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Rapid Responses: Rapid Responses published:
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ERRATUM table 5
- Anders Beich (5 September 2003)
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Role of Public Health community in identifying the problem drinkers
- Ediriweera B.R., Desapriya (10 September 2003)
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Number needed to screen and the prevention paradox
- Daniel C. Vinson (11 September 2003)
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Transcription errors and erroneous assumptions
- Peter Anderson (13 September 2003)
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Why do Beich et al. ignore selective screening?
- Nick Heather (13 September 2003)
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Neither errors nor erroneous assumptions – only disagreement and emotional misunderstanding
- Anders Beich, Thorkil Thorsen (15 September 2003)
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‘The Teachable Moment’ – opportunistic intervention for alcohol misuse.
- Robin Touquet, Robert Patton, Michael Crawford, and James S Huntley. (15 September 2003)
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Bad news for GP’s about alcohol counseling
- Jean-Bernard Daeppen, Nicolas Bertholet, and Bernard Burnand (18 September 2003)
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Screening and brief intervention in primary health care - worth doing in real life situations
- Kaija Seppä, Mauri Aalto (20 September 2003)
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Good doctors still enquire about their patient's drinking habits
- John R Kemm (20 September 2003)
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Misleading ‘Editorial’
- Tim Rapley (23 September 2003)
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INEFFECTIVE ALCOHOL SCREENING – BAD NEWS OR GOOD NEWS?
- Anders Beich, Thorkil Thorsen (26 September 2003)
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Alcohol screening as good as other recommended screens
- Richard Saitz (28 September 2003)
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Problem drinkers in Primary Care have complex needs
- Francis Labinjo (30 September 2003)
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Screening effect ten times greater than calculated by Beich et al.
- Nick Heather, Nick Heather, Robyn Richmond (1 October 2003)
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Doctors should ask every patient about alcohol
- Katherine M Conigrave, Elizabeth M Proude and John B Saunders (3 October 2003)
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Re: Screening effect ten times greater ... (by Heather and Richmond)
- Anders Beich, Thorkil Thorsen (5 October 2003)
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PROBLEMS IN USING NNT FOR STUDIES OF EXCESS DRINKING
- Ivar S. Kristiansen, Torbjorn Wisloff (8 October 2003)
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Re: PROBLEMS IN USING NNT FOR STUDIES OF EXCESS DRINKING
- Anders Beich, Thorkil Thorsen (9 October 2003)
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Re: Saitz R. Alcohol screening as good as other recommended screens
- Anders Beich, Thorkil Thorsen (20 October 2003)
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Beich et al. have got it wrong again
- Nick Heather (24 October 2003)
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Further errors in paper by Beich et al
- Paul G Wallace, Andy Haines (24 October 2003)
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Re: Beich et al. have got it right again
- Anders Beich (24 October 2003)
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Systematic screening for alcohol hazardous consumption :
- Philippe Michaud, Jean-Pierre Aubert (30 October 2003)
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Re: Further errors in paper by Beich et al (Response to Wallace and Haines)
- Anders Beich, Thorkil Thorsen (31 October 2003)
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Misrepresentation of published research
- Michael F. Fleming (5 November 2003)
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Re: Misrepresentation of published research (reply to Fleming)
- Anders Beich, Thorkil Thorsen (10 November 2003)
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Still serious reservations regarding this meta-analysis' conclusions
- Richard Saitz (13 November 2003)
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Calculations correct - conclusions depend on cultural background (reply to Saitz)
- Anders Beich, Thorkil Thorsen (30 November 2003)
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Intention-to-treat analysis was over-zealous - but this does not affect findings
- Ian R. White (9 December 2003)
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Beich et. al. Need to Make Data Analyses Available for Review
- Katharine A Bradley (14 December 2003)
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Does Beich et al add to the existing evidence?
- Olivia Wu, Robin Knill-Jones (17 December 2003)
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On accuracy of findings, the need for further analyses, and generalization beyond the trial context
- Anders Beich, Thorkil Thorsen (30 January 2004)
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On our use of the word "opponents" - we meant critics
- Anders Beich (2 February 2004)
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Playground football and the decline of respectful debate: alcohol screening and general practice
- Stephen Rollnick (7 March 2004)
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Anders Beich, research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark
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As a strange result of the editing process a few minor errors have been introduced into the Table 5 (screening effect for non-binge drinking) of our paper. In the study by Fleming (ref42) the screening effect (last column) figures should be: 3.7 (-0.3 to 7.5). In the study by Ockene (ref30) the max.no.of drinks (2nd column) should be: 5 drinks for men and 4 for women. In the study by Fleming (ref41) the max.no.of drinks (2nd column) should be: 5 drinks for men and 4 for women. In the study by Anderson (ref39) the max.no.of drinks (2nd column) should be: 11 drinks (men). On behalf of the authors I apologize for these disturbing errors. Anders Beich Competing interests: None declared |
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Ediriweera B.R., Desapriya, Research Associate BC injury Research and Prevention Unit, Centre for community Child health Research, BC, V6H 3V4
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Role of public health community in identifying problem drinkers Beich, A., Thorkil Thorsen, T., Rollnick, S., (1) recent systematic review shows that screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. Approximately 78% of Canadians consult a physician each year. Of these 6% are heavily dependent on alcohol, and up to 25% have or are at risk for alcohol-related health problems. (2)About 10% of premature death in Canada is caused by hazardous drinking, and more than 50% of fatal traffic crashes involve alcohol.(3) By assessing and treating alcohol abuse and alcoholism in their patients physicians can play an important role in preventing some traffic deaths and injuries. Individuals arrested for DWI have been targeted for preventive intervention of alcohol related problems. However in literature it was found that the high rates of diagnosed alcoholism among DWI arrestees suggest a need to identify individuals at risk earlier in the developmental process. Highway safety advocates and public health professionals have therefore suggested that an arrest for driving while impaired (DWI) offers a valuable opportunity to identify persons with substance-abuse disorders and refer them for treatment. But identifying offenders with these problems is challenging. Studies suggest that offenders in court-mandated screening programs often provide inaccurate information about their alcohol use and consequences and criminal histories. Offenders may fear recriminations from admitting to illegal drug use. Dissimulation may be motivated by fear of being labeled or mandated to undergo treatment for alcohol and drug problems. Denial, hostility, and suspicion also may contribute to under-reporting. The health, social and economic costs of alcohol abuse may be as high as $8.6 billion, of which $1.3 billion is spent on direct health care costs.(4)Physicians often fail to identify or are reluctant to intervene in cases of problem drinking, perhaps because of a lack of awareness, uncertainty about how best to intervene or doubts about the effectiveness of intervention.(5,6)There is, however, evidence that efforts to identify and treat problem drinkers can be cost effective (7) and that even brief low-cost behavioral interventions suitable for use in general health care settings are often helpful. (8-10) Although relapses are common following abstinence-oriented treatments many studies have shown that treatment can substantially reduce alcohol use and improve functioning in other areas of life as well.(5,6,7,8910) REFERENCES: 1. Beich, A., Thorkil Thorsen, T., Rollnick, S., Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis BMJ 2003;327:536-542 2.Alcohol Risk Assessment and Intervention (ARAI): A resource manual for family physicians. Mississauga (ON): College of Family Physicians of Canada; 1994 3. Smart RG, Ogborne AC. Northern spirits: A social history of drinking in Canada. Toronto: Addiction Research Foundation; 1998 4.Single E, Robson L, Xie X, Rehm J. The costs of substance abuse in Canada. Ottawa: Canadian Centre on Substance Abuse; 1996. Available: www.ccsa.ca/costhigh.htm (accessed 2003 Sep.7) 5.Negrete JC. The role of medical schools in the prevention of alcohol- related problems. CMAJ 1990;143(10):1048-53 6.Rankin JG, Ashley MJ, Brewster JM, Chow YC, Single E, Skinner HA. Preventing alcohol problems: preparing physicians for their roles and responsibilities [editorial]. CMAJ 1990;143(10):1005-6 7.Holder H, Longabaugh R, Miller WR, Rubonis AV. The cost effectiveness of treatment for alcoholism: a first approximation. J Stud Alcohol 1991;52:517-40 8.Hester RK, Miller WR. Handbook of alcoholism treatment approaches: effective alternatives. 2nd ed. New York: Plenum Press; 1994 9.Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993;315-35 10.Roberts G, Ogborne AC. Best practices in substance abuse treatment and rehabilitation. Ottawa: Ministry of Public Works and Government Services Canada; 1999. Competing interests: None declared |
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Daniel C. Vinson, Professor University of Missouri-Columbia
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Beich and colleagues(1) have raised an important question. What is a reasonable number needed to screen to improve one person’s health? For alcohol problems, that number is about 400. Is that too high? Firstly, consider the complexity of screening. A single question is reasonably sensitive and specific.(2) Its ease of use would reduce the work of screening, and that might make the large number needed to screen more acceptable. Secondly, consider the number needed to screen for other diseases, for example, hypercholesterolemia. If the prevalence of that condition is 25%, if half of those who screen positive accept treatment, and if the number needed to treat is 40 to 50 (it was 44 in the West of Scotland study(3)), one would improve the health outcomes of 2 or 3 patients if 1000 were screened, a number needed to screen of about 400. Beich and colleagues’ study is an example of the prevention paradox,(4,5) that few patients personally benefit from preventive interventions. Although there are fewer studies that brief alcohol interventions change patients’ health outcomes(6) than in pharmacotherapy for cholesterol, screening for alcohol problems is neither more nor less caught in that paradox. Dan Vinson, M.D. Department of Family and Community Medicine University of Missouri-Columbia Columbia, MO 65212 U.S.A. REFERENCES 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ. 2003;327(7414):536-542. 2. Williams RH, Vinson DC. Validation of a single question screen for problem drinking. J Fam Pract. 2001;50(4):307-312. 3. Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med. 1995;333(20):1301-1308. 4. Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed). 1981;282(6279):1847-1851. 5. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-38. 6. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26(1):36-43. Competing interests: None declared |
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Peter Anderson, Independent Consultant in Public Health Nijmegen University 6525HC Netherlands
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Incorrect data extraction Two of the eight studies that form part of the meta-analysis were mine (Scott & Anderson 1990; Anderson & Scott 1992). There are substantive errors in the numbers extracted from these studies and reported by the authors in tables 1, 2, and 3. Consequent to this there is an inaccuracy in the proportion of screened patients given the intervention reported in table 4. For example, according to the methodology of the authors, the figure for the men (Anderson & Scott 1992) should be 1.8% and not 3.05%, which actually makes the screening effect lower than that calculated in table 4 (but see below). The number of standard drinks has been calculated at 12g per drink (see footnote to table 2). This is certainly incorrect for the UK studies. Erroneous assumptions when calculating the screening effect The authors confuse research studies with normal practice, which affects their estimates of the screening effect, thus leading to flawed conclusions. For exampl, in our study of men (Anderson & Scott 1992), we used a screening questionnaire which included quantity frequency questions to measure alcohol consumption to identify the sample to include in the trial. 8483 men from 8 general practices completed the questionnaire. In normal general practice (and certainly how my own general practice operated at the time), interventions would be based on the results of this screening questionnaire. That is those people who had high alcohol consumption would either be offered advice to reduce their consumption or have their notes tagged, so that the next time they visited the practice they would be offered advice. 6% of the men scored positive on high alcohol consumption, so the proportion of screened patients given the intervention would normally be 6% or very close to it, and not the 3.05% reported in table 4 by the authors (which is inaccurate anyway - see above). What we did in the study was first to remove 20% (105) of the 524 identified heavy drinkers who then formed a part of another study. The remaining 419 were invited to an assessment interview for the design purposes of the study (such an interview would not be part of normal practice). 49% (205) attended the asssessment interview. Of these, 194 were heavy drinkers during the past week (a different measure to the quantity frequency questionnaire). We removed 40 of the 194 heavy drinkers during the past week who consumed more than 1050 grammes per week, as the protocol stipulated that we were studying the impact of the intervention on those consuming 350-1050 grammes of alcohol during the previous week. Again these heavier drinkers would normally be part of an intervention in normal general practice. This left us with 154 heavy drinkers randomly allocated to a control group and an intervention group. Thus the correct denominator to calculate the proportion of the screened patients given the intervention is not 8343, but just less than one third, 2640, adjusting for the above study designs. Thus the proportion of screened patients given the intervention is 154/2640=5.8%, similar to the 6% above. But, even without these errors, the conclusions by the authors are based on other erroneous assumptions. Health screening in general practice is not just about alcohol. It is about smoking, overweight, raised blood pressure etc. So the utility of screening has to be based on broader assumptions. A general practice can target its methods of screening to particular population groups or at particular times, such as new patient registration, which might decrease its workload and increase its efficiency. It is not correct to state that screening is not an effective precursor to brief interventions, without either undertaking cost effectiveness analysis or comparing it to other health interventions. In terms of health gain, screening and brief interventions for hazardous/harmful alcohol use might be a very cost effective intervention. No information is given about this. References Scott, E. & Anderson, P. (1990) Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Drug and Alcohol Review 10, 313-321; Anderson, P. & Scott, E. (1992) The effect of general practitioners advice to heavy drinking men. British Journal of Addiction 87,891-900. Competing interests: None declared |
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Nick Heather, Emeritus Professor School of Psychology & Sport Sciences, Northumbria University, Newcastle upon Tyne NE1 8ST
