Strength of Evidence Tables (original) (raw)
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Jonas DE, Garbutt JC, Brown JM, et al. Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Comparative Effectiveness Reviews, No. 64.)
- This publication is provided for historical reference only and the information may be out of date.
This publication is provided for historical reference only and the information may be out of date.
Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet].
Appendix GStrength of Evidence Tables
STRENGTH of EVIDENCE for KQ 1
Table G-1Screening (followed by a behavioral counseling intervention) compared with another screening approach, no screening, or usual care
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Morbidity | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Mortality | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Other long-term outcomes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
Abbreviations: CI = confidence interval; NA = not applicable.
STRENGTH of EVIDENCE for KQ 3
Table G-2Harms of screening for alcohol misuse and screening-related assessment
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Anxiety | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Stigma, labeling, or discrimination | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Interference with the doctor-patient relationship | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Opportunity costs (e.g., time taken away from other clinical activities) | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Increased alcohol, tobacco, or illegal substance use | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
Abbreviations: CI = confidence interval; NA = not applicable.
STRENGTH of EVIDENCE for KQ 4a
Table G-3Behavioral counseling interventions for adults compared with usual care
| Domains Pertaining to strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, mean change in drinks per week at 12 months | ||||||
| 14; 4,332 | Low;RCTs/Fair and Good | Consistent (I2 14%) | Indirect | Precise | WMD -3.6 (95% CI, -4.8 to -2.4) | Moderatea |
| Heavy drinking episodes, % without by 12 months | ||||||
| 8; 2,737 | Low;RCTs/ Fair and Good | Consistent (I2 17%) | Indirect | Precise | Risk difference 0.12 (95% CI, 0.07 to 0.16) | Moderatea |
| Recommended drinking limits achieved, % at 12 months | ||||||
| 13; 5,973 | Low;RCTs/Fair and Good | Consistent (I2 31%) | Indirect | Precise | Risk difference 0.11 (95% CI, 0.08 to 0.13) | Moderatea |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence | ||||||
| 3; 2,387 | Low;RCTs/Fair | Inconsistent | Indirect | Imprecise | Heterogeneous results reported with little data reported | Insufficientb |
a
These were graded moderate, rather than high, because they are intermediate outcomes (thus the Indirect ratings in the Directness column).
b
Unable to pool data or make a conclusion with the limited data reported among the secondary outcomes of the three studies reporting abstinence.
Abbreviations: CI = confidence interval; NA = not applicable; RCT = randomized controlled trial; WMD = weighted mean difference.
Table G-4Behavioral counseling interventions for older adults compared with usual care
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, mean change in drinks per week at 12 months | ||||||
| 2; 789 | Low;RCTs/Fair | Consistent | Indirect | Imprecise | WMD -1.74 (95% CI, -2.8 to -0.6) | Moderatea |
| Heavy drinking episodes at 12 months | ||||||
| 2; 789 | Low;RCTs/Fair | Inconsistent | Indirect | Imprecise | Mixed resultsb | Insufficientb |
| Recommended drinking limits achieved at 12 months | ||||||
| 2; 789 | Low;RCTs/Fair | Inconsistent | Indirect | Imprecise | Risk difference 0.09 (95% CI, 0.02 to 0.16) | Lowc |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
We have moderate confidence that behavioral interventions are beneficial in older adults because both trials found a benefit, but the magnitude of benefit is less certain, as one trial (Project GOAL1, 2) found a reduction of over 5 drinks per week for those in the intervention group compared with controls and the other (HLAYA3, 4) found a reduction of between 1 and 2 drinks per week compared with controls.
b
Project GOAL was a positive study, finding greater reduction in binge drinking in the previous 30 days (18% more subjects reported no binge drinking in the intervention group, p<0.025). The HLAYA study did not find a statistically significant difference for one or more heavy drinking days in the past 7 days at 12 months (OR, 0.89, 95% CI, 0.4v 1.97).
c
Both point estimates for the individual studies favored behavioral interventions, although the difference in GOAL reached statistical significance and the difference in HLAYA did not quite. Pooling the data for the two studies found a 9% absolute difference favoring behavioral interventions.
Abbreviations: CI = confidence interval; NA = not applicable; RCT = randomized controlled trial; WMD = weighted mean difference.
