Injury prevention/original research
DIAL: A Telephone Brief Intervention for High-Risk Alcohol Use With Injured Emergency Department Patients

Presented in part at the 2007 American College of Emergency Physicians Research Forum, October 2007, Seattle, WA.
https://doi.org/10.1016/j.annemergmed.2007.11.034Get rights and content

Study objective

Brief interventions for high-risk alcohol use for injured emergency department (ED) patients have demonstrated effectiveness and may have a more pronounced effect with motor vehicle crash patients. We report on 3-month outcome data of a randomized controlled trial of injured patients, using a novel model of telephone-delivered brief interventions after ED discharge.

Methods

ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, participants received by telephone an assessment of alcohol use and impaired driving and then were randomized to treatment (n=140) or standard care (n=145). Treatment consisted of 2 sessions of brief interventions done by telephone, focusing on risky alcohol use. At 3 months, both groups had an assessment of alcohol use and impaired driving.

Results

Two hundred eighty-five patients were randomized and had a baseline mean Alcohol Use Disorders Inventory Test (AUDIT) score of 11.0 (SD=7.4). Three-month follow-up assessments were completed on 273 (95%). Mean AUDIT score decreased in both the treatment (mean change=−3.4; 95% confidence interval [CI] −4.5 to −2.3) and standard care group (mean change=−3.2; 95% CI −4.2 to −2.2). Measures of impaired driving decreased for the treatment group (mean change=−1.4 95%; CI −3.0 to 0.2) compared with standard care group (mean change=1.0; 95% CI −0.9 to 2.9; P=.04; d=0.31). Participants were stratified post hoc into 3 groups by baseline alcohol problem, with the treatment effect only being in the highest-scoring group (d=.30).

Conclusion

Telephone brief interventions decreased impaired driving in our treatment group. Telephone brief intervention appears to offer an alternative mechanism to deliver brief intervention for alcohol in this at-risk ED population.

Introduction

Alcohol has a well-documented role in injury occurrence.1 There is a particularly strong connection between alcohol use and motor vehicle crashes, with alcohol involved in approximately 41% of fatal motor vehicle crashes and 256,000 persons being injured in alcohol-related motor vehicle crashes.2 The resultant economic costs of impaired driving are staggering and estimated to be more than $50 billion.3 Thus, impaired driving is a public health problem with significant human suffering and societal cost that necessitates further efforts at control.

Emergency departments (EDs) are an opportune setting for identifying persons using alcohol in a risky manner, especially in those presenting for injury4 or from a motor vehicle crash.5 Injury has also been identified as a motivator to change alcohol use.6 In patients admitted to a trauma service, a brief intervention for alcohol has been found to reduce injury recidivism7 and subsequent impaired driving arrests.8 With injured patients being treated in an ED and discharged to home, Longabaugh et al9 found that those with hazardous alcohol use who received brief intervention for alcohol while in the ED and a follow-up booster brief intervention within 2 weeks reduced alcohol-related negative consequences and alcohol-related injuries more than those who received only standard ED care. This effect was not dependent on whether the patients had consumed alcohol before their injury. Furthermore, the treatment effect was greatest in those patients being treated in the ED after a motor vehicle crash.10 All of these studies7, 8, 9, 10 used a brief intervention that was based on the technique of motivational interviewing.11 Thus, injured ED patients, motor vehicle crash patients in particular, appear to be a group to target for screening and a brief intervention for alcohol problems.

Although organizations have advocated for brief intervention for alcohol to be done within the clinical practice of the ED,12, 13 barriers exist that have prevented its universal adoption. In the busy environment of the ED, diagnosis and treatment of acute medical illness and injury regularly usurp prevention efforts. ED staff may perceive this as not being part of their clinical care of the injured patients or may not have the skills or additional resources to address alcohol use problems. For patients, the ED may not be the ideal environment for a brief intervention because it is a noisy, chaotic, stressful, and uncomfortable setting. While in the ED, the patient is likely to be fatigued, in pain, and possibly under the influence of alcohol, which may affect the efficacy of the intervention. The “teachable moment” perhaps does not only exist in the ED, but opportunities to offer an intervention for alcohol use may extend to a period beyond the initial ED visit. This view has led us to now explore whether brief intervention for alcohol would be effective with ED patients after discharge from the ED. A practical mechanism for reaching patients after discharge from the ED would be using the telephone. Telephone interventions have demonstrated efficacy as a modality to change behavior. Programs that include a telephone intervention component have addressed varied health issues, including alcohol use in a primary care setting,14 management of chronic diseases,15 depressive symptoms,16, 17 agoraphobia,18 nutrition,19 and smoking cessation.20, 21, 22 Midanik et al23 have also found, in comparing telephone and face-to-face interviews assessing alcohol-related harm, that the telephone survey yielded significantly higher rates of self-reported alcohol-related harm compared with the in-person survey, possibly because of increased anonymity with telephone surveys. Although only some of these telephone interventions are motivational interviewing–based brief intervention and none use an ED population, the existing barriers to brief intervention being done in the ED and the practicality of the telephone necessitates telephone-delivered brief intervention testing with an ED population.