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It seems that the article by Beich and colleagues [1] is riddled with errors [2] and is seriously flawed in other ways [3]. Accepting for the moment the validity of their findings, however, the authors base their conclusions on a misleading dichotomy of “universal” screening versus no screening at all. As was pointed out [4] in relation to a previous publication from this group [5], a middle way between these extremes is to target screening at specific types of consultation – special clinics in which the proportion of positive cases can be expected to be higher than average and general health checks, new patient registrations etc. at which enquiries about drinking are more acceptable to both patients and health professionals. A recent Delphi study of relevant expert opinion in the UK [6] concluded that selective screening of this kind was to best way to promote the widespread implementation of screening and brief intervention for excessive alcohol consumption in primary health care. In the Accident and Emergency setting, Huntly and colleagues [7] described a list of the “top ten” indications for the identification of excessive drinkers and a similar list could usefully be provided for the primary health care setting. By ignoring the possibility of selective screening, Beich et al. imply that the only alternative to screening all patients attending the practice is to confine attention to those with obvious alcohol-related problems. This is a surrender to a practice in which advice and help is offered only when it is already too late to prevent harm. The consequences of this for alcohol policy in the UK would be disastrous and it can only be hoped that those responsible for finalising the National Alcohol Harm Reduction Strategy are made aware of the flaws in Beich et al.’s article. In their keenness to reduce the GPs’ workload, Dr. Beich and his colleagues do a grave disservice to patients whose excessive drinking put them at risk of medical and other kinds of damage. Nick Heather PhD, Emeritus Professor of Alcohol & Other Drug Studies, School of Psychology & Sport Sciences, Northumbria University, Newcastle upon Tyne NE1 8ST REFERENCES 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. 2. Beich, A. Erratum table 5. Rapid response bmj.com 2003; 5 September. 3. Anderson, P. Transcription errors and erroneous assumptions. Rapid response bmj.com 2003; 12 September. 4. Heather N, Anderson P, Gual A & Seppa K. Some screening is necessary to identify excessive drinkers early in primary care. BMJ 2003;326:550. 5. Beich A, Gannik D and Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview and study of the experiences of general practitioners. BMJ 2002;325:870-872. 6. Heather N, Dallolio E, Hutchings D, Kaner E & White M. Implementing routine screening and brief alcohol intervention in primary health care: a Delphi survey of expert opinion. J Substance Use; in press. 7. Huntly J S, Blain C, Hood S & Touquet R. Improving detection of alcohol misuse in patients presenting to accident and emergency departments. Emergency Medicine Journal,2001;18:99-104. Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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Unfortunately, it seems hard to have an open and non-emotional discussion about the evidence base for screening and brief intervention seen from different perspectives. Pressure and desperation characterizes Peter Anderson’s response to our article (1). He claims that we have not used the right data from his study for our analysis (which we have) and claims that we have made miscalculations (which we have not). Had Dr. Anderson taken his time to read our article thoroughly and open-minded, he would have known the premises for our calculations. And he might better have understood our conclusions. For instance, he might then have been able to see that in order to make comparisons easier, all units of alcohol were correctly converted into 12 grams standard drinks, depending on the number of grams of alcohol per unit stated in each paper, his own included. We have used exactly the same numbers as he puts forward himself in his response: the data that are available in his paper (2). The only real disagreement here is the classical one about the denominator. The facts are once again: 8483 men were screened, 524 (6.2%) screened positive, 419 were invited for an assessment interview, whereas 105 were put in another arm of the study. Of the 419 less than half (205) showed up, another 40 were excluded because they drank too much (!!). The remaining 154 were randomized into two groups; the third arm of the study had 105. To render unto Caesar the things that are Caesar's we added 154 and 105 to get 259 (3.05%) who might have been receptive to the brief intervention offered at baseline. Peter Anderson says that the 105 should not have been included in this figure, so that the percentage is only 1.8%. On the other hand he also claims that under normal circumstances all 524 that screened positive would have been offered brief intervention. But the truth is that at least 245 of them were non-receptive as defined by Feinstein (3) and 40 were excluded because they drank much too much. Anderson had drinking data on 100 patients at follow-up. To generalize the findings from these 100 patients to everyday practice to everyone who screen positive would make no sense. We said in our review: according to the data available 259 patients (3.05%) might have been receptive to the brief intervention offered in this study. Peter Anderson correctly states that health screening in general practice is not only about alcohol. Other public health experts have trotted out their favourite ideas for things to screen for. We propose that the utility of screening should be studied for each of these other areas mentioned, as well. Dr. Anderson finds it incorrect of us to state that screening is not an effective precursor to brief interventions, without either undertaking cost effectiveness analysis or comparing it to other health interventions. Again, we can refer to our article where the issue of cost-effectiveness is touched upon. Screening 1000 to find (at best) two or three that report drinking less after one year is not effective seen from the consultation room. It is not possible to conduct reliable cost-effectiveness analyses on screening and brief intervention in general practice before we know the effectiveness of usual case finding and usual care within a framework that respects the dynamics of a clinical encounter. To date no one has compared the two. It has been assumed that the effectiveness of usual (excessive drinking) case finding and care was zero. We regard this assumption as wrong. And we urge others to embark upon scrutinizing the whole issue further. 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003; 327: 536-42. 2. Anderson P, Scott E. The effect of general practitioners' advice to heavy drinking men. Br J Addict 1992; 87: 891-900. 3. Feinstein AR. Clinical epidemiology. The architecture of clinical research. Philadelphia: Saunders, 1985. Anders Beich
Competing interests: None declared |
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Robin Touquet, Consultant Accident & Emergency, St Mary's Hospital, Paddington, London, W2 1NY, Robert Patton, Michael Crawford, and James S Huntley.
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EDITOR - Getz et al are right to say it is good medical practice to support health-promoting activities (1). One example quoted is the ‘teachable moment’ for alcohol misuse. This uses the presenting complaint, e.g. fall, collapse, head injury, assault, accident, for the Accident and Emergency Department (A&E) as the ‘learning opportunity’ (2). Thereby the patient may start to develop insight into the consequences of their drinking behaviour. Brief intervention (BI) is reported to be effective in the Emergency Room (ER) following injury, especially when carried out by Alcohol Health Workers secondary to initial detection from the medical or nurse practitioner dealing with the patient’s presenting complaint (3). Although the consequences of alcohol misuse are explained to the patient, to encourage the take up of the offered appointment with the AHW (4), the actual BI is not carried out in the initial consultation. Therefore this is not an additional role for the practitioner - that will create extra work and therefore possible stress – be it the General Practitioner or the A&E practitioner (nurse or doctor). Rather it is stress relieving to refer the patient on for BI – which is time consuming and requires special skills – in anticipation that the likelihood of reattendance and thereby further work is lessened. We question whether the above has been taken into account by Beich et al (5), who do not specify 1.) If screening was selective for presenting conditions known to be associated with alcohol misuse (e.g. indigestion or lack of sleep) and 2.) If the BI - secondary to initial positive screening - was carried out by AHWs. Screening needs to have a logical link to the patient’s reason for initial consultation(1) if it is to be a true ‘teachable moment’; it also then ethically correct, perhaps medico-legally correct as well! Many ‘Teachable moments’ for underlying alcohol misuse are available in hospital, e.g. A&E, Facio-maxillary clinics, fracture clinics, Sexually Transmitted Disease clinics, to name but a few, as well as in General Practice. However these must not place additional workload on the practitioner, thereby risking clinical inertia. Rather extra resources are needed to fund AHWs, not only to provide expert BI, but also to provide training, encouragement and feedback for the referring doctors and nurses. Robin Touquet Robert Patton Michael Crawford Psychological Medicine, Imperial College London, Charing Cross site, W6 8RP James S Huntley 1 Getz L, Sigurdsson JA, Hetlevik I. Is opportunistic disease prevention in the consultation ethically justifiable? BMJ 2003;327:498- 500. (30th August.) 2 Huntley JS, Blain C, Hood S, Touquet R. Improving detection of alcohol misuse in patients presenting to an accident and emergency department. EMJ 2001;18:99-104. 3 Longabaugh R, Woolard RF, Niremberg TD, Minugh AP, Becker B Clifford PP et al. Evaluating the effects of a brief intervention for injured drinkers in the emergency department. Journal of studies on alcohol 2001;62:806- 816. 4 Patton R, Crawford MJ, Touquet R. Impact of health consequences feedback on patients acceptance of advice about alcohol consumption. EMJ 2003:20:451-452. 5 Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-540. (6th September) Competing interests: The first 3 authors are in receipt of a grant from the Alcohol Education & Research Council (AERC) for a RTC trial of written advice for alcohol misuse compared to written advice and BI (work in preparation). |
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Jean-Bernard Daeppen, Alcohol Treatment Center 1011 Lausanne, Nicolas Bertholet, and Bernard Burnand
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Beich and colleagues give bad news to primary care doctors concluding their meta-analysis of the brief alcohol intervention literature saying that only two to three patients per thousand screened will benefit from brief alcohol interventions (1). We question the rationale of using data extracted from studies aimed at assessing the efficacy of brief intervention to conclude on the effectiveness of the screening procedure. In studies designed to evaluate the efficacy of a therapeutic intervention, it is important to ensure internal validity, and thus inclusion and exclusion criteria have to be restrictive. For instance, in order to guarantee a high proportion of follow-up data, subjects are required to have a stable home address, provide significant others’ addresses, and speak the official trial language. Some of the brief intervention trials excluded patients who received advice to cut down on drinking in the last 6 months or last year. Nevertheless, their exclusion could not be considered as lack of efficacy of the screening process. We agree that the implementation of screening for hazardous alcohol use in primary care is a major challenge. A recent study conducted by Beich and colleagues described some of the difficulties GPs might experience when conducting systematic screening in their daily medical practice, including that GPs were convinced that patients did not respond honestly to screening, heavy drinkers refused screening, screening was associated to adverse effects on the doctor-patient relationship (2). Additional studies are needed to optimize systems of screening, improve acceptability both from patients and health care providers’ perspectives. Because of a 25 % prevalence of hazardous drinkers in primary care (3) and screening performance that seems similar to other screening procedures – typical of community based preventive interventions-, the further development and implementation of screening and brief alcohol intervention is a promising area of development for primary care. In other word we suggest that Beich and colleagues’ study does not adequately address the question of the effectiveness of screening and that one major challenge here is the optimal teaching strategies aimed at improving students’ and GPs skills to conduct this kind of prevention measures (4). Jean-Bernard Daeppen, MD Alcohol Treatment Center Mont-Paisible 16 University Hospital 1011 Lausanne Switzerland Jean-Bernard.Daeppen@inst.hospvd.ch Nicolas Bertholet, MD Alcohol Treatment Center and Clinical Epidemiology Center, University Hospital, Lausanne, Switzerland Bernard Burnand, MD, MPH Clinical Epidemiology Center and Health Care Evaluation Unit, University of Lausanne, Switzerland References 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. Bmj 2003;327(7414):536-42. 2. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. Bmj 2002;325(7369):870. 3. Reid MC, Fiellin DA, O'Connor PG. Hazardous and harmful alcohol consumption in primary care. Arch Intern Med 1999;159(15):1681-9. 4. Yedidia MJ, Gillespie CC, Kachur E, Schwartz MD, Ockene J, Chepaitis AE, et al. Effect of communications training on medical student performance. Jama 2003;290(9):1157-65. Competing interests: None declared |
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Kaija Seppä, Professor Medical School, Department of General Practice, FIN-33014 University of Tampere, FINLAND, Mauri Aalto
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Beich et al. report figures which are very discouraging in relation to screening and brief alcohol intervention. (1) However, their technically excellent results do not take into account that in real life situations 1) patients do not have to sign informed consents and participate in studies, which presumably makes them more receptive to intervention, 2) they may (after intervention) reduce their drinking even though the amount is not big enough to classify them as ‘successful’ according to the scientifically strict criteria used in Beich et al.’s analysis, but in which a reduction may be meaningful in the process of changing behaviour or in preventing alcohol-related harm, 3) a smaller reduction may additionally have an impact on other alcohol-related symptoms e.g. depression. We calculated the total cost in Finland, if all adult patients registered with one GP (the number of patients used in this example was 1600) were screened either opportunistically or systematically. (unpublished) The cost of the more expensive choice, systematic screening, is of the same magnitude as the treatment cost of one acute pancreatitis at a university hospital (about 30 000€). (2) The corresponding cost of opportunistic screening preferred, for example, by GPs in Finland, is less than half of that. This comparison suggests that even the published result, (2.6/1000 patients benefit from brief intervention after systematic screening, which makes 4.2 patients in a population of 1600), although apparently an underestimation, would have a remarkable effect on public health. REFERENCES 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. 2. Sillanaukee PA, Kääriäinen J, Sillanaukee P, Poutanen P, Seppä K. Substance use-related outpatient consultations in specialized health care; an underestimated entity. Alcohol Clin Exp Res 2002;26:1359-1364. Competing interests: None declared |
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John R Kemm, Public Health Physician Birmingham
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The useful review by Beich, Thorsen and Rollnick (BMJ September 2003) provides no grounds to justify the sweeping conclusion that “Only two or three patients per thousand will benefit from the laborious activities entailed in screening” or the comment on the front cover of the issue that “Screening for alcohol problems is largely ineffective in primary care”. These fallacious conclusions appear to rest on the assumption that unless the process leads to an intervention, which causes the patient to reduce their drinking, no benefit has resulted. The conclusions are wrong for the following reasons. First knowledge of drinking habits is a valuable aid to clinical assessment. Faced with a clinical problem the most probable diagnosis is often different for a heavy drinker and a light or non drinker. It is therefore as important for the doctor to collect and record information on drinking habits as for them to do so for smoking habits. Second it is important that patients should realise that their doctors are interested in drinking habits that can affect health. “Just asking can make a difference”. Third the paper confuses screening to select patients for entry into a trial of a particular intervention with screening to identify patients who might benefit from a whole range of different interventions. Fourth in areas as complex as human behaviour it is unreasonable to classify all outcomes other than reduced drinking as failure. At the very least brief interventions are likely to produce shift from pre- contemplation to contemplation and it may well move the decisional balance in a direction that produces change at a later date. Finally the use of the term laborious to describe screening is unfortunate. Given a reasonably organised surgery it is very simple to ask patients to complete lifestyle questionnaires and to file these with the notes. Of course there is scope for discussion as to how the systematic collection and recording of information on drinking habits can best be integrated into the daily work of a busy general practice. There is also need for discussion as to how select patients for intervention and how to make those interventions more effective. However it is not reasonable to suggest that primary care should be taking less interest in patient’s drinking behaviour or be less concerned to help those, who drink in a risky or health damaging way, to change. Competing interests: I am a board member of Medical Council on Alcohol and of Alcohol Concern |
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Tim Rapley, Research Associate Centre for Health Services Research, University of Newcastle upon Tyne, NE2 4AA
