
Half of the studies were conducted in USA. Over half of the interventions were delivered by a primary care physician alone or with a health educator or nurse. The most commonly conducted evaluations were brief (six to 15 minutes) or extended (at least 15 minutes) multi-contact interventions. Most comparator groups received screening or assessment followed by usual care or a general health pamphlet.
Two reviewers independently selected studies for the review; disagreements were resolved by a third reviewer.
Assessment of study quality
Study quality was assessed by two independent reviewers in terms of the adequacy of randomisation, allocation concealment, similarity of groups at baseline, blinding, attrition and use of an intention-to-treat analysis. The strength of the evidence for each outcome was graded as high, moderate, low or insufficient (definitions given). Disagreements were resolved by a third reviewer.
Data were extracted by one reviewer to enable calculation of risk difference (RD) or risk ratio (RR) for binary outcomes and mean differences for continuous outcomes, along with 95% confidence intervals (CI). Data were checked by a second reviewer.
Methods of synthesis
Data were stratified by population (adults, older adults, young adults or college students and pregnant women). Where sufficient numbers of studies that were reasonably homogeneous were available, pooled risk differences and weighted mean differences (WMD), with 95% CIs, were calculated using random-effects models. All-cause mortality was analysed on a deaths per person-year basis to account for the different durations of follow-up across studies; pooled risk ratios and 95% CIs were calculated. Heterogeneity was assessed using Χ² and Ι². Subgroup analyses were used to explore the impact of intervention intensity, gender, country, deliverer of the intervention and setting.
Results of the review
Twenty-three RCTs were included (10,745 participants, range 72 to 1,559). Study duration ranged from six to 48 months. No RCTs were identified that compared screening and any comparator. Few studies reported evaluations of pregnant women or health care system influences; results were presented in the paper and associated full report.
Evidence supported the effectiveness of behavioral interventions for improving several intermediate outcomes for adults, older adults and young adults or college students. In adults the impact of such interventions at 12 months was significant for changes in number of alcoholic drinks consumed per week (WMD -3.573, 95% CI -4.758 to -2.389; Ι²=14%; 12 RCTs), achieving recommended drinking limits (RD 0.109, 95% CI 0.083 to 0.134; Ι²=31%; nine RCTs) and avoidance of heavy drinking episodes (RD 0.118, 95% CI 0.074 to 0.162; Ι²=31%; seven RCTs). There was no statistically significant reduction in all-cause mortality for adults (RR 0.64, 95% CI 0.24 to 1.7; four RCTs) or all age groups (RR 0.52, 95% CI 0.22 to 1.2; six RCTs). There was no evidence of direct clinical harms.
Opportunity costs were associated with the interventions; these ranged from five minutes to two hours dispersed over several in-person or telephone visits.
Behavioural counselling interventions improved behavioural outcomes for adults with risky drinking.
The review addressed a clear research question. The inclusion criteria were broad but appropriate and reproducible. The search for published studies was extensive but there were no attempts to identify unpublished studies and studies published in languages other than English were excluded. Each stage of the review process was conducted in duplicate, which reduced risks of error and bias. Quality was assessed with appropriate criteria and the results were published in full in the associated report. Appropriate methods of synthesis were used.
This was well-conducted review and although some studies may have been missed the conclusions are likely to be reliable.
Implications of the review for practice and research
The authors did not state any implications for practice or research in the paper.
Agency for Healthcare Research and Quality, USA.
Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Evans TS, Wood SD, Harris RP. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the US Preventive Services Task Force. Annals of Internal Medicine 2012; 25 September
Other publications of related interest
Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Swinson Evans T, Wood SA, Harris RP. Screening, behavioral counseling, and referral in primary care to reduce alcohol misuse. Rockville, MD, USA: Agency for Healthcare Research and Quality. Comparative Effectiveness Review No. 64. 2012.
Subject indexing assigned by CRD
Alcoholism; Humans; Mass Screening; Primary Health Care; Counseling; Behavior Therapy
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.