Table G-5Behavioral counseling interventions for young adults and college students compared with usual care
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, mean change in drinks per week at 6 months | ||||||
| 5; 2,255 | Low;RCTs/Fair and Good | Consistent | Indirect | Precise | Greater reduction with behavioral counseling interventions in 5 of 5 studies (6/6 comparisons); WMD, -1.7 drinks per week (95% CI, -2.6 to -0.7) for 3 studies reporting drinks per week; RRs from 0.74 to 0.79 for the 2 studies reporting rate ratios (all with statistically significant 95% CIs). | Moderate |
| Alcohol use, mean change in drinks per week at 12 months | ||||||
| 4; 2,151 | Low;RCTs/Fair and Good | Inconsistenta | Indirect | Imprecisea | Greater reduction with behavioral counseling interventions with effect sizes ranging from 1.25 to 4.16 drinks per week. | Moderatea |
| Heavy drinking episodes at 6 months | ||||||
| 5; 2,255 | Low;RCTs/Fair and Good | Consistent | Indirect | Precise | Greater reduction with in-person interventions of 0.9 heavy drinking days per month (WMD, -0.9, 95% CI, -1.5 to -0.3) and with web-based interventions (RR, 0.76, 95% CI, 0.61 to 0.93) | Moderate |
| Heavy drinking episodes at 12 months | ||||||
| 4; 2,151 | Low;RCTs/Fair and Good | Inconsistent | Indirect | Imprecise | No difference between groups for heavy drinking days per month (WMD, -0.2, 95% CI, -1.2 to 0.8) | Low |
| Recommended drinking limits achieved | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
Although there is some inconsistency because one of four studies (one of five comparisons) did not find a difference between groups, the best evidence suggests a difference, and there are several reasons why the study by Schaus and colleagues7 may not have found a difference: (1) the control group received an alcohol problems prevention booklet, which may bias results toward the null, and (2) the enrolled subjects had a much lower baseline alcohol consumption (around 8 to 9 drinks per week—half of what was reported in other studies), leaving less room for reduction in consumption. Thus, we graded this moderate, rather than low.
Abbreviations: CI = confidence interval; NA = not applicable; RCT = randomized controlled trial; RR = relative risk; WMD = weighted mean difference.
Table G-6Behavioral counseling interventions for pregnant women compared with usual care
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95%CI) | High, Moderate, Low, Insufficient |
| Alcohol use, mean change in drinks per week | ||||||
| 1; 250 | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | Difference between groups was not statistically significant (-0.3 vs. -0.4, p=NS, excluding patients who maintained abstinence through the end). | Low |
| Heavy drinking episodes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Recommended drinking limits achieved | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence | ||||||
| 1; 250 | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | For the overall sample, data were not reporteda | Insufficienta |
a
For the subgroup of subjects who were abstinent prior to assessment, those who received the intervention maintained higher rates of abstinence than those in the control group (86% vs. 72%, p=0.04, low strength of evidence).
Abbreviations: CI = confidence interval; NA = not applicable; NS = not significant; RCT = randomized controlled trial.
STRENGTH of EVIDENCE for KQ 4b
Table G-7Behavioral counseling interventions for adults compared with each other: Very brief interventions compared with brief interventions
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, % decreasing average daily amount at 9 months | ||||||
| 1; 1072a | Medium;bRCT/Fair | NA, single study | Indirect | Imprecise | _Men_VB: 40.8 vs. B: 40.3c_Women_VB: 43.2 vs. B: 45.1c | Insufficient |
| Heavy drinking episodes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Recommended drinking limits: Improvement in % of subjects above recommended weekly limit at 9 months | ||||||
| 1; 1072a | Medium;bRCT/Fair | NA, single study | Indirect | Imprecise | _Men_VB: 21 vs. B: 17c_Women_VB: 27 vs. B: 25c | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence, % abstinent at 9 months | ||||||
| 1; 1072a | Medium;bRCT/Fair | NA, single study | Indirect | Imprecise | _Men_VB: 5 vs. B: 8c_Women_VB: 7 vs. B: 12c | Insufficient |
a
Total number of subjects randomized in the study was 1,559;8 1,072 were randomized to the 2 study groups relevant for this comparison
b
One study making the comparison: WHO Brief Intervention Study, 1996.8 Interpretation of the head-to-head information to make a conclusion about how very brief and brief interventions compare in primary care settings is limited by heterogeneity of settings (with many settings outside of primary care, including those in emergency departments), heterogeneity of interventions (with various approaches or personnel used to deliver the intervention), and variations in the interventions across settings and countries.
c
p-values or confidence intervals not reported.