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The leader (1) that introduces the article by Beich and colleagues (2) is misleading. The opening sentence of the leader, in the section ‘This week in the BMJ’, notes that “Screening for excessive alcohol use and then providing brief interventions is not effective in general practice”. This statement suggests that both screening *and* brief interventions for excessive alcohol use are ineffective. Beich et al’s article provides no grounds to justify the description that brief interventions are ineffective in general practice or that brief interventions conducted after screening are ineffective in general practice. Their article was only concerned to engage with and comment on the research on the *screening component* of efficacy brief intervention trials. References 1. Anonymous. Alcohol screening in general practice is not effective. BMJ 2003; 327 2. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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Ediriweera and Desapriya (1) remind us that excessive drinking and alcohol-related problems are common and that even brief low-cost behavioural interventions suitable for use in general health care settings can be helpful. We agree on both issues. We found the average NNT for consumption below weekly limits in the trials meta-analysed to be 10 (7- 14). How the general practitioners can identify subjects among his/her patients for whom such an outcome of brief intervention in decency could be expected is another issue. Judging from the available evidence we conclude that screening does not seem to be an attractive alternative. Vinson (2) points out that our analysis exemplifies a more general prevention paradox: that only few patients personally benefit from preventive interventions. We believe that this paradox is actually generated by the systematic approaches to prevention suggested. Most of the preventive work that goes on already in general practice is not covered by this paradox. An experienced GP will typically use several types of knowledge and different sources of information (for example about the background, personality and present state of mind of the individual and functional capacity of his or her family at the moment) to decide when and where to address for example alcohol issues. Such information and knowledge cannot be provided by screening for risk factors extracted from large population studies. Daeppen (3) questions the rationale of using data extracted from studies aimed at assessing the efficacy of brief intervention to conclude on the effectiveness of the screening procedure. As examples he points out that some subjects might have been excluded from trials because they had no permanent address, did not speak the language or they had already received advice and not responded to it. In fact such cases were often lost or excluded even before the screening took place in the trials reviewed (as they might be in real life too). Anyway, we question that homeless people with alcohol problems would response to a GPs advice about drinking less (experiment or not). We also question that people who don’t speak the language would fit in the condensed SBI concept in everyday circumstances. And do we have reason to believe that subjects who have not yet responded to customized interventions will benefit from a subsequent brief standard intervention? We have pointed out, that in the trials we reviewed the considerable loss of 3 out of 4 subjects who had screened positive was first and foremost due to non-receptiveness, patients who screened false positive or “too positive” (or in some cases it was not specified why the subjects were lost). Only a few patients were lost because they were not accessible (i.e. died or moved away). Seppä and Aalto (4) as well as Kemm (5) put forward expectations for side benefit that might emerge in real life screening and brief intervention programmes. Intervention might cause some patients to reduce their drinking just a little bit, whereas others might move from precontemplation to contemplation in a process of change, and maybe screening has a beneficial effect in itself, they say. We have no wish to repudiate such speculative positive side effects and it was not within the aims of our meta-analysis to deal with them. We can however, easily think of negative side effects that might have to be considered as well; alienation, stigmatization, distrust and activation of defence reflexes being some of them. Touquet et al. (6) suggest that screening needs to have a logical link to the patient’s reason for initial consultation if it is to be a true ‘teachable moment’; it is also then ethically correct, and perhaps medico-legally correct as well, they say. We agree about the need for logic, timing and legitimacy, but we are not sure that screening is a very precise term to use then. Screening is by definition directed at (large) groups while the strategy rolled out by Touquet is targeted at individual cases. In the individual case we believe that the communication process (including establishing rapport, agenda setting, information exchange, and lowering resistance) is the hard part. This part requires skills and should be developed further in our opinion. We won’t comment on Nick Heather’s (7) unfriendly sidestepping the issue by attempting to raise doubts about the rigour of our review by referring to trivial errors that emerged from the editing process in one electronically published table. Regarding the opinion of Heather that our study “is seriously flawed in other ways”, we refer to our reply to Peter Anderson (8). We have reviewed universal screening as a precursor to brief intervention because it has been the widespread recommendation by WHO and others (Heather included) for several years. Now he suggests selective screening. Little is known about selective screening, but we urge Heather to review the evidence for selective screening in general practice and to include in his review the relation between case finding approach, the level of acceptance among patients and the overall effectiveness of such programmes. By referring to a study on expert opinions (by himself, not yet published) he takes us into a level in the hierarchy of evidence often flawed by attitude and personal interests and therefore usually given little attention in contemporary decision-making. We have taken note of the fact that the real disagreement is about the interpretation of the result of our meta-analysis rather than about the results as such. Among the responses to our meta-analysis we have not yet seen any substantial arguments against our conclusion that, seen from the consultation room, screening is at best a low-effective and not very attractive alternative for excessive drinking case-finding. Before any reasonable cost effectiveness calculations can be made we suggest that screening based programmes should be compared to patient-centred clinical approach like the one taking place already. Comparing screening only with screening and brief intervention is comparing two aliens. We consider our conclusion to be good news for anyone who truly believes that preventive work in health care is something else and much more than an increasing number of single risk factor or single disease focused standardized screenings and interventions. We believe that GPs should be much more directly involved in the process of quality improvement regarding the big issue of alcohol. No doubt that more could be done in general practice, especially if GPs were given influence on and ownership of future strategies, in stead of just being exposed to advanced implementation and marketing strategies for the dissemination of prevention programmes that might turn out to severely lack compatibility when put into practice (9). 1. Ediriweera BR, Desapriya. Role of Public Health community in identifying the problem drinkers. Rapid response bmj.com 2003; 10 September. 2. Vinson DC. Number needed to screen and the prevention paradox. Rapid response bmj.com 2003; 11 September. 3. Daeppen J-B. Bad news for GP’s about alcohol counselling. Rapid response bmj.com 2003; 18 September. 4. Seppä K et al. Screening and brief intervention in primary health care - worth doing in real life situations. Rapid response bmj.com 2003; 20 September. 5. Kemm JR. Good doctors still enquire about their patient's drinking habits. Rapid response bmj.com 2003; 20 September 6. Touquet R et al. ‘The Teachable Moment’ – opportunistic intervention for alcohol misuse. Rapid response bmj.com 2003; 15 September. 7. Heather N. Why do Beich et al. ignore selective screening? Rapid response bmj.com 2003; 13 September. 8. Beich A, Thorsen T. Neither errors nor erroneous assumptions – only disagreement and emotional misunderstanding. Rapid response bmj.com 2003; 15 September. 9. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview and study of the experiences of general practitioners. BMJ 2002; 325: 870-872. Anders Beich Thorjil Thorsen Competing interests: None declared |
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Richard Saitz, Associate Professor of Medicine and Epidemiology Boston Medical Center + Boston University Schools of Medicine & Public Health, Boston, MA, 02118,USA
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Beich et al. (1) set out to test the effectiveness of screening for decreasing excessive drinking, using efficacy trials. They conclude that screening is not an effective precursor to brief intervention and raise questions about the efficiency of universal screening in general practice. While I do not question the results of their meta-analysis, I believe they have drawn some incorrect conclusions. The proper study design to answer the question posed would be a randomized study of screening and brief intervention versus no screening (usual care case finding). No such studies were identified. Without citing such a study (e.g. Welte et al is an example though not randomized (2)) it is difficult to draw conclusions about the effectiveness of screening on clinical outcomes. In lieu of citing appropriate studies to answer the question, the authors reviewed randomized trials of brief intervention. Clinical trials are well known to sacrifice generalizeability for internal validity. It should be no surprise that many potential subjects are excluded. Beich et al. might say this is the point. But I believe clinicians are accustomed to generalizing the results of clinical trials beyond the highly selected populations studied. In the studies reviewed, a research screen preceded the brief intervention. The authors justify this choice of study by making the assumption that reasons for exclusion and dropout after a positive screening test, but before intervention, would be similar to what would occur in practice. This assumption is almost certainly incorrect. In clinical practice, there is no informed consent for research, no necessity to return for research visits for intervention, and no need to exclude patients with comorbidity or more severe alcohol problems. A screening test by a clinician could immediately be followed by feedback of results and further assessment and discussion (e.g. brief intervention). For example, I ask the screening questions and begin talking with the patient about their answers immediately. I do this with homeless individuals, people who do not speak my language (via an interpreter), and others who would not be in clinical trials. I am not unlike other primary care physicians in that respect. Admittedly, however, there are no randomized trials, nor will there likely ever be trials that prove effectivness in these patients. The authors state that a physician finding that 9% of those screened will screen positive could be disappointed, and imply that the 0.2-0.3% of those screened who will benefit from intervention is a small number (by using the word “only” and by their conclusions and recommendations). But these findings differ little from those for other conditions. In a randomized trial of hypertension treatment, 1% of those screened were enrolled, and the absolute risk reduction (ARR) for stroke was 3% in 5 years (number needed to treat [NNT] 33, compared to ARR 3% and NNT 10 for alcohol)(3). Similarly, a randomized trial of colorectal cancer screening found that fewer than half completed recommended annual screens, and the ARR for colorectal cancer mortality was 0.3% over 13 years (NNT 333)(4). As with Beich et al.’s finding of a “low” number who benefit, these data should not and have not dissuaded physicians from considering screening for hypertension and colon cancer to be standard practice. A seemingly low number who benefit in a clinical trial does not mean that screening is ineffective. Classic randomized trials are clearly not the right sources of data for drawing conclusions regarding the efficiency or effectiveness of screening. And doctors do not seem disappointed when they do not find colon cancer or benefit from hypertension screening. They are familiar with delivering preventive services routinely to all patients and know they are doing the right thing in clinical practice screening for colon cancer, breast cancer, hypertension, hypercholesterolemia, and providing vaccinations--all interventions guided not by specific patient characteristics beyond gender and age, and all proven effective by large population-based clinical trials. Universal screening with validated instruments is much better for identifying patients with alcohol problems than any currently known alternative. And the data summarized by Beich et al. support the notion that brief intervention after screening is efficacious. Pragmatic trials (5) and cost-effectiveness analyses in the future will likely find that alcohol screening followed by brief intervention is effective and cost- effective, much like other medical conditions routinely identified by screening. I do agree with Beich et al. that these data are needed, and that even when they are available, we will find that many people need to be screened to benefit few (as is true for most preventive interventions). Selective screening is a possible option but unlikely to be the best choice since risky drinking is best identified before consequences that would lead selective screening to occur. Scientists can respectfully disagree about the implications of valid results. The discussion about this paper seems to be just that kind of disagreement. Until further data are available for alcohol screening and intervention (cost-effectiveness analyses and effectiveness trials), I respectfully disagree with the conclusions drawn by Beich et al. and see no reason for recommendations for universal screening to change. 1. Beich A, Thorkil T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. 2003;327:536-42. 2. Welte JW, Perry P, Longabaugh R, Clifford PR. An outcome evaluation of a hospital-based early intervention program. Addiction. 1998 Apr;93(4):573 -81. 3. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program. JAMA 1991;265:3255-64. 4. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993;328:1365-1371. 5. Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 2003;290:1624-1632. Competing interests: None declared |
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Francis Labinjo, Consultant in Substance Misuse West Kent Health & Social Care NHS Trust 4 Manor Road Chatham ME4 6AG
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Beich et al (1) raise the important question about the screening for excessive alcohol use in general practice. Wu et al(2)convey an even more serious message about problem drinkers who have other problems such as mental illness, where they found that the rate of help seeking is so low as to be a public health concern. The report (3) of an inquiry by the Advisory Council on the Misuse of Drugs, after assessing the impact of problem alcohol use on children, makes a key recommendation that problem alcohol use by pregnant women should be routinely recorded at the antenatal clinic and these data linked to stillbirths, congenital abnormalities in the new-born, and subsequent developmental abnormalities in the child. Johnson et al (4) in a study in South London of the co- occurrence of severe mental illness and substance use disorder found that 34% of patients misused alcohol only and a further 22% used alcohol and cannabis. The reality in primary care settings is therefore complex and multifaceted. Kendrick et al (5)looked at patient and practice factors associated with contact with specialist services. The only predictors they found, were whether or not the patient's practice offered a special service on-site and greater patient needs of care on the Camberwell Assessment of Need(CAN). In my opinion the way forward is to approach this problem from a multi-agency perspective within primary care, including general practice. References: 1. Beich A, Thorsen T, and Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis BMJ 2003; 327: 536-542 2. Wu LT, Ringwalt CL, Williams CE. Use of substance abuse treatment services by persons with mental health and substance abuse problems. Psychiatric Service 2003; 54(3): 363-9 3. Hidden Harm. Responding to the needs of children of problem drug users. The report of an Inquiry by the Advisory Council on the Misuse of Drugs. Home Office. 2003 4. Miles H, Johnson S, Amponsah-Afuwape S. Finch E, Leese M, Thornicroft G. Characteristics of subgroups of individuals with psychotic illness and a comorbid substance use disorder. Psychiatric Services. 2003; 54(4):554-61 5.Kendrick T, Burns T, Garland C, Greenwood N, Smith P. Are specialist mental health services being targeted on the most needy patients? The effects of setting up special services in general practice. British Journal of General Practice 2000; 150: 121-126. Competing interests: None declared |
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Nick Heather, Emeritus Professor School of Psychology & Sport Sciences, Norhtumbria University, Newcastle upon Tyne, NE1 8ST, Nick Heather, Robyn Richmond
