Archive for January, 2012

Nurse-delivered alcohol interventions more accepted

The U.S. Joint Commission recently approved new hospital accreditation measures related to alcohol screening, brief intervention, and referral to treatment (SBIRT) for all hospitalized patients. Yet little is known about the effectiveness of brief interventions (BIs) or inpatient acceptability of SBIRT when performed by healthcare professionals other than physicians. A new study has found high hospital-patient acceptability of and comfort with nurse-delivered SBIRT.

Results will be published in the April 2012 issue of Alcoholism: Clinical & Experimental Research.

Identifying Unhealthy Alcohol Use

“SBIRT is widely endorsed for identifying and managing unhealthy alcohol use that ranges from hazardous or ‘risky’ drinking to the more serious alcohol abuse and dependence,” explained Lauren M. Broyles, a research health scientist at the VA Pittsburgh Healthcare System, assistant professor of medicine at the University of Pittsburgh, and corresponding author for the study.

“A more recent focus has extended to identification of hazardous drinking – consumption that exceeds guidelines established by the National Institute on Alcohol Abuse and Alcoholism – as more than 14 standard drinks/week or more than four/occasion for men, and more than seven standard drinks/week or more than three/occasion for women and healthy individuals age 65 or older,” she said. “Despite [supporting] evidence, recommendations and mandates concerning SBIRT implementation, uptake by healthcare providers in real-world clinical settings is still relatively limited.”

“SBIRT is a brief conversation, about 10 to 15 minutes, about hazardous alcohol consumption,” added Deborah S. Finnell, a research nurse scientist at the VA Western New York Healthcare System and associate professor of nursing at the University at Buffalo. “Healthcare team members could easily deliver SBIRT, assuming they are qualified. Since nurses provide 24-hour care in hospitals, nurses are most likely to have contact with patients compared with other healthcare team members, such as physicians and social workers.”

High Rate of Acceptability

Broyles and her colleagues conducted a cross-sectional survey of 355 (342 males, 13 females) hospitalized medical-surgical patients at a large university-affiliated medical center that is part of the U.S. Department of Veterans Affairs.

Results indicated acceptability for nurse-delivered SBIRT was high. Patient acceptability for eight out of 10 individual nurse-delivered SBIRT tasks was greater than 84 percent. Roughly 20 percent of the patients reported some degree of personal discomfort with the discussions; in general these individuals had a lower belief in their ability to reduce their drinking risk, were older than 60 years of age, had a positive alcohol screening, and were of non-black race.

“We found, in general, that acceptability for nurse-delivered SBIRT tasks was associated with how people perceived their own alcohol-related risks,” explained Broyles. “Patients had higher acceptability if they felt that they were able to determine and reduce their own alcohol-related health risks, and if they had expressed concern about their own alcohol use. Conversely, roughly 20 percent of the patients expressed annoyance or embarrassment with the questions while also showing high levels of acceptability. While this might seem contradictory, patients might feel embarrassed or uncomfortable with the topic or discussion even though they see the discussions as a legitimate, necessary, and acceptable part of the nurse’s role.”

Alcohol and Health Risks

“This study also highlights the importance of being patient-centered,” said Finnell. “Patients are accepting of receiving information from nurses about changing their alcohol use and about self-help groups. Specifically, when patients can make the connection between their alcohol use and health risks, they may be more accepting of having the conversation with the nurse and continuing that conversation about decreasing the amount of alcohol they consume. Additionally, nurses providing patient-centered care will be sensitive to signs that the patient is uncomfortable during the conversation.”

Broyles agreed. “For hazardous drinkers, nurses and other healthcare providers can normalize alcohol screening and BI by drawing analogies, for themselves and their patients, to screening and structured health behavior advice for other health conditions,” she said. “Normalizing talk about unhealthy alcohol use and alcohol use disorders in general medical settings, by general medical providers, in general medical encounters in this way may help both providers and patients feel more comfortable.”

Finnell said she was not surprised that patients were comfortable with nurse-delivered SBIRT. “I have been amazed at what patients share with me during my interactions with them,” she said. “Americans consistently rank nurses ‘very high’ or ‘high’ on honesty and ethical standards. The concept of trust is an important element in the nurse-patient relationship.”

