Improving emergency medicine residents' approach to patients with alcohol problems: A controlled educational trial

doi:10.1067/mem.2002.123693

Annals of Emergency Medicine

Volume 40, Issue 1, July 2002, Pages 50-62

Presented at the Society for Academic Emergency Medicine annual meeting, Atlanta, GA, May 2001.

https://doi.org/10.1067/mem.2002.123693 Get rights and content

Abstract

Study objective: We determine whether training using a structured skills-based intervention would improve emergency medicine residents' knowledge and practice in screening and intervening with patients presenting to the emergency department with alcohol problems. Methods: In a controlled trial conducted at 2 similar emergency medicine residency programs associated with urban, Level I trauma centers, a 4-hour didactic, video, and skills-based workshop was conducted. Main outcome measures included (1) scores on changes in self-reported knowledge, current practice, self-efficacy, role-responsibility, attitudes and beliefs, and provider readiness to change from baseline to 1 year after intervention and (2) change in practice as measured by record review before and after intervention. Results: The intervention group (n=17) had a significant increase in knowledge scores (P <.001) and practice with regard to percent of medical records with evidence of screening and intervention (17% before versus 58% after; 95% confidence interval [CI] 31 to 50; P <.001); no change was observed in the control group (n=19). These increases were significantly different between groups (95% CI 30 to 54; P <.001). There were no significant differences within or between groups for composite scores derived for current practice, self-efficacy, role responsibility, or readiness to change. Conclusion: A brief, structured, educational intervention for residents contributed to significant improvement in knowledge and practice with regard to patients with alcohol problems. [D'Onofrio G, Nadel ES, Degutis LC, Sullivan LM, Casper K, Bernstein E, Samet JH. Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial. Ann Emerg Med. July 2002;40:50-62.]

Introduction

Alcohol problems are a leading cause of preventable illness and injury¹ and represent a substantial portion of the 95 million emergency department visits each year.² Recent evidence has demonstrated the efficacy of early intervention for patients with alcohol problems.3, 4 These studies have been performed in a variety of settings including primary care,5, 6 inpatient trauma centers,⁷ and EDs.8, 9, 10

The ED visit has also been shown to be a “teachable moment”¹¹ and represents an ideal opportunity for screening and brief intervention.12, 13 Despite this knowledge, few emergency physicians incorporate routine screening, intervention, and referral into their practice.14, 15 Barriers to screening and intervention have been described and include physician characteristics such as education, attitudes and beliefs, perceptions of role responsibility, and confidence (self-efficacy).16, 17

Recently, attention has focused on the development of trained faculty and curricula in medical schools and graduate medical training programs.¹⁷ Federal programs such as the Substance Abuse and Mental Heath Services Administration's Faculty Development Program grants were established to meet this need. These grants helped to develop faculty with expertise in alcohol-related issues. Although the program focused on a broad scope of medical, nursing, and social work school educators, it was small, and its ability to trigger widespread change among emergency medicine faculty was very limited. Achieving progress toward the training of emergency medicine physicians in this realm requires medical educators to devote precious training time to screening and intervention for alcohol problems in the ED setting. Standard didactic educational programs have not been shown to effectively change physician behavior and subsequently improve patient outcome.¹⁸ There is evidence that skills-based interactive sessions can change practice.19, 20 This support, however, is methodologically limited because it is based on observational studies without adequate controls.

We hypothesized that training using a structured skills-based intervention would improve emergency medicine residents' knowledge and performance in screening and intervening with patients presenting to the ED with alcohol problems. To test this hypothesis, we developed a skills-based educational intervention and tested it in a controlled trial among emergency medicine residents. We also assessed whether emergency medicine residents' attitudes and beliefs, perceptions of role responsibility, and self-efficacy influenced their knowledge and performance.

Section snippets

Materials and methods

First- and second-year emergency medicine residents from Yale University and Harvard University participated. Both programs were similar in that they were new, 4-year programs with only 2 years of residents at the time of the study. The primary site hospitals were similar, urban, university, Level I trauma centers. The study was reviewed by the Human Investigation Committee and determined to be exempt from review under federal regulations.

Residents at Yale University received a 4-hour

Results

Seventeen residents comprised the intervention group, and 19 comprised the control group. Table 1 describes general characteristics, past alcohol education, and perceived clinical experience.

. Resident characteristics.

Characteristic	Intervention (n=17)	Control (n=19)	Difference (95% CI)
Demographics
Age, y, mean (SD)	30.2 (3.4)	30.4 (2.7)	−0.2 (−2.3 to 1.9)
Male sex, %	64.71	78.95	−14.2 (−43.4 to 15.0)
Race/ethnicity, %
White	76.47	89.47	−13.0 (−37.4 to 11.4)
Asian	17.65	10.53	7.1 (−15.7 to 29.9)
Other	5.88	0	5.9 (−5.3

Discussion

Multiple consensus statements have been issued recommending that physicians routinely perform screening and brief intervention with their patients, including the reports of the Institute of Medicine in 1990²⁹ and the US Preventive Services Task Force in 1997.³⁰ National organizations such as the NIAAA³¹ and the American Medical Association³² have also made specific recommendations. Regardless of these efforts, most physicians do not conform to formal practice guidelines, including using

Acknowledgements

We thank Rebecca Mascia, BS, for assisting with data collection and Tara Tripp, MA, for statistical programming.

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^*: Supported by grants #T15 SP07773 and #T26 SP08355 from the Center of Substance Abuse Prevention Faculty Development Program, Substance Abuse Mental Health Services Administration, US Department of Health and Human Services, Washington, DC (Dr. D'Onofrio and Dr. Samet).

^☆☆: Address for reprints: Gail D'Onofrio, MD, MS, Section of Emergency Medicine, Yale University School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519; 203-785-4363, fax 203-785-4580; E-mail [email protected]

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Education/Original ContributionImproving emergency medicine residents' approach to patients with alcohol problems: A controlled educational trial*,☆☆

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Ann Emerg Med

Ann Emerg Med

Prev Med

Ninth Special Report to Congress on Alcohol and Health National Institute on Alcohol Abuse and Alcoholism

Epidemiology of alcohol-related emergency department visits

Acad Emerg Med

Brief interventions for alcohol problems: a review

Addiction

Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers

J Gen Intern Med

Brief physician advice for problem alcohol drinkers

JAMA

Provider training for patient-centered alcohol counseling in a primary care setting

Arch Intern Med

Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence

Ann Surg

Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department

J Consul Clin Psych

Intervention by an alcohol health worker in an accident and emergency department

Alcohol Alcohol

Injury as a motivator to reduce drinking

Acad Emerg Med

Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients

Alcohol Clin Exp Res

Patients with alcohol problems in the emergency department, part 1: improving detection. Society for Academic Emergency Medicine Substance Abuse Task Force

Acad Emerg Med

Alcohol intoxication, injuries, and dangerous behaviors—and the revolving emergency department door

J Trauma

Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists

J Gen Intern Med

Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism

JAMA

Changing physician performance: a systematic review of the effect of continuing medical education strategies

JAMA

Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

JAMA

Training community-based clinicians in screening and brief intervention for substance abuse problems: translating evidence into practice

Substance Abuse

Education/Original Contribution
Improving emergency medicine residents' approach to patients with alcohol problems: A controlled educational trial*,☆☆