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After reading the recent article by Beich and colleagues(1), we went back to our 1995 article reporting an evaluation of the “Alcoholscreen” brief intervention programme in Sydney, Australia(2). We found that the findings of our study were seriously misrepresented in the Beich et al. article. In Table 4 they report the "proportions of sensible drinkers at follow-up" as 16/96 (16.67%) for the intervention group and 13/93 (13.98%) for the control group. The first of these is clearly the percentage of those in the intervention group reporting drinking under recommended levels at initial assessment, not at follow-up. The provenance of the second figure for the non-intervention control group is completely mysterious and does not correspond with any of the outcome percentages we reported in our paper. In fact, the proportions of good outcomes (i.e., those who had changed from being hazardous drinkers at initial assessment to “sensible” drinkers at 12-month follow-up) in our study were 7.3% in the intervention group and –5.4% in the control group, giving an Absolute Risk Reduction (ARR) of 12.7 and a Number Needed to Treat of roughly 8, rather than 2.7 and 37 respectively as calculated by Beich et al.. Equally misleading is the calculation of the prevalence of excessive drinking in the practice which the authors define as the number randomized to study groups (and therefore available for brief intervention) divided by the number screened. As has been pointed out(3), this ignores patients who were not offered brief intervention in the trials in question purely because of the requirements of a research study (i.e., those withholding informed consent to participate in research, those missed by the consent procedure or research assessment and those who would be difficult to trace for follow-up), but who would be offered brief intervention in real world conditions of general practice. Admittedly, we do not know what the outcome of intervention among such patients is likely to be, but it is clearly illegitimate to exclude them from the calculation of a screening effect in routine practice, as do Beich et al., because “the reasons for exclusion and dropout after a positive result on screening in the studies were similar to the reasons for the practitioner or the patient choosing to undergo no further assessment or intervention..." (p.541). One might also argue that patients excluded by the research protocol because of too high levels of dependence or problems and those who had previously received treatment for alcohol problems could also benefit from routinely- offered brief intervention by being encouraged to seek (further) treatment. In any event, subtracting from the number screened only those patients in our trial who met exclusion criteria (high dependence or problems, illness indicating abstinence, psychiatric disturbance, current or previous alcohol treatment, pregnant or planning pregnancy) gives a prevalence of 6.4%. Multiplying this by the ARR gives a screening effect of 8.1, 10 times the figures given by Beich et al.! The assumption on which our calculation is based, that patients who did not receive intervention in our trial for research-related reasons would have as good an outcome as those who did, is somewhat questionable, but far less questionable than the opposite assumption made by Beich et al. which is completely arbitrary, misleading and obviously tendentious. We do not know whether other trials used by the authors in their meta -analysis were as poorly represented as ours, but think this quite possible. Even if they were not, however, we find it depressing that an article founded on the kind of inaccurate calculations and highly dubious assumptions we have demonstrated in relation to our own study, should have been published in the BMJ, especially in view of the incalculable damage that this publication, if taken seriously, might do to the effort to reduce alcohol-related harm in Britain, Australia and elsewhere. Nick Heather,
Robyn Richmond
REFERENCES 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. 2. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90: 119-132. 3. Anderson, P. Transcription errors and erroneous assumptions. Rapid response bmj.com 2003; 12 September. Competing interests: None declared |
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Katherine M Conigrave, Staff specialist Drug Health Services, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, Sydney NSW 2050, Elizabeth M Proude and John B Saunders
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Re: Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis Beich et al question the feasibility of screening in general practice for excessive alcohol use as a precursor to brief interventions. Most of the screening in the Beich meta-analysis was conducted during the consultation. In our experience doctors don't like using questionnaires, and will often selectively apply them rather than screening all patients. The questionnaires were identified in the report only as ‘general health or lifestyle questionnaires’: their validity is not clear or how long they took to complete. The rate of drinking problems detected was less than 1%, while a WHO study in primary health care settings identified 22% of subjects ‘at risk’ using the using the well validated 10 item AUDIT questionnaire. These figures are in keeping with a prevalence of alcohol dependence of 5% in the adult population and at least double that number drinking above recommended limits. [1] Rather than disrupt the medical consultation, we prefer the 3-minute WHO AUDIT questionnaire, which is completed by every new patient in the waiting room. The experience of family doctors who have used this model is that most patients are happy to complete the questionnaire and to receive advice. [2] The University of Sydney has developed a brief and simple intervention kit (Drink-less) which provides a practical and non- confronting means for the doctor to provide advice to the patient on drinking, modelled on the WHO's successful five minute intervention. Studies have consistently shown that brief intervention reduces alcohol consumption. The meta-analysis points out that we shouldn’t expect consumption to necessarily return to within recommended limits. With the known association between level of consumption and social and physical problems, any reduction is desirable. Several studies have documented reduced problems after intervention. [3, 4, 5] We know that as little as five minutes of advice on drinking has proven benefit in reducing consumption. This is acceptable to the patient and can be integrated into a busy practice. If doctors were to stop providing brief advice on drinking as a result of reading this meta-analysis it would clearly be a huge mistake. If we used the parallel of hypertension, it would be like GPs no longer checking and treating blood pressures because the simplest available treatment only reduced BP by 30%, but didn't reduce necessarily reduce the diastolic back to 80 mm Hg. There is a role for maximising the efficiency of screening and constantly improving treatment modalities, as there is with any condition, but in the meantime doctors should ask every patient about alcohol consumption. Yours sincerely A/Prof. Katherine M. Conigrave, Staff Specialist, Drug Health Services, Central Sydney Area Health Service Building 82, Royal Prince Alfred Hospital, Missenden Rd, Camperdown NSW 2050 Phone 61 (02) 9515 8650 Fax (02) 9515 8970 email: katec@med.usyd.edu.au Prof. John B. Saunders, Professor of Alcohol & Drug Studies,
University of Queensland
Dr Elizabeth M. Proude, Research Officer, University of Sydney
References: 1. WHO Brief Intervention Study Group. A randomised cross-national clinical trial of brief interventions with heavy drinkers. American Journal of Public Health 1996; 86(7): 948-955 2. Gomel MK, Saunders JB, Wutzke SE, Hardcastle DM, Carnegie MA. Implementation of early intervention for hazardous and harmful alcohol consumption in general practice. Final report for the Research into Drug Abuse program. Department of Human Services & Health, July 1996 3. Berglund G, Nilsson P, Eriksson K-F, Nilsson J-A, Hedblad B, Kristenson H, Lindgarde F. Long-term outcome of the Malmo Preventive Project: mortality and cardiovascular morbidity. Journal of Internal Medicine 2000; 247(1): 19-29 4. Senft RA, Polen MR, Freeborn DK, Hollis JF. Brief intervention in a primary care setting for hazardous drinkers. American Journal of Preventive Medicine 1997; 13(6): 464-70 5. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review. Addiction 2002; 97(3): 293-4 Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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Heather and Richmond have read their own paper (1) from 1995 once again and they now ask us how we have calculated proportions of sensible drinkers and risk reductions in our meta-analysis (2) in which we included their paper. We have already stated in this our paper: we have determined the risk reduction (benefit increase) as the difference between proportions of sensible drinkers at follow-up in the respective groups, i.e. proportions of the ones randomized. In their report Heather and Richmond have unfortunately omitted to state the number of subjects drinking below limits at follow-up, i.e. only percentages in the text were available for our purpose, but facts taken from their paper are; At follow-up 24.0% were within limits in the intervention group. 66 intervention patients participated in the follow- up. 24% of 66 equal 16 patients. In the control group 61 patients participated in the follow-up of which 21.5% =13 were within limits. The intervention group (Alcoholscreen) counted 96 subjects, the control group 93. Unfortunately the randomization failed to distribute excessive drinkers evenly among groups in this particular study: at baseline there were more excessive drinkers in the intervention group than in the control group. Heather and Richmond propose that absolute risk reduction can simply be calculated as the difference between the proportion changes (baseline minus follow-up) in the respective groups. Unfortunately this is not a legitimate way to calculate risk reduction because we are no longer dealing with a binomial outcome: subjects can either become excessive drinkers, stay sensible drinkers, give up excessive drinking, stay excessive drinkers, or they can get lost between baseline and follow-up. The problem can be easily illustrated by trying to comprehend what it really means that “those who had changed from being hazardous drinkers at initial assessment to “sensible” drinkers at 12-month follow-up” ends up being -5.4% in the control group, as suggested by Heather and Richmond. It does not make any sense, does it? We admit that this misapprehension of risk reduction (ore benefit increase) is not uncommon. Nevertheless, we are somewhat embarrassed to have to put this in the open and we only do so in order to avoid that the discussion of our paper is disturbed by too much noise. Anders Beich Thorkil Thorsen References 1. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90:119-132. 2. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. Competing interests: None declared |
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Ivar S. Kristiansen, Senior reseracher Norwegian Centre for Health Technology Assessment, Torbjorn Wisloff
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In a recent paper in the BMJ, Beich and co-workers use the number-needed-to-treat (NNT) to express the effectiveness of interventions aimed at reducing excessive drinking (1). Unfortunately, their use of NNT may be misleading. In table 4 of the paper, confidence intervals (CI) for NNT are incorrectly computed (2). For example, the 95% CI of the absolute risk reduction in the Manwell study was (-0.009, 0.225) and Beich claims that the corresponding CI for NNT is (4, -113). It's not! NNT has two CIs: one at (-infinity, -111) and another at (4, infinity). Four other CIs are subject to the same type of miscalculation. More important, the authors compute the NNT at an arbitrary length of follow-up (12 months). It is unlikely that the effects of "brief interventions" are constant in time. Rather it seems plausible that the proportions that abandon excessive drinking are changing over time. While some give it up forever, others give it up for shorter or longer periods, or not at all. In this case, the effect would be better expressed in terms of average number of years without excessive drinking. It would require repeated measurements and time-to-event (survival) analysis for proper expression of the benefit. Finally, NNT cannot be used to infer the probability that the individual patient will benefit (3). It is therefore misleading to claim that "only two to three patients per thousand screened will benefit". Small reductions in problem-free-drinking time in many patients can create the same risk reduction and NNT as large reductions in a few patients. NNT is a problematic effect measure for interventions that postpone rather than totally prevent adverse outcomes. Ivar Sonbo Kristiansen, MD PhD MPH
References 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003; 327: 536-42. 2. Altman DG. Confidence intervals for the number needed to treat. BMJ 1998; 317: 1309-12. 3. Kristiansen IS, Gyrd-Hansen D, Nexoe J, Nielsen JB. Number needed to treat: easily understood and intuitively meaningful? Theoretical considerations and a randomized trial. J Clin Epidemiol 2002; 55: 888-92. Competing interests: None declared |
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Anders Beich, research fellow Central Res.Unit of General Pract., Panum Inst., Unversity of CPH, DK-2200 Copenhagen, Denmark, Thorkil Thorsen
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Sometimes details mean everything, sometimes they are trivial. Kristiansen and Wisloff(1) reproach us in a didactic tone (talking about miscalculations?) for choosing a way of reporting confidence intervals for NNT that can at worst be characterized as imprecise. We all know that a confidence interval for NNT cannot be a continuous interval when it covers both benefit and harm (when the interval for ARR includes 0). We would have preferred to report the interval example (4, -113) as (NNTB 4 to infinity to NNTH 113) like proposed by Altman et al.(2), and we actually did our first draft to BMJ. We were asked by the editorial board not to use infinity in our confidence intervals, thus we had no choice but to revert to a notation used before in BMJ (3) in our final manuscript. We would prefer to discuss this somewhat subtle matter further some other time. Kristiansen and Wisloff then reproach us that we have not used for example a time-to-event outcome in stead of just sensible drinking at 12 month follow-up (“an arbitrary length of follow-up”) , thereby demonstrating that they have not read the papers included in our meta- analysis and have no specific knowledge on the subject of our analysis. Others might prefer a continuous registration of blood alcohol concentration for each subject in the trial sample to monitor the intervention effect, but unfortunately there is not a buffet of outcome measures out there. Finally, Kristiansen and Wisloff put forward the public health maxim that if enough patients make small reductions even in problem free drinking this might create a large “amount of risk reduction” all in all. Again, had they read the papers in question they would have known that quite a few of these small reductions in question would be taking place in the flat neighbourhood of nadir on a consumption-mortality (or consumption -morbidity) curve. In one study mentioned by Kristiansen and Wisloff (4) the mean consumption in the trial sample was 14 drinks per week (SD=9). The possibility of confusion of statistical significance and clinical significance should be kept in mind every time the public health maxim mentioned above is put forward. We deliberately chose a medically and clinically relevant outcome measure like (at least) drinking within sensible weekly limits (at a time after intervention comparable between studies), because this makes some sense when you are facing the individual patient in a clinical context. Anders Beich Thorkil Thorsen REFERENCES: 1. Kristiansen IS et al. Problems in using NNT for studies of excess drinking. bmj.com, 8 Oct 2003 2. Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with confidence. London: BMJ Books, 2000. 3. Rembold CM. Number needed to screen: development of a statistic for disease screening. BMJ 1998; 317: 307-12. 4. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res 2000; 24: 1517-24 Competing interests: None declared |
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Anders Beich, research fellow Central Res.Unit of General Pract., Panum Inst., Unversity of CPH, DK-2200 Copenhagen, Denmark, Thorkil Thorsen
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Richard Saitz scrutinizes our conclusions and raises a few quite important issues in his response. In fact he has in a very nice way summarized the most important criticisms raised in different rapid responses to our paper (1) and we appreciate very much the thoroughly constructive tone of his response. Our answers here are meant in the same spirit. WHICH STUDIES TO INCLUDE ANSWERING OUR QUESTION: We would have preferred to review studies that compared screening and brief intervention with usual case finding and usual care, but we haven’t been able to locate any taking place in general practice. It seems that screening for hazardous drinking became an imperative a long time ago and therefore part of the control conditions. The study cited by Saitz (2) is an evaluation example of a hospital-based early intervention program (screening and intervention versus usual case finding and care) that seems to have had some impact but only on subjects with signs of alcohol dependence, that is: a different context and a different target group. Until studies on program effectiveness, compatibility and suitability are available we can disagree on how to use results from efficacy studies. Unlike Saitz, we believe that clinicians should demand that effectiveness studies of prevention programs are carried out before implementation is recommended. Besides, we should realize that the justification of such programs is depending on compatibility, suitability and other matters as well; and somehow it seems a naturalistic fallacy to recommend general practitioners to take on new tasks just because evidence of cost-efficacy is available. An implicit value judgment has been put in between efficacy and implementation somewhere. We believe such judgments should be put in the open and not be ignored or concealed. GENERALIZING FROM STUDIES ON HIGHLY SELECTED POPULATIONS: Saitz believes that clinicians are accustomed to generalizing the results of clinical trials beyond the highly selected populations studied. When practicing evidence based medicine it should include that the clinician considers the following factors (3): “- Is the relative risk reduction that is attributed to the intervention likely to be different in this case because of the patient's physiological or clinical characteristics? - What is the patient's absolute risk of an adverse event without the intervention? - Is there significant comorbidity or a contraindication that might reduce the benefit? - Are there social or cultural factors that might affect the suitability of treatment or its acceptability? - What do the patient and the patient's family want?” Why is it that lifestyle preventive initiatives should not trigger the very same questions within the clinician? Why should good clinical practice be overruled by preventive automatics? Saitz believes that the drop-out between screening positive and receiving brief intervention in real life practice will not be similar to the drop-out in a trial (no informed consent needed, no need to return for further visits, and no need to exclude patients with comorbidity, severe alcohol problems or homelessness) If the intervention is to be motivational and of use to the patient we believe there needs to be a clinical parallel to informed consent (asking permission to touch upon lifestyle issues, and explaining why), especially when there is no immediate logical link to the patient's reason for coming to see the doctor. In clinical situations the need for further visits would likely emerge if the first visit was successful in establishing rapport and an agenda that included drinking. But routinely giving brief intervention to alcohol dependent patients regardless is in our view likely to be a mismatched intervention. Giving brief intervention to people who are seriously ill or living in the street we consider to be ill-timed or even unethical. COMPARABILITY OF NNTs AND DOCTORS DISSAPOINTMENTS: We do not believe that NNTs can be compared the way Saitz does it. NNT for reducing alcohol consumption to within sensible limits should not be compared to NNT for avoiding one stroke or one case of advanced colorectal cancer. It certainly matters which benefit we are talking about. Proxy measures can be relevant but they should not be confused with consequences like these. Saitz says that “doctors do not seem disappointed when they do not find colon cancer or benefit from hypertension screening”. But doctors would probably be disappointed if they were screening for colorectal cancer and found themselves unable to offer effective treatment to more than 3 out of 100 early cancers diagnosed. Such a screening would not fit well with the rationale for screening as defined by WHO (4). According to our analysis, the factual documentation in trials on screening and brief intervention suggests that 3 out of 100 screened positive (2-3 out of 1,000 screened) benefit from the “therapy”. SAITZ CONCLUDES: “Universal screening with validated instruments is much better for identifying patients with alcohol problems than any currently known alternative”. We find this conclusion to be somewhat tautological. Better implies a reference point, but the reference point (usual case finding as it takes place in most countries) has not been established yet. Saitz also concludes that our review supports the notion that brief intervention after screening is efficacious. We kindly remind him that we discovered abundant sources of bias in the trials included for meta- analysis, all tending towards overestimation of effect. We omitted to give guesstimates of the size of these biases in order not to blur the screening message. Nevertheless, we are somewhat surprised that nobody, not even the authors of the most biased trials, have taken a position in regard to our scrutiny of the internal validity of these trials. Anders Beich Thorkil Thorsen REFERENCES 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-42. 2. Welte JW, Perry P, Longabaugh R, Clifford PR. An outcome evaluation of a hospital-based early intervention program. Addiction. 1998;93:573-81. 3. Sheldon TA, Guyatt GH, Haines A. Getting research findings into practice - When to act on the evidence. BMJ 1998;317:139-42. 4. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization, 1968. Competing interests: None declared |