Abbreviations: B = brief intervention up to 15 minutes; CI = confidence interval; NA = not applicable; NS = not statistically significant; RCT = randomized controlled trial; VB = very brief intervention up to 5 minutes.
Table G-8Behavioral counseling interventions for adults compared with each other: Very brief interventions compared with extended multicontact interventions
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; (Design/Quality) | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, reduction in weekly consumption (drinks/week) at 12 months | ||||||
| 1; 192a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | VB: -2.1 vs. EM: -7.0b | Insufficientb |
| Heavy drinking episodes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Recommended drinking limits: % of subjects above recommended limits (%change from baseline) at 12 months | ||||||
| 1; 192a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | VB: 77.1 (-2.1) vs. EM: 76.0 (-7.3), p=NS | Low |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence, % abstinent at 9 months | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
Total number of subjects randomized in the study was 378;9 192 were randomized to the 2 study groups relevant for this comparison.
b
p-values or confidence intervals not reported to determine statistical significance.
Abbreviations: CI = confidence interval; EM = extended multicontact intervention (multiple contacts, some or all longer than 15 minutes); NA = not applicable; NS = not statistically significant; RCT = randomized controlled trial; VB = very brief intervention up to 5 minutes; vs. = versus.
Table G-9Behavioral counseling interventions for adults compared with each other: Brief interventions compared with extended multicontact interventions
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, Change in # of drinks in last 30 days at 12 months | ||||||
| 1; 201a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | B: -33.20 (-48.19 to -18.21) vs. EM: -21.99 (-32.32 to -11.65) | Low |
| Heavy drinking episodes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Recommended drinking limits | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence, Change in # of days abstinent at 12 months | ||||||
| 1; 201a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | B: +2.54 (0.53 to 4.56) vs. EM: +3.58 (1.58 to 5.57) | Low |
a
Total number of subjects randomized in the study was 301;10 201 were randomized to the 2 study groups relevant for this comparison.
Abbreviations: B = brief intervention up to 15 minutes; CI = confidence interval; EM = extended multicontact intervention (multiple contacts, some or all longer than 15 minutes); NA = not applicable; NS = not statistically significant; RCT = randomized controlled trial; vs. = versus.
Table G-10Behavioral counseling interventions for adults compared with each other: Extended multicontact interventions compared with extended multicontact interventions
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, Change from baseline in alcohol grams per day at 12 months | ||||||
| 1; 269a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | EM (FC): -13.0 vs. EM (SC): -12.2, p=0.217 | Low |
| Heavy drinking episodes | ||||||
| 1; 269a | Medium;RCT/Fair | NA, single study | Indirect | Imprecise | Overall data NR, only reported for subgroupsb | Insufficient |
| Recommended drinking limits | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence, Change in # of days abstinent at 12 months | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
Total number of subjects randomized in the study was 408;11 269 were randomized to the 2 study groups relevant for this comparison.
b
Among those with alcohol dependence: EM (FC): 61.2% vs. EM (SC): 51.4%, p=0.387; among abusers/at-risk drinkers: EM (FC): 77.6% vs. EM (SC): 78.0%, p=1.00; among those with heavy episodic drinking only: EM (FC): 80.6% vs. EM (SC): 72.5%, p=0.577
Abbreviations: CI = confidence interval; EM = extended multicontact intervention (multiple contacts, some or all longer than 15 minutes); FC = full care; NA = not applicable; NR = not reported; RCT = randomized controlled trial; SC = stepped care; vs. = versus.
