Abstract
Background: There is clear evidence of the detrimental impact of hazardous alcohol consumption on the
physical and mental health of the population. Estimates suggest that hazardous alcohol consumption
annually accounts for 150,000 hospital admissions and between 15,000 and 22,000 deaths in the UK. In
the older population, hazardous alcohol consumption is associated with a wide range of physical,
psychological and social problems. There is evidence of an association between increased alcohol
consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic
stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is
identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can
also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in onethird
of all suicides in the older population.
Objective: To compare the clinical effectiveness and cost-effectiveness of a stepped care intervention
against a minimal intervention in the treatment of older hazardous alcohol users in primary care.
Design: A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation.
Setting: General practices in primary care in England and Scotland between April 2008 and
October 2010.
Participants: Adults aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test (10-item)
(AUDIT) were eligible. In total, 529 patients were randomised in the study.
Interventions: The minimal intervention group received a 5-minute brief advice intervention with the
practice or research nurse involving feedback of the screening results and discussion regarding the health
consequences of continued hazardous alcohol consumption. Those in the stepped care arm initially
received a 20-minute session of behavioural change counselling, with referral to step 2 (motivational enhancement therapy) and step 3 (local specialist alcohol services) if indicated. Sessions were recorded and
rated to ensure treatment fidelity.
Main outcome measures: The primary outcome was average drinks per day (ADD) derived from
extended AUDIT – Consumption (3-item) (AUDIT-C) at 12 months. Secondary outcomes were AUDIT-C
score at 6 and 12 months; alcohol-related problems assessed using the Drinking Problems Index (DPI) at 6
and 12 months; health-related quality of life assessed using the Short Form Questionnaire-12 items (SF-12)
at 6 and 12 months; ADD at 6 months; quality-adjusted life-years (QALYs) (for cost–utility analysis derived
from European Quality of Life-5 Dimensions); and health and social care resource use associated with the
two groups.
Results: Both groups reduced alcohol consumption between baseline and 12 months. The difference
between groups in log-transformed ADD at 12 months was very small, at 0.025 [95% confidence interval
(CI) –0.060 to 0.119], and not statistically significant. At month 6 the stepped care group had a lower
ADD, but again the difference was not statistically significant. At months 6 and 12, the stepped care group
had a lower DPI score, but this difference was not statistically significant at the 5% level. The stepped care
group had a lower SF-12 mental component score and lower physical component score at month 6 and
month 12, but these differences were not statistically significant at the 5% level.
The overall average cost per patient, taking into account health and social care resource use, was £488
[standard deviation (SD) £826] in the stepped care group and £482 (SD £826) in the minimal intervention
group at month 6. The mean QALY gains were slightly greater in the stepped care group than in the
minimal intervention group, with a mean difference of 0.0058 (95% CI –0.0018 to 0.0133), generating an
incremental cost-effectiveness ratio (ICER) of £1100 per QALY gained. At month 12, participants in the
stepped care group incurred fewer costs, with a mean difference of –£194 (95% CI –£585 to £198), and
had gained 0.0117 more QALYs (95% CI –0.0084 to 0.0318) than the control group. Therefore, from an
economic perspective the minimal intervention was dominated by stepped care but, as would be expected
given the effectiveness results, the difference was small and not statistically significant.
Conclusions: Stepped care does not confer an advantage over minimal intervention in terms of reduction
in alcohol consumption at 12 months post intervention when compared with a 5-minute brief (minimal)
intervention.
physical and mental health of the population. Estimates suggest that hazardous alcohol consumption
annually accounts for 150,000 hospital admissions and between 15,000 and 22,000 deaths in the UK. In
the older population, hazardous alcohol consumption is associated with a wide range of physical,
psychological and social problems. There is evidence of an association between increased alcohol
consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic
stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is
identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can
also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in onethird
of all suicides in the older population.
Objective: To compare the clinical effectiveness and cost-effectiveness of a stepped care intervention
against a minimal intervention in the treatment of older hazardous alcohol users in primary care.
Design: A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation.
Setting: General practices in primary care in England and Scotland between April 2008 and
October 2010.
Participants: Adults aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test (10-item)
(AUDIT) were eligible. In total, 529 patients were randomised in the study.
Interventions: The minimal intervention group received a 5-minute brief advice intervention with the
practice or research nurse involving feedback of the screening results and discussion regarding the health
consequences of continued hazardous alcohol consumption. Those in the stepped care arm initially
received a 20-minute session of behavioural change counselling, with referral to step 2 (motivational enhancement therapy) and step 3 (local specialist alcohol services) if indicated. Sessions were recorded and
rated to ensure treatment fidelity.
Main outcome measures: The primary outcome was average drinks per day (ADD) derived from
extended AUDIT – Consumption (3-item) (AUDIT-C) at 12 months. Secondary outcomes were AUDIT-C
score at 6 and 12 months; alcohol-related problems assessed using the Drinking Problems Index (DPI) at 6
and 12 months; health-related quality of life assessed using the Short Form Questionnaire-12 items (SF-12)
at 6 and 12 months; ADD at 6 months; quality-adjusted life-years (QALYs) (for cost–utility analysis derived
from European Quality of Life-5 Dimensions); and health and social care resource use associated with the
two groups.
Results: Both groups reduced alcohol consumption between baseline and 12 months. The difference
between groups in log-transformed ADD at 12 months was very small, at 0.025 [95% confidence interval
(CI) –0.060 to 0.119], and not statistically significant. At month 6 the stepped care group had a lower
ADD, but again the difference was not statistically significant. At months 6 and 12, the stepped care group
had a lower DPI score, but this difference was not statistically significant at the 5% level. The stepped care
group had a lower SF-12 mental component score and lower physical component score at month 6 and
month 12, but these differences were not statistically significant at the 5% level.
The overall average cost per patient, taking into account health and social care resource use, was £488
[standard deviation (SD) £826] in the stepped care group and £482 (SD £826) in the minimal intervention
group at month 6. The mean QALY gains were slightly greater in the stepped care group than in the
minimal intervention group, with a mean difference of 0.0058 (95% CI –0.0018 to 0.0133), generating an
incremental cost-effectiveness ratio (ICER) of £1100 per QALY gained. At month 12, participants in the
stepped care group incurred fewer costs, with a mean difference of –£194 (95% CI –£585 to £198), and
had gained 0.0117 more QALYs (95% CI –0.0084 to 0.0318) than the control group. Therefore, from an
economic perspective the minimal intervention was dominated by stepped care but, as would be expected
given the effectiveness results, the difference was small and not statistically significant.
Conclusions: Stepped care does not confer an advantage over minimal intervention in terms of reduction
in alcohol consumption at 12 months post intervention when compared with a 5-minute brief (minimal)
intervention.
| Original language | English |
|---|---|
| Number of pages | 176 |
| Journal | Health Technology Assessment |
| Volume | 17 |
| Issue number | 25 |
| DOIs | |
| Publication status | Published - Jun 2013 |