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Nick Heather, Emeritus Professor School of psychology and Sport Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST
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In their reply(1) to our comments(2) on their article in the BMJ(3), Beich and Thorsen compound the errors in the original publication. First, they explain how they calculated the EER and CER given in their Table 4 but this calculation ignores the fact that the analysis, as is clearly stated in our paper(4), was by intention to treat, with patients lost to follow-up regarded as failures. Thus using their method of calculation the correct EER should be 23/96 and the CER 20/93. This mistake at least deserves another published erratum to their article. Secondly, if they had read our article carefully they would have discovered why some patients in both groups were recorded as having good outcomes (i.e., drinking below recommended levels) at initial assessment. This was because screening and entry to the trial was based on a rough quantity-frequency consumption measure but, for greater accuracy, the outcome measure was a detailed retrospective diary of actual drinking over the past week. It is quite understandable that some patients should be above limits on the former but not the latter. Beich and colleagues based their calculation of absolute risk reduction on the standard method which can only deal with “events” occurring during a follow-up period and assumes that intervention and control groups are initially identical with respect to the outcome measure. In our case, however, this assumption and the standard method are clearly inappropriate, since it makes no sense to calculate the “risk” in the intervention group without also taking account of the initial probability of a good outcome in the same group of subjects. Thus to calculate the risk difference(5), we need to subtract the proportion in each group showing a good outcome initially from the proportion in each group showing a good outcome at follow-up. Contrary to Beich and Thorsen’s view, it makes perfect sense that this could be a negative quantity in the control group i.e., an increase in risk of harm rather than benefit. The consequence is that we arrive at an ARR, NNT and screening effect exactly as stated in our earlier comment(2). Finally, while contributors to this important debate have every right to argue their case as strongly as possible, the interests of the debate, and indeed of people risking their health through their alcohol consumption, would be better served if Beich and his colleagues could refrain from the sort of unpleasant sarcasm found in their concluding paragraph. References 1. Beich A, Thorsen T. Re: Screening effect ten times greater … (by Heather and Richmond). Rapid response bmj.com 2003; 5 October. 2. Heather N, Richmond R. Screening effect ten times greater than calculated by Beich et al.. Rapid response bmj.com 2003; 1 October.. 3. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. 4. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90: 119-132. 5. Deeks JJ, Altman DG. Effect measures for meta-analysis of trials with binary outcomes. In Egger M, Davey Smith G, Altman DG, eds. Systematic reviews in health care: meta-analysis in context. London: BMJ Books, 2001: 313-335. Competing interests: None declared |
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Paul G Wallace, Professor Royal Free and University College School of Medicine NW3 2PF, Andy Haines
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Sir, In common with other authors of trials of alcohol intervention cited by Anders Beich and colleagues(1), we went back to our paper reporting the MRC trial of general practitioner intervention of patients with excessive alcohol consumption which was published in the BMJ in 1988(2). As many of the authors of the other trials, we found significant errors in the reporting of our trial, which we enumerate below: 1. Definition of excessive drinking was NOT >22u/week (males) and > 13 units/week females) as reported. It was ACTUALLY =/> 34 units/week (males) and =/>21 units/week (females), ie substantially higher than that reported by Beich et al 2. The mean consumption at entry to the trial was NOT 42 units/ week (men) and 24 units/week (women). It was ACTUALLY 62.2 /week (men-treat) and 63.7u/week (men-control), and 35.1 u/week (women-treat) and 36.8 u/week (women control) according to the interview data. In other words, the levels of consumption in all groups at entry to the trial were substantially higher than those erroneously reported by Beich et al. 3. The treatment goal was NOT 22 units/week (men) and 13 units/week (women). It was ACTUALLY not more than 18 units/week for men and 9 units/week for women, though the cut points for excessive drinking at the12 month follow-up assessment remained =/>35 units/week (men) and =/> 21 units/week (women). 4. The change in the number of drinks consumed per week were NOT as stated in the paper ie -6.7 u/week (men) and -3.5 u/week (women). They were ACTUALLY -10.1 u/week (men) and -5.2 u/week (women). The authors suggest that “the two largest studies may have been affected by attrition bias”. Our study was one of the two cited by the authors, and we think it highly unlikely that attrition bias would have increased the apparent treatment effect. Indeed, we used a very conservative method for the intention to treat analysis, which assumed no reduction at all from baseline consumption in subjects in the treatment group who were lost to follow-up, whereas even the control group reduced their consumption. Thus, if anything our study would have tended to underestimate the true treatment effect. Finally, the authors suggest that our study together with all the others included in the meta-analysis, showed that “screening in general practice does not seem to be an effective precursor to brief interventions” This statement is confusing and potentially misleading. It should be made clear to the readers that the screening methods employed by all of the studies reviewed by Beich et al were designed specifically for use in RCTs of intervention strategies, and were not necessarily optimal for routine clinical practice, where a different set of drivers and constraints exist. In our own study, we adopted a method designed to yield the largest number of previously unidentified excessive drinkers in the shortest period of time, in order to enable us to recruit efficiently to the trial of intervention. In the discussion section of our paper we stated: “In practice, the Health Survey Questionnaire could be used to define a “high risk group,” either by the GP or as part of health promotion activities, undertaken by the nurse. Intervention could be started immediately, thus avoiding the problem of dropouts.” Taking into account all of these issues, together with the points made by the other authors of the trials included in the meta-analysis, we would suggest that the paper by Anders Beich and his colleagues needs some fundamental revisions. We believe that it would be helpful if Dr Beich and his fellow authors could now openly acknowledge the errors in their paper, and issue an appropriate statement for the readers of the BMJ and others. Yours etc Paul Wallace, Professor, Dept Primary Care and Population Sciences, UCL Andy Haines, Dean, London School of Hygiene and Tropical Medicine. 1 Anders Beich, Thorkil Thorsen, and Stephen Rollnick Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis BMJ, 2003; 327: 536 - 542 2 Wallace P, Cutler SF, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988. 297: 663?668 Competing interests: None declared |
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Anders Beich, research fellow Central Res.Unit of General Pract., Panum Inst., Unversity of CPH, DK-2200 Copenhagen, Denmark
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We have clearly stated the premises for our calculations, we have not made any of the mistakes claimed by Heather, we have read the paper in question carefully, and we propose that the readers do the same if they want to judge for themselves. We have not intentionally used sarcasm in any of our replies to Heather. Anders Beich Competing interests: None declared |
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Philippe Michaud, coordinator programme bmcm 8 avenue du général Gallieni, F92000 NANTERRE, Jean-Pierre Aubert
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Systematic screening for alcohol hazardous consumption: the best way to enter a dialogue on alcohol with patients. Philippe Michaud, MD, coordinator of Programme ‘Boire Moins c’est
mieux’, 8 avenue Gallieni F-92000 NANTERRE Jean-Pierre Aubert, MD, general practitioner, part-time lecturer, Xavier-
Bichat medical school, 32 Rue Hermel, F-75018 PARIS
The discussion of the article of Beich, Thorsen and Rollnick (1) has something emotional, Beich says (2), and it is true that all teams working, as he still recently did, in the framework of WHO phase IV study, felt on their faces the pain of the slap: the advocacy for dissemination and implementation of early detection and brief intervention by general practitioners could become much harder after this article. Beich (3) assumes that WHO has chosen a wrong strategy which expose GPs to ‘advanced implementation and marketing strategies for the dissemination of prevention programmes that might turn out to severely lack compatibility when put into practice’. Nevertheless, we think that through this discussion we touch one of the most sensible point concerning the difficulty of alcohol screening. Screening is not the most difficult medical task. Kemm (4) writes ‘given a reasonably organised surgery it is very simple to ask patients lifestyle questionnaires and to file this in the note’. Conigrave (5) and her Australian colleagues write that ‘patients were happy to complete the questionnaire and to receive advice’. The reluctance about systematic screening is, in France like anywhere else, often related to the fear of a confront with resistant patients (7). But the fears can rapidly be overcome after some weeks of practicing excessive drinking detection and brief intervention. Why and how? First, the general public has a high level of confidence in GPs, and a telephone survey conducted in the framework of our programme in a 1608 person sample showed that GPs’ legitimacy on alcohol screening and intervention was widely approved (83%) (8). Second, resistance is on doctors’ side, except maybe, but not certainly, for patients dependent on alcohol (see below). The doubts about utility, legitimacy, feasibility, efficiency are the main sources of health workers’ absence of initiative for a dialogue about drinking. And it is true even in the situations where assessment of alcohol consumption is of major importance : e.g. pregnancy, or HCV infection. So even when it is necessary to ask, and unethical not to ask, doctors don’t ask because they don’t dare, they don’t know how, they fear to be ‘intrusive’. Third, experience of a frequent dialogue on alcohol with their patients can persuade most doctors of patients’ acceptance. This is the main reason why we think that the best way to carry away a change in medical opinions and practices is to make doctors try a systematic approach of screening : a more ‘opportunistic’ approach often leads to stereotypes and stigmatisation – and defence reflexes (why me ?). And selective screening is a non-sense a certain situations, like pregnancy. Moreover, the more easily an ‘excessive drinker’ is detected, the more probably he or she is dependent : in that case a brief intervention could be ineffective (or apparently ineffective), leading the doctor to the conclusion that all brief interventions are ineffective. In France, most GPs do not have any assistant in their surgeries, and when asked about the feasibility of alcohol screening, say they’d prefer a standardized interview questionnaire to AUDIT in the waiting room. Through a marketing strategy achieved as recommended by WHO, we offered them such an adapted screening tool, and we recently trained in two-hour training sessions 78 GPs - 17 % of our medical sample, proposing them a systematic screening activity and the typical content of a 6 to 8-minute intervention. The interviews achieved before training and after three months of practice show the high level of change in doctors’ opinion about feasibility of a dialogue – even with dependent people. (9) To end our comments, we’d say that a systematic screening can be used in a client-centred relationship, for alcohol as for hypertension or hypercholesterolemia. Clients can rapidly be informed that it belongs to doctor’s routine. And you can in most cases avoid the patient’s refusal - simply by begging for permission. We do believe that there is no harm to ask dependent persons, if with respect and empathy. Both of us, the addiction specialist as well as the general practitioner, heard many times ‘alcoholics’ complaining that their doctors never accepted the lines they threw (10). We wonder whether we should propose to train the patients about motivational approach so that their doctors accept to enter a dialogue on alcohol. 1. Beich A, Thorsen T and Rollnick T. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542 2. Beich A, Thorsen T. Neither errors nor erroneous assumptions – only disagreement and emotional misunderstanding. Rapid response bmj.com 2003; 15 September. 3. Beich A, Thorsen T. Ineffective alcohol screening – bad news or good news ? Rapid response bmj.com 2003; 26 September. 4. Kemm JR. Good doctors still enquire about their patients’ drinking habits. Rapid response bmj.com 2003; 15 September. 5. Conigrave KM, Proude EM and Saunders JB Rapid response bmj.com 3 october 2003; 6. Samuel R., Michaud P. Le généraliste face au risque ‘alcool’ : une étude qualitative. Pratique médicale et thérapeutiques (2002), 21, 23-26. 7. Saunders JB, Sonia E Wutzke General Practitioners’ current practices and perceptions on preventive medicine and early intervention for hazardous alcohol use: A 16 country study. French chapter by Huas D, Bouix JC, Gache P and Rueff B. WHO, 2000. 8. Michaud P, Fouilland P, Grémy I, Klein P. Alcool, tabac, drogue : le public fait confiance aux médecins. La Revue du Praticien-Médecine générale, 2003, 17 : 605-608. 9. Michaud P, Fouilland P, Abesdris J, de Rohan S, Dewost AV. Rapport d’enquęte ‘trois méthodes de promotion’, ANPAA, Paris, 2003. 10. Aubert JP : editorial, La Revue du Praticien-Médecine générale, 1999, 13, 1889-90 Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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What Wallace and Haines in paragraphs 1-4 claim to be errors are simply our conversions (x 2/3) from units of alcohol (8 grams ethanol) to drinks (12 grams ethanol). The conversions were done only for comparison purposes as mentioned in our paper. The helpfulness for UK readers of such conversions can apparently be discussed but they can hardly be classified as errors. Intention-to-treat approaches to analysis do not exclude the possibility of attrition bias. If only a few more failures are lost from (or denied in) the intervention group (or a few more successes are lost from the control group) it can seriously affect the benefit increases estimated. When follow-up rates differ between comparison groups we believe there is good reason to be alert to such bias. The use of self- reported outcome measures in combination with no blinding of participants is a mixture that in our opinion enables the possibility of such a bias. The screening disagreement is seemingly a hard one to solve. It is of course true that we included screening and brief intervention studies that were primarily designed to evaluate the efficacy of intervention, but in most of these studies screening is included in the concluding implications and recommended for use in daily practice. In their response to our paper Wallace and Haines repeat their recommendations from 1988 of the very same tool they used for RCT screening in their impressive study: "In practice, the Health Survey Questionnaire could be used to define a “high risk group,” either by the GP or as part of health promotion activities, undertaken by the nurse. Intervention could be started immediately, thus avoiding the problem of dropouts" We have not tried to conceal what we did. The title of our paper clearly states that we're looking at screening in general practice trials. We have deliberately chosen a conservative interpretation of external validity by counting successes per 1,000 screened, because we do not think that preventive medicine should build on hopes, aspiration, or speculation. We are saddened by the hurtful tone in some of the responses to our paper. We very much welcome any responses to our paper by clinicians, researchers or others who wish to discuss our conclusions or make queries. We have no wish to engage in further rhetorical contradiction, but we feel obliged to respond when disagreement about the best way to express a certain amount of alcohol (about which there is no disagreement) is presented as error. Anders Beich and Thorkil Thorsen Competing interests: None declared |