We do not know which ED patients would benefit from a brief intervention. If brief intervention is found to be effective with certain subgroups of ED patients, limited resources could be concentrated with those groups. Previous research has demonstrated a more pronounced effect of brief intervention with ED motor vehicle crash patients than other injured patients.10 This finding, along with the prevalence of alcohol use problems in motor vehicle crash patients,5 yields utility for this subgroup to be examined for treatment effect with a telephone brief intervention for alcohol. Also, we lack data on the number of alcohol problems among injured ED patients that provide the floor and ceiling for brief intervention to be effective. It may be that brief intervention has a differential effect on ED patients that depends on their alcohol problem severity. Using the Alcohol Use Disorders Inventory Test (AUDIT)24 screening data from a treatment-seeking sample, Donovan et al25 found that classifying patients according to 4 AUDIT score zones produced a linear relationship between the zone and measures of alcohol problem severity. Thus, AUDIT score zones appear to be a reliable instrument to divide patients into groups based on the number of alcohol problems and could be used to examine whether ED patients' alcohol problem severity predicts their response to brief intervention.

With the telephone being used successfully in counseling and having potential advantages for delivering brief intervention with ED patients, we decided to alter the locus of brief intervention for ED patients. The primary aim of the present study is to test the effect of brief intervention given by telephone soon after the patient's ED visit and followed by a “booster” brief intervention telephone session 2 weeks later on the extent of hazardous drinking and frequency of impaired driving at a 3-month follow-up. The secondary aims are to test whether the effectiveness of brief intervention given by telephone is moderated by the patient's initial alcohol problem severity and to test whether ED motor vehicle crash patients are more responsive to brief intervention given by telephone than are other injured ED patients.

Section snippets

Study Design

DIAL, Decreasing Injuries from ALcohol, is a randomized clinical trial using a 2-group design for injured ED patients discharged to home. All participants were recruited while in the ED, but enrollment, assessment, randomization, and all interventions were done by telephone in the days after discharge. The treatment group received a brief intervention about their high-risk alcohol use during that same telephone call and a subsequent brief telephone booster brief intervention session. The

Characteristics of Study Subjects

From November 2003 to June 2006, 17,234 patients were treated in the EDs while research assistants were present. The majority of patients were ineligible for our study because they were there for treatment of a medical illness, were to be admitted to the hospital, or were too clinically unstable to be screened. During this period, there were 6,335 motor vehicle crash and other injured ED patients for the research assistants to screen for eligibility. Research assistants did not screen 249

Limitations

The most significant limitation of our study was the large number of patients who were excluded from it, in part because of the many ED patients who were ineligible for our protocol because they were presenting for treatment of illnesses and not an injury. Future research in this area should address the efficacy of brief intervention for noninjured ED patients.

Despite our having a certificate of confidentiality from National Institutes of Health and assuring patients of the confidentially of

Discussion

Previous research31 has demonstrated the effectiveness of brief intervention delivered in an ED setting. Outcomes have included a decrease of negative consequences from alcohol use with injured ED patients9 and a decrease in reported impaired driving after a brief intervention delivered in the ED to alcohol-using adolescents.28 Our study expands on these results by demonstrating decreased impaired driving after a telephone brief intervention on hazardous alcohol use with adult injured ED

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    Supervising editor: Debra E. Houry, MD, MPH

    Author contributions: MJM, RL, TN, and RW conceived and designed the study. MJM obtained funding. All authors participated in the conduct of the study. JB provided statistical assistance. MJM drafted the article, and all authors contributed substantially to its revisions. MJM takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The study was funded by the Centers for Disease Control and Prevention's (CDC's) National Center for Injury Prevention and Control (R49/CCR1232280; Mello, principal investigator) and is registered at clinicaltrials.gov (NCT00457548).

    Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessary represent the official views of the CDC.

    Publication dates: Available online April 23, 2008.

    Reprints not available from authors.

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