Table G-11Behavioral counseling interventions for young adults or college students compared with each other: Brief interventions compared with brief multicontact interventions
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Alcohol use, total drinks in the past 2 weeks at 6 months | ||||||
| 1; 283a | Low;RCT/Good | NA, single study | Indirect | Imprecise | For each group compared with the control group:B: RR, 0.77 (95% CI, 0.63 to 0.95)BM: RR, 0.79 (95% CI, 0.64 to 0.97) | Low |
| Alcohol use, total drinks in the past 2 weeks at 12 months | ||||||
| 1; 283a | Low;RCT/Good | NA, single study | Indirect | Imprecise | For each group compared with the control group:B: RR, 0.77 (95% CI, 0.63 to 0.95),BM: RR, 0.87 (95% CI, 0.71 to 1.06) | Low |
| Heavy drinking episodes, heavy drinking episodes in the past 2 weeks at 6 months | ||||||
| 1; 283a | Low;RCT/Good | NA, single study | Indirect | Imprecise | For each group compared with the control group:B: RR, 0.78 (95% CI, 0.55 to 1.12)BM: RR, 0.65 (95% CI, 0.45 to 0.93) | Low |
| Heavy drinking episodes, heavy drinking episodes in the past 2 weeks at 12 months | ||||||
| 1; 283a | Low;RCT/Good | NA, single study | Indirect | Imprecise | Neither group reached statistical significance compared with control, but results trended toward favoring the intervention groups (RRs from 0.71 to 0.75 with upper limits of CIs at 1.01 and 1.07). | Low |
| Recommended drinking limits | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Followup with referrals | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Abstinence, Change in # of days abstinent at 12 months | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
Total number of subjects randomized in the study was 576;12, 13 283 were randomized to the 2 study groups relevant for this comparison.
Abbreviations: B = brief intervention up to 15 minutes; BM = brief multicontact intervention; CI = confidence interval; NA = not applicable; RCT = randomized controlled trial; RR = rate ratio.
STRENGTH of EVIDENCE for KQ 5
Table G-12Adverse effects associated with behavioral counseling interventions compared with usual care
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; # of Subjects | Risk of Bias (Design/Quality) | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Increased smoking | ||||||
| 5;a 2,067 | LowRCTs/Fair and Good | Consistent | Direct | Imprecise | No difference between groups (unable to calculate effect size) | Low |
| Opportunity costs/time | ||||||
| 23; 10,519 | LowRCTs/Fair and Good | Consistent, within a given intensity category | Indirectb | Imprecise | Range from about 5 minutes to approximately 2 hours, depending on planned intervention intensity | Moderate |
| Anxiety | ||||||
| 2; 226 | Low to mediumRCTs/Fair | Consistent | Direct | Imprecise | No difference between groups (unable to calculate effect size) | Low |
| Stigma, labeling, discrimination, or interference with doctor-patient relationship | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Illegal substance use | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
4 of the studies were conducted in adult populations; 1 study enrolled older adults, and a subgroup analysis of TrEAT also provided information on older adults. We found no evidence in young adults/college students or pregnant women.
b
We considered this indirect because the time for the intervention was not actually measured in most studies. Authors generally reported the estimated/planned time for interventions, rather than measured/actual time.
Abbreviations: CI = confidence interval; NA = not applicable; RCT = randomized controlled trial.
STRENGTH of EVIDENCE for KQ 6
Table G-13Behavioral counseling interventions for adults compared with usual care or with each other
| Number of Studies; Number of Subjects | Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | |||
|---|---|---|---|---|---|---|
| Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient | |
| Mortality, all-cause mortality (person-years) | ||||||
| 4; 2,006 | Low to medium;RCTs/Fair and Good | Inconsistent | Direct | Imprecise | Rate ratio 0.64 (95% CI, 0.24 to 1.7)a | Low |
| Alcohol-related accidents | ||||||
| 4; 1,117 | Medium;RCTs/Fair and Good | Consistent | Direct | Imprecise | Unable to determine a magnitude of effectb | Insufficient |
| Alcohol-related liver problems | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Outpatient/primary care visitsc | ||||||
| 5; 876 | Low;RCTs/Fair and Good | Inconsistent | Direct | Imprecise | No significant difference (WMD, 0.14 visits, 95% CI, -0.5 to 0.2) | Low |
| Hospitalizations (hospital days) | ||||||
| 3; 1,417 | Low;RCTs/Fair and Good | Inconsistent | Direct | Imprecise | Best evidence found a significant difference in hospital days in the last 6 months for the intervention group than the control group at 6, 12, and 48 months (35 vs. 180, 91 vs. 146, and 420 vs. 664, p<0.001, p<0.001, and p<0.05, respectively).d | Low |
| Emergency visits | ||||||
