Effectiveness and cost-effectiveness of opportunistic screening and stepped-care interventions for older alcohol users in primary care.

Objective: To compare the clinical effectiveness and cost-effectiveness of a stepped-care intervention versus a minimal intervention for the treatment of older hazardous alcohol users in primary care. Design: A multi-centre, pragmatic RCT. Setting: Primary care general practices in England and Scotland. Participants: Patients aged >= 55 years scoring >=8 on the Alcohol Use Disorders Identification Test. Interventions: Minimal intervention consisted of 5-minutes of brief advice. Stepped care consisted of an initial 20-minutes of behavioural change counselling. Step 2 was three sessions of Motivational Enhancement Therapy. Step 3 was a referral to local alcohol services. Progression between each step was determined by outcomes one month after each step. Main outcome measures: Average drinks per day, AUDIT-C, alcohol-related problems using the Drinking Problems Index, health-related quality of life using the Short Form 12. Costs measured from a NHS/Personal Social Care perspective. Estimated health gains in quality adjusted life-years measured assessed EQ-5D. Results: Both groups reduced alcohol consumption at 12 months but the difference between groups was small and not significant. No significant differences were observed between the groups on secondary outcomes. In economic terms stepped care was less costly and more effective than the minimal intervention. Conclusions: Stepped care does not confer an advantage over a minimal intervention in terms of reduction in alcohol use for older hazardous alcohol users in primary care. However stepped care has a greater probability of being more cost-effective. Trial Registration: Current controlled trials ISRCTN52557360