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Michael F. Fleming, professor Department of Family Medicine, UW - Madison, 777 South Mills St., Madison WI 53715
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I would like to comment on the article recently published in your journal by Anders Beich and colleagues (1). I was the PI on 3 of the 8 studies used in their analysis (2,3,4). Project TrEAT was conducted on adults 18-65, Project Goal on persons over 65 and the subanalysis of the TrEAT sample focused on women of childbearing age. I have seven concerns about the information contained in the article. First, Table 1 is not accurate. Category 1 lists the number of participants in each of the 8 studies used for their analysis. I assume these numbers were derived from the number of subjects who were randomized and participated in follow-up interviews. I am not sure why they did not list the total number randomized since we followed an intention-to-treat analysis. In addition, we obtained data from medical records, claims data, and public accident records on 100% of the sample. The correct numbers should have been 774 not 723 for TrEAT, 158 not 146 for GOAL, and 205 not 174 for the third trial. Second, the authors do not define the other categories contained in Table 1 and I was unable to understand the derivation of the numbers cited. Each of my papers cited (2,3,4) contained a sampling tree which stated what happened to all subjects screened. For example the second category presented in Table 1 was “Subjects excluded or not eligible”. The number listed for Project TrEAT was n=63. This number is incorrect. For some reason they chose to ignore persons excluded for symptoms of alcohol withdrawal, persons drinking more than 50 drinks per week, persons who were alcohol dependent, patients drinking below cut-off limits. Another example is the category “The number of persons screened lost for reasons not clearly specified”. The authors used the number 853 for Project TrEAT. The article (Fleming, 1997) clearly states why the 853 subjects were not randomized. I do not understand why the authors placed these subjects in the “Lost category”. They were not lost. The authors misrepresented published data. Third, the authors suggest my studies may have been affected by attrition bias. We had follow-up data on 98% of the subjects in Project TrEAT at one or more of the 5 follow-up interviews. We utilized a conservative method for the intention to treat analysis. We had utilization, cost, mortality and legal data on 100% of the subjects randomized. Attrition bias is unlikely. Fourth, the authors state lack of blinding may have led to an exaggerated treatment effect. The authors ignored the finding that less than 13% of subjects in the control group reported any kind of physician intervention during the 12-month follow-up period (see Fleming 1997). In addition, chart review found that only 4 control subjects out of 382 were referred to alcohol treatment. Researchers who conducted the follow-up interview could not identify group assignment. These findings suggest blinding was effective. Fifth, the authors chose to ignore the finding of significant reductions in health care utilization with Project TrEAT. This finding confirms a robust treatment effect reported with alcohol. Reducing health care utilization is a downstream effect that requires significant reductions in alcohol use. Again, they misrepresented our data. Sixth, the authors chose not to report the 48-month follow-up data on Project TrEAT which demonstrated highly significant reductions in alcohol use, utilization, deaths (36 months only), costs and accidents over 48 months, not just at 12 months. This data was published 18 months prior to the Beich article. Seventh, the biggest concern I have with the report is the use of research data to estimate the clinical utility of alcohol screening and brief intervention. The authors report that only 2 or 3 persons out of 100 could potentially benefit from screening and brief intervention. They base this hypothesis on comparing the number of primary care patients screened by the number who appear to benefit from the intervention. Recruiting subjects to participate in clinical trials is a difficult business - whether the trial is a blood pressure trial or a heart disease trial or a lipid trial or an alcohol trial. If one reviews RCT’s reported in BMJ over the last 5 years, one finds that less than 90% of persons who have high blood pressure or heart disease or lipid problems or depression or alcohol problems and who are potentially eligible are randomized into these studies and participate in the follow-up procedures. That is why these trials have to screen tens of thousands of subjects to obtain sufficient sample sizes. There are a number of reasons why patients do not participate in RCT’s. These include failure to meet all the eligibility criteriam lack of time, fear of research and confidentiality issues. There is also the issue of informed consent. However, that does not mean that all patients who screen psotive for high blood pressure or high-risk alcohol use will not benefit from a trial that shows a positive treatment effect. The authors conclude that only 2 of the 17 (2,925/17,695 see figure 1 Fleming 1997) patients who screened positive in the Project TrEAT study would benefit from brief intervention. Where is the evidence to show that the other 15 persons out of 100 will not benefit from screening and intervention? Can you imagine the public outcry if the British government agreed to provide blood pressure treatment to only 10% of persons with this problem? In addition, who is to decide which 10% of the population is most likely to benefit? I am disappointed with the authors and the editorial board of BMJ. An editorial and public apology to the authors of these trials for the misrepresentation of the evidence is in order. References: 1) Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general pracice: systematic review and meta-analysis. BMJ. 2003;327(Sept 6):536-540. 2) Fleming MF, Barry KL, Manwell, LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997; 277(13):1039- 1045. 3) Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. Brief physician advice for alcohol problems in older adults. A randomized community based trial. Journal of Family Practice. 1999;48(5):378-384. 4) Manwell LB, Fleming MF, Mundt M, Stauffacher E, Barry K. Treatment of problem alcohol use in women of childbearing age: Results of a brief intervention trial. Alcohol: Clinic Exp Res. 2000;24:1517-1524. 5) Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief Physician Advice for Problem drinkers: Long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002:26(1):36-43. Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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We are pleased that Dr. Fleming has taken time to respond to our meta -analysis since his substantial contribution to the evidence on screening and brief intervention was so strongly represented in our analysis. On the other hand we are of course sad that he feels that we have misrepresented his work. Meta-analysis is by nature reductionistic and every choice you make implicates a selection by rejection too. We will go through Dr. Fleming’s seven concerns here and hopefully we will shed some light in the dark corners of our analysis and show that we have no sinister motives. 1) “Table 1 is not accurate”: Table 1 of our paper is dealing with external validity only, i.e. how the studies moved from an intended population of subjects (in need of intervention) to the study participants who were followed up according to a protocol. The losses are the total losses from the available group (in this case the ones who screen positive). The span for these losses is from screening to follow-up. The numbers in the table were not used for meta-analysis, Table 1 was only constructed to investigate and stimulate debate on how far the effect of brief intervention in these studies could be generalized. 2) “..the authors do not define the other categories contained in Table 1”: The categories were defined in our Figure 1 based on a model from Alvan Feinsteins textbook “Clinical Epidemiology. The architecture of clinical Research” (our reference 20, a great classic in our opinion). These categories summarize and include losses from before and after randomisation, and this can be a bit confusing. Unfortunately Figure 1 was not included in the abbreviated paper version (which we regret), and we have probably overrated the popularity of Feinstein in our enthusiasm of his approach to epidemiology. 3) “..the authors suggest my studies may have been affected by attrition bias”: In our opinion intention to treat analysis does not solve the problem of attrition bias. Very few subjects carry the effect of intervention in most of the studies we reviewed. In the three studies by Fleming et al. the difference in number of sensible drinkers between comparison groups at 12 month follow-up was 12, 30 and 22 respectively. If only a few more failures were lost from (or denied in) the intervention group (and/or a few more successes were lost from the control group) it could seriously affect the benefit increases estimated. When follow-up rates differ between comparison groups as is the case in the largest of Flemings studies we believe there is good reason to be alert to such bias. 4) “..the authors state lack of blinding may have led to an exaggerated treatment effect”: Dr. Fleming argues well that the possibility of contamination is very unlikely in his study. Our concern was not so much contamination as it was the possible bias due to differential attrition. The combination of self-reported outcome measures, paying study participants for completing the study, and the impossibility of blinding study participants in our opinion enables the possibility of such a bias towards overestimation of treatment effect. In general studies that are unable to blind participants tend to overestimate the effect of an intervention. 5) “..the authors chose to ignore the finding of significant reductions in health care utilization”: We have not argued that any of the other results obtained in project TrEAT should be ignored. Again, meta -analysis is reductionistic by nature and our perspective was that of the clinician (if I screen and advice my patients to drink less how many of them will follow my advice and drink sensibly after a year?). The reductions in health care utilization have already achieved great attention. We believe these results deserve further attention and should be discussed in regard to their clinical significance / importance, what these findings actually reflect, and for whom among the ones screened such outcome can be expected. In our opinion statistical significance is not a result in itself but more of a precondition for the discussion of clinical importance, relevance, suitability, et cetera. 6) “..authors chose not to report the 48-month follow-up data on Project TrEAT”: We did not miss this reference (ref 25 in our paper), only we had chosen 12 month follow-up for comparison purposes. We believe that these statistically significant long term results deserve further attention, reflection and discussion too. 7) “..the biggest concern I have with the report is the use of research data to estimate the clinical utility of alcohol screening and brief intervention”. This point has been already been discussed in previous correspondence with other opponents and we will try to avoid repeating ourselves. A few new perspectives have been raised by Dr. Fleming though. He is requesting evidence to show that the persons not included in his studies will not benefit from screening and intervention. We recommend that the burden of proof remain with the ones who recommend that “new technologies” should be implemented. Establishing trials to show that something is not effective requires extremely large samples and is rarely done. It does not seem like a productive line to follow in our opinion. However, a fair request would in our opinion be to ask for pragmatic studies on effectiveness of intervention, screening, and the combination of screening and brief intervention (used on the intended population) before recommending they be widespread implemented. The question is whether an intervention complex by nature can at all be shown to be effective in a trial focusing on real life effectiveness. It seems there has been a tendency to standardize and simplify interventions (and refine study groups) simply in order to be able to study them by use of methods developed for comparing simple interventions (ie pharmachotherapy). Maybe it is time to adjust research methods and designs to studies of the complex, difficult job general practitioners try to do every day to promote good health. Dr. Fleming compares SBI with hypertension screening and treatment by asking “Can you imagine the public outcry if the British government agreed to provide blood pressure treatment to only 10% of persons with this problem?” This comparison indicates that we have not been very precise in our conclusions. We have only aimed at adducing arguments that the evidence for screening based brief interventions is unlikely to be generalizable “in general” and that the evidence available is produced on highly selected groups. The latter we did by meta-analyzing screening effectiveness in the trials taking place in general practice. We strongly recommend that general practitioners respond to all complaints or symptoms in which alcohol is likely to be an etiologic agent or likely to act as a barrier for treatment or problem solutions. These clinical appropriate occasions are innumerable. The fact that only a few minutes of advice is sometimes helpful, even in some patients approached by trial screening, should in our opinion encourage practitioners to raise the subject when ever appropriate. To include screening in the recommendations remains unwarranted in our opinion. We do hope that Dr Fleming can see from this reponse that our conclusions are not either wholly right or wrong, let alone a deliberate attempt to misrepresent his findings. It is our wish to move away from an abrasive and confrontational argument, towards a discussion in which our research and the underlying issues are addressed in a constructive manner. Anders Beich Thorkil Thorsen Competing interests: None declared |
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Richard Saitz, Associate Professor of Medicine and Epidemiology Boston Medical Center, 02118
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I would like to address points of agreement and disagreement I have with Beich et al, their original paper and subsequent letters. I intend my comments as collegial and have developed them with the purpose of furthering this scientific discussion in as dispassionate a way as possible. Beich et al. are correct that studies of brief intervention efficacy are likely somewhat biased towards the alternative hypothesis. Further, I also agree that the outcome of stroke or death is not the same as the outcome of drinking less. However, Kristenson’s work and Fleming’s studies have found differences in hard outcomes (death, crashes). I do agree that preventive interventions should be rigorously tested prior to offering them widely to people who, after all, are presumed healthy. Preventive interventions around which there is universal agreement have been tested in the ideal way Beich et al suggest--eg for breast cancer and colorectal cancer screening, but this has not yet been done for alcohol. The only reason I mentioned the Welte study in my letter was because it was the closest I could find (but it was not randomized, focused on a hospitalized population, and had a multifaceted intervention). But we do know from studies that without screening most cases of alcohol problems are missed. And we also know screening identifies these unrecognized cases. This is the reference point I refer to in concluding that screening is better than not. What is missing from the literature is the next step: screening plus brief intervention vs no screening at all (challenging methodologically and ethically but conceivable, I think). I agree with Beich et al. in their recent letter that effectiveness studies or pragmatic clinical trials could help resolve the issues they raise. Furthermore, if we want to know if brief interventions for alcohol problems will reduce death, we will need a large, long-term study, and perhaps several such studies, as has been done in the field of hypertension and myocardial infarction. While we await such studies (which may never appear), I disagree with Beich et al. about cost-utility analysis. Such studies should be done to help us understand whether screening and brief intervention for alcohol problems works and is worth it ("effective and cost effective"). Of course a value judgment gets placed between efficacy and implementation. And on the contrary---cost utility analyses do not ignore or conceal these judgments; they explicitly measure them for all to see. This is one of the advantages of these analyses. As for generalizing beyond study populations---I agree that the same way we generalize interventions is how we should generalize preventive interventions. But that does not prevent a concept such as universal screening---that is, one may have a policy of universal screening but, of course, not perform the screen in a practice where or when it doesn’t make sense or in a patient who objects. This is how universal recommendations are actually implemented in practice. I do also disagree with Beich et al.’s conclusion regarding doctors and disappointment. For colon cancer, 333 have to be screened to benefit one. I don’t see how that is different (except for the outcome prevented) from having to screen 29 or 33 or 333 people to benefit 1 with alcohol brief intervention. When we identify colon cancer by screening, it is NOT true that all identified are helped/saved. I think the situation (except for the outcome) is quite analogous. Another disagreement is that I don’t think that a relatively large number needed to screen or treat (NNT) automatically means that a preventive intervention is not worth doing. The NNT for vaccination is likely astronomical. And many people in society and physicians accept high NNTs for preventive interventions. I also completely disagree that there needs to be some special consent for a primary care physician to touch on lifestyle issues. Patients come to primary care physicians in part for preventive health care. This includes routinely asking about and talking about sex, diet, exercise, as well as more "medical" items such as physical exam and tests for cancers and heart disease. No patient is surprised when a physician asks about smoking and advises they quit. No special consent is necessary for this discussion (this statement is separate from the fact that a brief intervention may certainly be more effective if the physician obtains some kind of permission---this in no way would look like extensive research informed consent.). I believe that while Beich et al.’s study is certainly correct that many need to be screened to identify cases and many cases need to be identified to benefit few, the exact numbers shouldn’t be generalized because I still hold that the transition from screening to intervention is very different in research vs clinical practice. So, given the methodological issues raised by the letters, I must agree that while Beich et al.’s study is interesting and useful to prompt the research community to move forward, it was not a good BMJ editorial decision to have this be a cover story (or frankly, even an article in a general journal). A specialty research journal may have been more appropriate, to reach and stimulate discussion among researchers. The BMJ article may do more harm than good. One final thought: has there ever been a study of asking about cigarette use and brief intervention versus no screening and intervention (I dont know the answer but I suspect not)? Should we wait for that study in order to advise physicians to screen and intervene? Is that somehow different? Perhaps we should wait for the evidence--following this line of reasoning, we would (I do not think we should). Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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We consider it a favour that Richard Saitz has taken time to reflect on and summarize our discussion with himself and other opponents to our meta-analysis. We very much appreciate the constructive tone of his reflective response, in spite of the obvious and fundamental disagreements we have. We are glad that he recognizes the most likely direction of efficacy bias and that surrogate measures should be treated as surrogate measures. Saitz mentions the term alcohol problems several times in his response, like for example: “without screening most cases of alcohol problems are missed”. However, most of the “problems” recognized by the screening tools used in the US trials as well as by the tools recommended by WHO and others are hazardous drinking. For example it is considered hazardous drinking for men (women) to drink five (four) drinks on one occasion (1) or to consume an average of 14(11) drinks per week (2). Drinking above such limits might imply a higher risk of getting an “alcohol problem”, i.e. harm that can be related to alcohol drinking somehow. We believe that we are operating in an area of risk rather than harm with the vast majority of drinkers pointed out by these screening tools. In a study we published last year (3), the impression of Danish doctors who tried the screening approach was that patients with traceable alcohol problems to a great extent refused screening, gave poor excuses for not being able to participate, stayed away from the surgery during the screening period, or lied when answering the screening questions. As a result of this selection, hazardous drinkers, most of whom had not experienced any medical consequences from their way of drinking, were the ones most likely to be included for brief intervention. The practitioners found it surprisingly hard to establish rapport and compliance with this group when advising them to drink less and none of the doctors would continue to screen their patients for excessive drinking. When we wrote that value judgements were introduced between efficacy and implementation we did not think of value in the sense of “good value for the money” (cost-utility). We were thinking of more fundamental values belonging in cultural or existential dimensions of the work doctors do in general practice, such as: “…always respecting the autonomy of their patients…..integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts” (4). In the case of alcohol drinking, societies have decided, and we strongly agree, that doctors should be able to contribute to prevention and treatment of alcohol problems. But we find it important that such contributions are carried out within the patient-centred framework referred to above. The issue of alcohol should be raised whenever clinically meaningful, and for those who want to stick to standard questions, questionnaires or tests, these could easily be used within the single consultation for assessing drinking. Our screening concerns cover the taking advantage of the opportunity when patients go to see their doctor in good faith and find themselves screened for behaviours not in any way related to their reason for seeking help. In our opinion it is not enough to refer to the impression that “No patient is surprised when a physician asks about smoking and advises they quit”. It is possible that the same thing could happen for alcohol, but it is not necessarily the same as it being very helpful to the patients. There is always a dear price to pay when declaring war on specific behaviours in a society, and doctors should watch out when taking part. Not only could we risk the relationship with the single patient on which the whole future care of this patient depends. We could end up contributing to marginalization and stigmatization of large groups of subjects with addictive behaviours in the name of benefit for the very few who can comply with our advice and become “one of us” (the slender and tip -top conditioned, non-smoking, and sensibly drinking population) in stead of “one of them”. What other screening programmes SBI or a smoke screen can or should be compared to seems to depend highly on culture and tradition. It has become clear to us by having this discussion what huge differences there are between USA and some European countries in the way we think about screening in general practice / family medicine. Screening for early stages of disease, risk factors, and risky behaviours has apparently been a core ingredient of preventive medicine in USA for so many years that it has become a reference point (Saitz refers to smoke screen and brief advice as the natural thing for a general practitioner to do, and something that no one would question). Screening is not a standard condition for prevention in our culture, so we are still in a position to question the helpfulness of screening and ask questions about provider and receiver preferences as well as possible negative consequences emerging from such screening programmes. We do not think that screening and brief intervention for hazardous drinking is comparable to vaccination programs or even cancer screening programmes for many reasons. The most important difference is of course the “surprise attack nature” of the alcohol screening. People do not suddenly find themselves in a vaccination programme or colon cancer screening programme when visiting their doctor for other reasons. Such programmes are general campaigns, and screening is offered to the public, with careful information on possible gains as well as fair mention of side effects etc. In our opinion this is opposed to screening for unhealthy life style issues like smoking or hazardous drinking among patients seeking help for all kinds of reasons. Saitz says: “One may have a policy of universal screening but, of course, not perform the screen in a practice where or when it doesn’t make sense or in a patient who objects”. But who is to decide where or when it makes sense? Is it the political-administrative system, is it the specialty society of the country or region, or is it the single practitioner? Patients will rarely object openly, they know they are depending on the services of the health care system. A genuine and open- minded exploration of patients’ experiences with an alcohol agenda imposed by their doctor regardless of their own agenda has to our knowledge never been carried out. We believe this to be another deficiency in the SBI evidence base. We agree with Saitz that the discussion of our paper so far has probably suffered from it being a cover story. We were not informed about the cover story in forehand but we do of course accept the freedom of the editor to decide about the cover. To avoid too much attention we explicitly asked BMJ for exception from a planned press alert before publication and this was granted. On the other hand we do not share the view that our paper does not belong in a general journal. We trust that clinicians are able to distinguish between screening every health care visitor for hazardous lifestyles as one approach and asking and advising whenever a clinically meaningful opportunity is present as a very different approach. In fact we believe that our paper might make more health professionals more aware of the difference between the two approaches in general and the missing evidence for screening as a helpful case finding precursor in the case of hazardous or harmful drinking. Anders Beich & Thorkil Thorsen References: 1. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med 1999; 159: 2198-205 2. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 1997; 277: 1039-45 3. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ 2002; 325: 870 4. Allen J et al. The European definition of general practice/family medicine. WONCA Europe, 2002. Competing interests: None declared |
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Ian R. White, Senior Scientist MRC Biostatistics Unit, Cambridge CB2 5LJ, UK
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I would like to comment on the extraction of data from published reports in this meta-analysis. Beich et al [1] correctly aimed to perform intention-to-treat analysis by regarding all missing outcomes as treatment failures, but I question the implementation of the intention-to-treat analysis. The data extraction for the trial by Richmond et al [2] has been criticised on two grounds. First, the extracted data differ from the results in the primary publication [3]. This is entirely legitimate, because the primary outcome in the meta-analysis was the proportion of successes at follow-up, while Richmond et al's published result was largely driven by a baseline imbalance [4]. Second, in extracting the data, Beich et al made a correction for missing outcomes, ignoring the fact that the published analysis had already made such a correction [5]. Correcting this error changes Beich et al's results of 16/96 (intervention) vs. 13/93 (control) to 23/96 vs. 20/93, and reduces the risk difference from 2.7% to 2.5%. This error is unimportant, but unfortunately Beich et al have not acknowledged it. On reading the reports of the other trials, I found two further errors, also resulting from incorrect handling of missing data. The trial by Wallace et al [6] also reported an analysis using an intention-to-treat approach in which those not interviewed were assumed to be still drinking excessively. For example, in the treated arm, 448 men and women were randomised. At 12 months, 247 were considered to be drinking excessively and 201 were not. It is possible to work out that the 247 excessive drinkers include 85 men and women who were not interviewed. Beich et al, however, give the number of successes as 116, which can only be calculated by wrongly subtracting the number of missing outcomes (85) from the correct number of successes (201). Correcting this error changes the results from Beich et al's 116/448 vs. 48/459 to 201/448 vs. 122/459, and increases the risk difference for this trial from 15.4% to 18.3%. The trial by Ockene et al [7] only reported the numbers of successes for the subgroup with excessive weekly drinking at baseline; further, it excluded individuals with missing outcome. In assigning individuals with missing outcomes as failures, Beich et al have used all those randomised as a denominator. This implicitly treats all those not drinking excessively at baseline as failures, which is unreasonable. It is not possible to get a correct analysis, because Ockene et al do not report total numbers drinking excessively at baseline. An improvement on Beich et al's approach is to exclude from the denominator all those with observed outcome and non-excessive weekly drinking at baseline, but to include all those with missing outcome. This changes the results from Beich et al's 102/274 vs. 66/256 to 102/216 vs. 66/193, and increases the risk difference for this trial from 11.4% to 13.0%. It is important to note that these over-zealous applications of intention-to-treat analysis have little effect on the results of the meta- analysis. Correcting all three errors increases the intervention effect from 10.5% to 11.5%. The numerical findings of the meta-analysis should therefore be accepted. References 1 Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542. 2 Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90:119-32. 3 Heather N, Richmond R. Screening effect ten times greater than calculated by Beich et al. Rapid response bmj.com; 1 October 2003. 4 Beich A, Thorsen T. Re: Screening effect ten times greater (by Heather and Richmond). Rapid response bmj.com; 5 October 2003. 5 Heather N. Beich et al have got it wrong again. Rapid response bmj.com; 24 October 2003. 6 Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-8. 7 Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med 1999;159:2198-205. Competing interests: I have received a fee from the Health Development Agency for writing a review of this meta-analysis. |
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Katharine A Bradley, Associate professor, Department of Medicine, University of Washington HSRD 152, VA Puget Sound, 1660 S. Columbian Way, Seatle WA 98108 USA
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Dear Editors, I have read with interest and appreciation the many letters regarding the controversial meta-analysis by Beich and colleagues. I have several comments to add. Were the original studies misrepresented in the review? The letters have unfortunately not clarified this question for me. Beich et al. converted data from the original studies to standard-sized drinks and therefore drinking thresholds changed. This may account for the confusion. Nevertheless, at best, it has been difficult for the authors of the original studies to follow the manipulations of the data extracted from their papers. Given the consistent complaints that data were misrepresented or analyses inappropriate, it seems essential to resolve the confusion. One approach would be for the authors to post a table of all data analyses on the web. Such a table could show the raw data extracted from each article, conversion to standard drink units, and all other intermediate steps to the final data presented, including all equations and conversion factors for standard-sized drinks. This would allow each original author to determine whether errors had indeed occurred and if so where they occurred (line and column of the table). We encourage the BMJ editors and authors to make the data analyses available so that the extensive accusations of misrepresentation of the original studies can be resolved. Are the benefits of alcohol screening and brief intervention worth the cost? I do not believe a meta-analysis of efficacy studies can answer this question. The costs and benefits of any clinical practice depend on the setting. Nevertheless, I believe Beich and colleagues have made an important contribution to the literature on brief intervention. First, they have called attention to the fact that efficacy studies likely exaggerate the benefits of screening and brief intervention in the “real” world, although the extent of such exaggeration is debatable, and will need to be ascertained by effectiveness trials. Second, the debate inspired by this article has revealed that there are significant differences of opinion regarding the clinical importance of decreased self -reported drinking after brief intervention. Many primary care providers will not devote scarce time with patients to brief intervention until they know that brief interventions integrated into routine primary care appointments not only decrease drinking but also result in objective health benefits to patients. While several trials have demonstrated objective benefits of brief intervention such as decreased liver function tests or hospital utilization, these trials scheduled special visits for the brief interventions.(1, 2) Beich et. al.’s review therefore highlights the need for additional large effectiveness trials which attempt to translate the benefits of early efficacy trials into practice and have adequate power to detect any objective health benefits of brief interventions. Sincerely, Kathy Bradley References 1. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297:663-668. 2. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA 1997;277(13):1039- 1045. Competing interests: None declared |
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Olivia Wu, research assistant Public Health, Division of Community Based Sciences, University of Glasgow, Glasgow G12 8RZ, Robin Knill-Jones