| 2; 901 | Low;RCTs/Fair and Good | Consistent | Direct | Imprecise | Trend favoring control, but not statistically significant. At 6, 12, and 48 months for intervention vs. control: 47 vs. 70, 60 vs. 62, and 302 vs. 376, p>0.10, p>0.10, and p<0.10, respectivelyd | Low |
| Costs | ||||||
| 2; 901 | LowRCTs/Fair and Good | Inconsistent | Direct | Imprecise | 12 months: average per subject benefit over 1,100andbenefit−costratio5.6:1(951,100 and benefit-cost ratio 5.6:1 (95% CI, 0.4 to 11.0).48 months: cost per patient of 1,100andbenefit−costratio5.6:1(95205, benefit per patient of $7,985, for a resulting benefit-cost ratio of 39 (95% CI, 5.4 to 72.5)d | Low |
| Legal events: assault/battery/child abuse, resist/obstruct officer/disorderly conduct, criminal damage/property damage, theft/robbery, other arrests, controlled substance/liquor violations | ||||||
| 1; 774 | LowRCT/Good | NA, single study | Direct | Imprecise | No statistically significant differences reported except for controlled substance/liquor violations (2 vs. 11, p<0.05)a | Low |
| Sick days and employment stability | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Quality of Life | ||||||
| 3; 353 | MediumRCTs/Fair | Consistent | Direct | Imprecise | No differencee | Low |
a
Analyses with the addition of the included studies in older adults (GOAL) and in younger adults14 trended further toward favoring behavioral interventions, but remained nonstatistically significant (rate ratio 0.52, 95% CI 0.22 to 1.2; 6 studies, 2,255 subjects).
b
Four studies reported data on accidents in adults. Studies were not designed or powered to detect differences in these outcomes. The best available evidence comes from Project TrEAT (N=774),15 which reported outcomes after 48 months of followup. The study found lower numbers of motor vehicle crashes with fatalities (0 vs. 2), motor vehicle crashes with nonfatal injuries (20 vs. 31), and motor vehicle crashes with property damage only (67 vs. 72), that were not statistically significantly different between the intervention and control groups. Two studies (Anderson 1992 and Scott 1990) reported accident scores (from an alcohol-related problems scale), both with endpoint scores numerically favoring the intervention group.16, 17 Neither found a significant change from baseline data for the intervention group or for the control group. One study conducted in Thailand reported alcohol-related accidents (1 in the intervention group and 4 in the control group) and alcohol-related traffic accidents (3 in the intervention group and 5 in the control group).18
c
List the actual outcome measures that were reported for primary care utilization.
d
Summary effect sizes and data are from Project TrEAT, as it provided the best evidence (due to design, sample size of 774, risk of bias, and duration of followup). For hospitalizations, two smaller studies of shorter duration reported no statistically significant difference between groups for hospitalization outcomes, but Senft and colleagues (N=516) reported a slightly lower percentage of subjects hospitalized in the intervention group than the control group at 24 months that was not significant (21.2% vs. 22.0%, p=0.81) and a trend toward fewer mean hospital days for those hospitalized (4.7 vs. 6.6, p=0.37); Lock and colleagues (N=127) reported no significant difference between groups for hospital inpatient stays. 48-month cost data are from the societal perspective.15, 19
e
Two 12-month studies reported no difference in change in mean life quality scores between the intervention and control groups (0 vs. 0 and -0.3 vs. -0.3).16, 17 A nurse-led intervention (N=127) reported no significant differences between the intervention and control groups at 6 or 12 months for change in SF-12 physical or mental health scores.20
Abbreviations: CI = confidence interval; NA = not applicable; RCT = randomized controlled trial; vs. = versus; WMD = weighted mean difference.
Table G-14Behavioral counseling interventions for older adults compared with usual care or with each other
| Domains Pertaining to strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Mortality, all-cause mortality (person-years) | ||||||
| 1; 158 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | Intervention vs. control: 1 death vs. 4, p=NR | Insufficient |
| Morbidity | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Utilization | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Costs | ||||||
| 1; 158 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | No statistically significant difference in economic outcomes through 24 monthsa | Low |
| Legal events, sick days, and employment stability | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Quality of life | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
The total costs of health care and social consequences were estimated to be 5,241(955,241 (95% CI, 5,241(952,995 to 7,487)perpatientinthetreatmentgroupand7,487) per patient in the treatment group and 7,487)perpatientinthetreatmentgroupand6,289 (95% CI, 3,549to3,549 to 3,549to9,029) per patient in the control group.2
Abbreviations: CI = confidence interval; NA = not applicable; NR = not reported; RCT = randomized controlled trial; vs. = versus.
