#PHTwitJC 21: Summary and Discussion

Thanks to everyone who contributed to the lively discussion and appraisal of the following papar: Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial, British Medical Journal, http://www.bmj.com/content/346/bmj.e8501.

The full transcripts are well worth a read, and available in html and PDF form in the archive.  However, if a quick summary is what you are looking for, you’ve come to the right place. Read on…

1. Were the aims of the study clearly defined?

It was agreed that the study aim was clear; to compare the effectiveness of three different brief interventions for reducing hazardous and harmful drinking in primary care.  The authors had identified a gap of pragmatic trials in the literature, and therefore this study will contribute to this evidence gap.

This paper reported on the findings of one of the 3 trials within a larger study: Screening and Intervention Programme for Sensible drinking trial  (SIPS trial).  The full study protocol can be found here.

2.  Was a randomised-control trial design appropriate to answer this research question?

@KateT_Health observed that the design involved multiple types of comparison incorporated in a nested design, which is more clever and pragmatic.  As @Duncautumnstore noted, the method was appropriate to assess effectiveness – i.e. whether this intervention works in a real-life setting.  This research design is also effective at minimising contamination between subjects, and due to the small number of questions posed to participants would hopefully reduce questionnaire fatigue.

@NiamhCreate raised concern regarding not using a control group (i.e. a group of participants who receive no intervention) and the inability to measure assessment reactivity.  This was acknowledged by other contributors, however as @Fibigibi13 noted, a no-intervention-control arm may have been unethical. Author @Dotbirch agreed that assessment reactivity was an issue, however also highlighted that GPs don’t record alcohol consistently, therefore it was difficult to assess.

Overall it was agreed this was an appropriate and practical design to answer the research question.

3.  Were general practices appropriately allocated to intervention and control groups?

@PHTwitJC suggested that self-selection bias may have influenced the results in both the practices and patients recruited into the trial. However the methods were transparent and practical, in the sense that a certain level of self-motivation would be needed to implement such interventions in primary care anyway.

4.  Could anything else explain these results? (e.g. chance, bias, confounding, truth)

The authors noted that no statistically significant benefit was found comparing interventions.  @PHTwitJC noted the results were unlikely to be chance due to statistical analysis (p>0..05) and unlikely to be confounders due to randomisation.  Therefore the study results were likely to either represent a truth, or could be explained through bias…

@RoryMorr and @Duncautumnstore debated whether the study was underpowered to show a true effect, and queried whether the clinically meaingful difference for the AUDIT score was too high.

It was suggested that participants may have been influenced by wider population lifestyle campaigns, however @dotbirch pointed out that the Change4Life alcohol campaign was not active during the study period.  This is a common problem when trying to assess public health interventions – influencers of behaviour never occur in a vaccuum!
5.  What are the implications of the study for public health practice?

Many participants were interested in the implications due to the current push in the NHS to ‘Make Every Contact Count’ and the Department of Health Directive for 2013 to include brief interventions for alcohol within the NHS Health Checks.

@Fibigibi13 highlighted that an additional message for NHS Health Checks may make it difficult for health care practitioners to cover everything in allocated time-slots – particularly where patients may have complex needs.

@RoryMorr informed that the Scotland Government currently has a target set for brief alcohol interventions in primary care, and suggested that the advice may need to be revised, as this study showed little benefit in providing intervention beyond information leaflets.

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