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In our view, the conclusions of this review should be interpreted with caution for a number of reasons which are indicated below. The aim of the review was to determine the effectiveness of screening in general practice for locating excessive alcohol users who can benefit from brief interventions. We have found methodological flaws in this review and feel it has failed to achieve its stated objective. The research question suggested an evaluation of screening, however, we find it surprising that the term “screening” was not one of the keywords included in the literature search. The keywords used in their literature search would only be successful in retrieving randomised controlled trials on the efficacies of brief interventions. A systematic review on screening strategies for excessive alcohol use would be expected to be similar to Fiellin et al (2000) [1], comparing various alcohol consumption screening strategies such as AUDIT and CAGE in a variety of clinical settings including primary care. Although three of the eight studies in Beich’s review incorporated CAGE, the review has failed to draw comparisons between various screening strategies. In addition, we find the measure of “screening effect”, based on “the prevalence” misleading. The “screening” procedure described in these studies was a means of selecting appropriate participants for specific trials [2]. In our view, their calculation cannot be interpreted as reflecting screening in real clinical practice. Despite the controversy over appropriate data extraction, the Beich review has presented a summary of some of the current evidence in the area of brief interventions for excessive alcohol users. It has been demonstrated that correcting for the errors in the data extraction had little effect on the overall results of the meta-analysis [3]. Similar but more informed reviews had already been conducted showing positive results [4-5]. The Beich review has presented data that indicated similar conclusions – that some effectiveness has been shown by brief intervention – although, as pointed out by Poikolainen [5], the magnitude of the effectiveness was not uniform (ranged from ARR 1.6% to 15.4%). Some of the effects may be explained by confounding factors and should be investigated. The results of this meta-analysis showed improvement with brief interventions and statistically significant differences were reported in three of the eight trials and the overall pooled data. This should be the main conclusion of the review. However, it should also be noted that the Beich review has also failed to include some of the studies that were included in previous reviews [4-5] of brief interventions. Therefore, we feel that the Beich review should not be accepted as evidence of the effectiveness of screening, and furthermore since their meta-analysis of brief interventions in general practice is incomplete, their conclusions add little to current literature. References 1. Fiellin D, Reid C, O’Connor P. Screening for alcohol problems in primary care: a systematic review. Arch Int Med 2000;160(13):1977-1989. 2. Saitz R. Alcohol screening as good as other recommended screens [rapid response]. BMJ 2003;327:536-542. 3. White IR. Intention-to-treat analysis was over-zealous – but this does not affect findings [rapid response]. BMJ 2003;327:536-542. 4. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief intervention for alcohol problems: a meta-analysis review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002;97:279-92. 5. Poikolainen K. Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Prev Med 1999;28:503-9. Competing interests: We have received a fee from the Health Development Agency for writing a review of this meta-analysis. |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark, Thorkil Thorsen
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REPLY TO IAN WHITE ( INTENTION-TO-TREAT ANALYSIS WAS OVER-ZEALOUS - BUT THIS DOES NOT AFFECT FINDINGS) We thank Ian White for his helpful comments and corrections (1) to our paper (2). We acknowledge that his correction to our data extraction from the study by Wallace et al.(3) is right. Our correction for missing outcomes was over-zealous and we slightly underestimated the benefit increase from intervention. In the case of the paper by Richmond et al.(4), the correct numbers did not appear in the original paper, only “percentages of patients in each group reporting drinking above NHMRC levels in the previous week” were available. The correct numbers were finally stated by Heather in one of his responses to our paper (5) showing that we slightly overestimated the benefit increase from intervention in this particular case. The study by Ockene et al.(6) is not the only one of the eight studies to include intervention subjects that at baseline did not drink above the weekly consumption treatment goal. In fact, only in the UK trials (3,7,8) all subjects had a weekly consumption above limits at baseline. In some studies, when compared to eligibility and inclusion criteria, the excessive drinking definitions were apparently changed to a higher number of drinks during analyses for unknown reasons (9-11). It could be argued that it is scientifically unreasonable to consider those who at baseline did not exceed the treatment goal as failures at follow-up. Anyhow, we calculated the number needed to treat (or screen) for the benefit of one subject giving up unsafe weekly consumption, i.e. “clinically important change” as defined by Heather (12). When seen from the clinician’s chair we believe that these numbers are fully reasonable. The main thing here: Ian White finds it important to note that these differences do not affect findings and that the numerical findings of our paper can be accepted. REPLY TO KATAHRINE BRADLEY (BEICH ET. AL. NEED TO MAKE DATA ANALYSES AVAILABLE FOR REVIEW) We are pleased that Kathy Bradley (13) finds our paper to be an important contribution to the literature on brief intervention. We find it important to once again emphasize that the conversions from units of alcohol to standard-sized drinks we made were for descriptive and comparative purposes only and were straight forward. Our conversions did not change any thresholds or numbers that were used for effect calculations. Therefore, and because Ian White has apparently done a commissioned review of our paper (1) and concluded that the numerical findings of our paper can be accepted, we believe there is no need for further posting of tables of data analyses on the web. We believe it is time to concentrate on discussing the essential questions raised in our paper and the debate that followed. THE RATIONALE OF USING DATA EXTRACTED FROM STUDIES AIMED AT ASSESSING THE EFFICACY OF BRIEF INTERVENTION TO CONCLUDE ON THE EFFECTIVENESS OF THE SCREENING PROCEDURE It has been questioned by several opponents (including some of the authors of the studies we reviewed) whether a meta-analysis of efficacy studies can answer the question of alcohol screening and its effectiveness? In fact, we were ambivalent ourselves. On the other hand, since seven of the eight reports we included for meta-analysis openly claimed to deliver evidence for screening as a case finding approach, we felt confident to go through with it. Listed below are some prime investigator citations from the papers: “Our study lends support for this approach [screening by use of health survey questionnaire] and should encourage general practitioners and other members of the primary health care team to include counselling about alcohol consumption in their preventive activities” – Wallace et al. 1988(3) ..[T]here is sufficient evidence from the present study and the MRC study [Wallace et al.(3)] to recommend systematic screening of patients’ alcohol consumption by general practitioners and the giving of advice to those found to be at risk.” – Anderson & Scott(7). “This trial supports the implementation of screening, assessment, and brief intervention for all patients who seek health care services in primary care community-based settings” - Fleming et al 1997(9). “This study provides evidence that screening and very brief (5- to 10 -minute) advice and counselling delivered by a physician or nurse practitioner as part of routine primary care significantly reduces alcohol consumption by high-risk drinkers.” - Ockene et al.1999(6). One cannot both have one's cake and eat it. The reports of the original studies concluded that their results could be generalised beyond the randomised trial context as regards both screening and brief intervention. It is hard to find any real evidence for alcohol screening (14) and maybe that is why these reports have repeatedly been used in the reasoning for implementing alcohol screening programmes in general practice. We believe that our paper and the discussion that followed provide an opportunity for the authors of these reports to come forward and moderate their conclusions by excluding screening from their evidence claims. Anders Beich Thorkil Thorsen . References 1. White IR, Intention-to-treat analysis was over-zealous - but this does not affect findings. Rapid response bmj.com; 9 December 2003. 2. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-42. 3. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988; 297: 663-8. 4. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90:119-32. 5. Heather N. Beich et al have got it wrong again. Rapid response bmj.com; 24 October 2003. 6. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med 1999; 159: 2198-205. 7. Anderson P, Scott E. The effect of general practitioners' advice to heavy drinking men. Br J Addict 1992; 87: 891-900 8. Scott E, Anderson P. Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Drug Alcohol Rev 1990; 10: 313-21. 9. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 1997; 277: 1039-45 10. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res 2000; 24: 1517-24 11. Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract 1999; 48: 378-84 12. Heather N, Campion PD, Neville RG, McCabe D. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme). J R Coll Gen Pract 1987; 37: 358-63. 13. Bradley KA. Beich et. al. Need to Make Data Analyses Available for Review. Rapid response bmj.com, 13 Dec 2003 14. Whitlock EP. Alcohol screening in primary care. BMJ(USA) 2003;327:E263-E264 Competing interests: None declared |
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Anders Beich, Research fellow Central Res.Unit Gen.Pract., University of Cph., Panum Institute, 2200 Copenh.N, Denmark
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In our recent rapid response (1) we wrongly used the word opponent. We meant critic or reviewer (the meaning of the Danish word opponent), definitely not adversary, enemy or rival. What an inopportune mistake to make in a debate that has at times been rather heated. I am sorry that my knowledge and command of English is not perfect and I apologize for any emotional discomfort we may have caused by such confusion of languages. Anders Beich Beich A et al. On accuracy of findings, the need for further analyses, and generalization beyond the trial context. bmj.com, 30 Jan 2004 Competing interests: None declared |
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Stephen Rollnick, Professor Department of General Practice, University of Wales, College of Medicine
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The debate, defence and downright dismissal of the paper I published with two Danish colleagues [1] about alcohol screening makes for frankly depressing reading. All agree, it seems, about the need to deal constructively with alcohol issues in primary care, and about the benefits of brief intervention. The debate is about screening. Even though I was a co-author of this paper, I made a decision to remain outside of the exchange in these columns, because of the aggressive tone of so many of the contributions. At worst, the exchange has resembled a football match, where calling “foul” and winning the game has been the primary goal. It is a relief to note that things have calmed down. I withdrew, despite my continued support for the integrity and motives of my colleagues Anders Beich and Thorkil Thorsen. I can assure readers that while we might not have got the research question right (often the case in research) and we might have been over-zealous in some respects, we nevertheless tried very hard to conduct the analyses thoroughly and fairly. I hope that the review commissioned by the Heath Development Agency [2], which found some errors that did not affect the substantive findings, is enough to encourage all to move beyond the football match. The danger, if we don’t, is that discussion merely revolves around establishing the “correct” value of NNS (numbers needed to screen), when in truth, the viability of alcohol screening goes way beyond this issue. I do feel that both the BMJ and we co-authors have made mistakes. As Rapley points out [3], the BMJ were stretching things to suggest in ‘This week in the BMJ’, that “Screening for excessive alcohol use and then providing brief interventions is not effective in general practice”. I also feel that we overstated our conclusions, an example of which is cited by Kem [4], who rightly implies that it is a matter of opinion as to whether screening is laborious or not. As a number of other contributors have pointed out, our meta-analysis is not the ideal way to assess the effectiveness of screening. Its just a small first step. The ferocity of many responses to our paper astonished me. Clearly, I have misjudged the momentum that has built up around alcohol screening. I thought that it was still in need of considerable debate and refinement, yet others were clearly (and sincerely) working towards to widespread dissemination in general practice. This came home to me when I was invited to attend a “friendly” debate soon after the publication of our paper, at a meeting of European alcohol researchers. At one point in the debate, it was suggested that an analysis be conducted of the number of people likely to lose their lives as a result of GPs abandoning alcohol screening after reading our paper. In the face of this kind of reaction, I can only attempt a frank account of my motives and aspirations. It began for me with involvement in the Phase II World Health Organisation project in the early 1980’s, and continued in others. I tried to encourage organisations and practitioners to come on board with screening projects, I paced scores of hospital wards looking for drinkers, read patient comments on GP screening forms, coached nurses doing screening and brief intervention, and generally immersed myself in the world that lies one layer beneath the level of principle investigator, that of a project manager. I emerged with concerns about exactly what is said to which patients, why and by whom [5,6]. Looking back, I think I was struggling with the marriage between preventative and curative medicine. Why, for example, were young male drinkers included in screening when epidemiological research suggested that this group had the highest rate of spontaneous remission [7]? Why were so many refusing to consent or subsequently dropping out? Why were the reports we wrote of our research so analytic in tone, and devoid of any glimpses of the messy world I had worked in? Over the next ten years, like soldiers through the mist, the controlled trials of brief intervention emerged, confidently recommending that widespread screening should also take place? Evidence for the former was considered as evidence for the latter. The term SBI (screening and brief intervention) was even being used as if it were a single activity (selective screening was a relatively recent suggestion). Under these circumstances, I concluded, it seemed quite reasonable to consider a separate analysis of the screening data from these studies. No-one had done this kind of work before. The trial authors (myself included in the case of the World Health organisation study) seemed happy to recommend screening as effective on the basis of research studies of intervention efficacy. In contrast, I thought that my collaboration with Beich and Thorsen was an altogether more modest activity. I hesitate to analyse the motives of colleagues who responded to our methodology with such ferocity, but it was like being at the receiving end of an academic slap in the face from those who felt that the march of alcohol screening should not be derailed. If this judgement is wrong, I apologise wholeheartedly. It might be useful to acknowledge that there are some underlying issues here that still need to be resolved. We, and presumably the GPs and patients we serve, probably vary in our enthusiasm for lifestyle intervention in everyday practice, and about where screening fits into this activity [8]. For example, I feel enthusiastic about alcohol screening in hospitals, particularly in emergency settings, and less so in general practice. I am, and have been for many years, worried about the labelling of patients with new lifestyle problems, particularly where there is no connection to an existing medical problem. In talking to excessive drinkers and listening to audiotapes of GP consultations, I am convinced that screening for excessive drinking is not equivalent, in reality, to screening for hypertension. The issue of blame surfaces, and we need to give GPs the tools to handle this with skill and with respect for patients. Seen in this light, it would be sad if the issue of NNT is allowed to become the ultimate test that either derails or supports the progress of alcohol screening. If our paper, or the way we presented our work, reinforced this kind of oversimplified thinking about screening, then I very much regret that. NNT is just one small piece of the puzzle. The need for talking about risk wont go away [9], it’s a question of how it is done. Giving GPs the freedom to strike their own balance, in a discerning and responsible way, is the challenge. Where alcohol screening and intervention fits into this educational challenge is an interesting question. I am not sure we have the answers yet, and I don’t think we will find them by citing NNS values, or for that matter, by falling, as we sometimes have done, into a win at all costs “debate”. 1. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003;327:536-542 2. White IR. Intention-to-treat analysis was over-zealous – but this does not affect findings [rapid response]. BMJ 2003;327:536-542. 3. Rapley T Misleading ‘Editorial’. Rapid response BMJ.com 2003; 23 September 4. Kemm JR. Good doctors still enquire about their patient's drinking habits. Rapid response bmj.com 2003; 20 September 5. Rollnick S. Early Intervention: How early and in what context? Aust Drug Alc Rev 1987; 6: (4). 6. Rollnick S, Butler C, Hodgson R. Brief alcohol intervention in medical settings: Concerns from the consulting room. Addict Res 1997; 5: 331-342. 7. Fillmore KM. Alcohol Use Across the Life Course. Toronto: Addiction research Foundation, 1988. 8. Getz L, Sigurdsson J, Hetlevik I. Is opportunistic disease prevention in the consultation ethically justifiable? BMJ, Aug 2003; 327: 498 - 500. 9. Stott NCH. Opportunistic Health Promotion in General Practice. Rapid response BMJ.com 2003; 1 September Competing interests: None declared |
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