Table G-15Behavioral counseling interventions for young adults and college students compared with usual care or with each other
| Domains Pertaining to Strength of Svidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Mortality | ||||||
| 1; 104 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | One of the trials (Kypri 2004) reported one death in the control group and zero in the intervention group. | Insufficient |
| Motor vehicle events | ||||||
| 1; 226 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | Fewer events in intervention group than control groupa | Low |
| Alcohol-related liver problems | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Hospitalizations (hospital days) | ||||||
| 1; 226 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | Lower number of days of hospitalization for the intervention group, but did not reach statistical significance: 131 vs. 150, p=NSa | Low |
| Emergency visits | ||||||
| 1; 226 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | Fewer emergency department visits for the intervention group than for the control group: 103 vs. 177, p<0.01 | Low |
| Academic outcomes | ||||||
| 2; 680 | Low;RCTs/Fair and Good | Consistent | Direct | Imprecise | Fewer consequences related to academic role expectations (rate ratio between 0.70 and 0.80)d | Moderate |
| Legal events | ||||||
| 1; 226 | Medium;RCT/Fair | NA, single study | Direct | Imprecise | No statistically significant differences reported except for controlled substance/liquor violations: 0 vs. 8, p<0.01b | Low |
| Costs | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Quality of life | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
a
Evidence is from a subgroup analysis of young adults (18 to 30) from Project TrEAT. The study reported significantly fewer motor vehicle crashes with nonfatal injuries for those in the intervention group than for controls (9 vs. 20, respectively; p<0.05) and fewer total motor vehicle events (114 vs. 149; p<0.05) after 48 months of followup.6
b
No statistically significant difference for total legal events (16 vs. 26), assault/battery/child abuse (6 vs. 6), resist/obstruct officer/disorderly conduct (6 vs. 3), criminal damage/property damage (1 vs. 3), theft/robbery (1 vs. 3), and other arrests (2 vs. 3). However, the study did report a difference for controlled substance/liquor violations, with 0 in the intervention group compared with 8 in the control group (p<0.01).6
c
Both studies used the Academic Role Expectations and Alcohol Scale (AREAS).12, 14 The larger (N=576) trial reported fewer academic consequences for the intervention groups than control groups at 12 months (rate ratio: single-contact intervention 0.80, 95% CI, 0.66 to 0.97; multicontact intervention 0.75, 95% CI, 0.62 to 0.90).12 In the smaller trial (N=104), results did not quite reach statistical significance at 6 months, but point estimates for rate ratios were similar (0.72, 95% CI, 0.51 to 1.02).14
Abbreviations: CI = confidence interval; NR = not reported; NS = not sufficient; RCT = randomized controlled trial; vs. = versus.
Table G-16Behavioral counseling interventions for pregnant women compared with usual care or with each other
| Domains Pertaining to Strength of Evidence | Magnitude of Effect | Strength of Evidence | ||||
|---|---|---|---|---|---|---|
| Number of Studies; Number of Subjects | Risk of Bias; Design/ Quality | Consistency | Directness | Precision | Summary Effect Size (95% CI) | High, Moderate, Low, Insufficient |
| Mortality | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Morbidity | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
| Other long-term outcomes | ||||||
| 0; 0 | NA | NA | NA | NA | NA | Insufficient |
Abbreviations: CI = confidence interval; NA = not applicable.
References
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Jonas DE, Garbutt JC, Brown JM, et al. Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Comparative Effectiveness Reviews, No. 64.) Appendix G, Strength of Evidence Tables. - PDF version of this title (3.1M)
In this Page
- STRENGTH of EVIDENCE for KQ 1
- STRENGTH of EVIDENCE for KQ 3
- STRENGTH of EVIDENCE for KQ 4a
- STRENGTH of EVIDENCE for KQ 4b
- STRENGTH of EVIDENCE for KQ 5
- STRENGTH of EVIDENCE for KQ 6
- References