How stages of change can predict screening and brief intervention outcome for alcohol problems in young adult emergency department patients

Presenter: Arshadul Haque MBBS, MPH

Luba Leontieva MD, J Helmkamp PhD, K Horn EdD, J Williams MD, P Ehrlich MD,

Acknowledgements: W Manley RN, P Furbee MS, M Murray

Research Funded by grant from CDC/NCIPC

Research Group

Objectives

To examine beginning stages of change among ED patients.To identify patients with alcohol problems.Provide a brief motivational intervention.Evaluate alcohol problems at a later date. Provide prediction model for decrease in alcohol problems, if any, based on stages of change.

Methods

Study Design: quazi-experimental, prospective, convenience sample

Participants : patients ages 18 to 29 Setting: university-affiliated ED Timeframe: August 1998 through December

2000 Inclusion Criteria: consumption of alcohol in

the previous year Exclusion Criteria: life- or limb-threatening

conditions,mentally incompetence, communication deficits, police custody, and over-intoxication

Methods

Research Staff: social workers and alcohol counselors with training in motivationalinterviewing. Stage of Change: assessed by asking patients to selection from five choices (score 1 to 5) – which best described their attitude towards changing their drinking behavior at the time of their baseline screeningIntervention: Motivational interviewing described in Miller and Rollnick, 1991Follow-up: Telephone interview 3-months after initial ED visit

AUDIT- Intake section

1. In the past year, how many drinks containing alcohol do you have on a typical day, when you are drinking?1 or 2 3 or 4 5 or 6 7 or 9 10 or more 0 1 2 3 4

 2. How often do you drink that amount?

Never <Monthly Monthly Weekly Daily/almost daily 0 1 2 3 4

3. How often in the past year you had 5 (male)/4 (female) or more drinks on one occasion?

Never <Monthly Monthly Weekly Daily/almost daily 0 1 2 3 4

AUDIT- Dependence section1. How often during the past year have you found that you were not able to

stop drinking once you had started?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 42. How often during the past year have you needed a first drink in the morning

to get yourself going after a heavy drinking session?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 4 3. How often during the past year have you had a feeling of guilt or remorse

after drinking?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 4 4. How often during the past year have you been unable to remember what

happened the night before because you had been drinking?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 4 

AUDIT- Harm section

1. How often during the past year have you not done what was normally expected from you because of drinking? For example, have you ever missed work or class?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 42. Has your drinking contributed to an injury to yourself or anyone else?

Never Yes, but not in the last year Yes, during the last year 0 2 4 3. Has a relative, friend, doctor, or other health worker been concerned

about your drinking or suggested that you should cut down?Never Yes, but not in the last year Yes, during the last year

0 2 4 

Stages of Change

1. Pre-contemplation stage: I have no thoughts of changing

2. Contemplation Stage: - I need to consider changing some day- I think I should change, but I am not quite ready

3. Preparation Stage: I am thinking about how to change my drinking

4. Action Stage: I am taking action to change, for example, I am cutting down

Methods

Outcome Measures: Decrease in scores within the AUDIT domains of intake, harm and

dependency Statistical Analysis:

Frequency analyses for demographic description of patients

Repeated ANOVA for stage of change movement Logistic regression to examine predictive capability of stage of change; pre-contemplators used as the reference group

Significance level: p < 0.05

4,308 – eligible-------------------------------------- 3,963 –: consented

3,890 – screened------------------------------------ 1,858 (48%) –: screen-positive

495 –: did not receive an intervention

1,304 – received an intervention---------------- 935 (71%) –: followed-up at three months

805 (90%) – indicated that they were still drinking drinking 130 (10%) –: indicated that they had stopped drinking

Flowchart of patients in the ED from August 1998 through December 2000

Variables Received an intervention % (1,304)

Age* 18-22 70% (915) 23-29 30% (389)

Sex* Women 42% (548) Education* Some college 65% (847) No college (HS or less) 35% (452) Student status Not a student 40% (515) Employment status Unemployed 51% (671) Marital/cohabitation status Not married/cohabiting 77% (999) Roommate status* Live with roommate/family 77% (1,007) Tobacco User 64% (836) Alcohol treatment Past treatment/help received 14% (178) * - data incomplete

Socio-demographic characteristics of screen-positive patients

Variables Baseline Three months follow-up % (801**) % (805) ______________________________________________________________________________ Stages of change

Pre-contemplation 53% (425) 48% (387) Contemplation 28% (220) 24% (193) Preparation 7% (56) 5% (36) Action 12% (100) 23% (189)

* Patients in various stages of change groups at baseline were subsequently found at different levels of change at follow up **Data for 4 patients was missing

Stages of change status for the group of screen-positive patients followed- up at three months*

Variables of Interest A U D I T Domain Changes Intake Harm Dependency OR 95% CI Sig. OR 95% CI Sig. OR 95% CI Sig. ______________________________________________________ Contemplation

I need to consider change someday 0.69 0.46-1.03 0.07 1.62 1.12-2.36 0.01* 1.36 0.94-1.98 0.10 I think I should change, but I am not ready yet

0.54 0.29-1.00 0.05 1.85 1.02-3.33 0.04* 1.19 0.66-2.14 0.55 Preparation

I am thinking how to change my drinking behavior 0.85 0.41-1.75 0.65 1.56 0.83-2.95 0.17 2.20 1.13-4.27 0.02* Action

I am taking action to change 2.24 1.06-4.72 0.03* 2.80 1.59-4.91 0.00* 3.59 1.97-6.57 0.00* § Pre-contemplators were used as a reference category * p < .05

Logistic Regression Analyses for Predictors of Positive Behavior Outcome§

Baseline Three month follow-up

Stage of

Change Scores

2.4

2.0

Average stage of change scores movement of screen-positive patients from baseline to three months follow-up. (p<0.000)

Conclusions

Stages of change are predictive for decrease in drinking following a brief interventionAs a group, patients moved to more advanced stage of change level at 3-month follow-upHealthcare professionals can use stages of change to tailor intervention procedures

Limitations

Relatively young patients ED situated in small, rural, college

town with predominately Caucasian population