Appropriate Training Needed

Both Broyles and Finnell emphasized the need for appropriate training, practice, support, and pragmatic strategies for incorporating alcohol SBIRT into existing clinical practices and routines. “Our findings suggest that once trained in SBIRT and motivational interviewing techniques, providers can proceed with greater confidence in alcohol-related risk assessment and risk-reduction conversations with patients,” said Broyles.

“While this study focused on nurse-delivered SBIRT, the take-home points are highly relevant to other clinicians,” added Finnell. “Clinicians who have been asked about barriers to delivering SBIRT report concern about jeopardizing their relationship with the patient. This study shows that patients are accepting of alcohol-related discussions, particularly brief counseling about alcohol, educational materials about changing alcohol use, and information about alcohol self-help groups. The findings from this study should alert nurses, physicians, and other health care providers to be prepared to meet the needs of these patients.”

January 22nd, 2012  in Alcoholism No Comments »

Poorest Smokers Face Toughest Odds

Quitting smoking is never easy. However, when you’re poor and uneducated, kicking the habit for good is doubly hard, according to a new study by a tobacco dependence researcher at The City College of New York (CCNY).

Christine Sheffer, associate medical professor at CCNY’s Sophie Davis School of Biomedical Education, tracked smokers from different socioeconomic backgrounds after they had completed a statewide smoking cessation program in Arkansas.

Whether rich or poor, participants managed to quit at about the same rate upon completing a program of cognitive behavioral therapy, either with or without nicotine patches. But as time went on, a disparity between the groups appeared and widened.

Hardest Time With Cravings

Those with the fewest social and financial resources had the hardest time staving off cravings over the long run. “The poorer they are, the worse it gets,” said Professor Sheffer, who directed the program and was an assistant professor with the University of Arkansas for Medical Sciences at the time.

She found that smokers on the lowest rungs of the socioeconomic ladder were 55 percent more likely than those at the upper end to start smoking again three months after treatment. By six months post-quitting, the probability of their going back to cigarettes jumped to two-and-a-half times that of the more affluent smokers. The research will be published in the March 2012 issue of the “American Journal of Public Health” and will appear ahead-of-print online under the journal’s “First Look” section.

More Poor People Smoke

In their study, Professor Sheffer and her colleagues noted that overall, Americans with household incomes of $15,000 or less smoke at nearly three times the rate of those with incomes of $50,000 or greater. The consequences are bleak. “Smoking is still the greatest cause of preventable death and disease in the United States today,” noted Professor Sheffer. “And it’s a growing problem in developing countries.”

Professor Sheffer suggested reasons it may be harder for some to give up tobacco forever.

Smoking relieves stress for those fighting nicotine addiction, so it is life’s difficulties that often make them reach for the cigarette pack again. Unfortunately, those on the lower end of the socioeconomic scale suffer more hardships than those at the top – in the form of financial difficulties, discrimination, and job insecurity, to name a few. And for those smokers who started as teenagers, they may have never learned other ways to manage stress, said Professor Sheffer.

For people with lower socioeconomic status (SES), it can be tougher to avoid temptation as well. “Lower SES groups, with lower paying jobs, aren’t as protected by smoke-free laws,” said Sheffer, so individuals who have quit can find themselves back at work and surrounded by smokers. Also fewer of them have no-smoking policies in their homes.

Not Addressed in Treatment

These factors are rarely addressed in standard treatment programs. “The evidence-based treatments that are around have been developed for middle-class patients,” Professor Sheffer pointed out. “So (in therapy) we talk about middle-class problems.”

Further research would help determine how the standard six sessions of therapy might be altered or augmented to help. “Our next plan is to take the results of this and other studies and apply what we learned to revise the approach, in order to better meet the needs of poor folks,” she said. “Maybe there is a better arrangement, like giving ‘booster sessions’. Not everybody can predict in six weeks all the stresses they will have later on down the road.”

“Some people say [quitting] is the most difficult thing in their life to do,” said Sheffer. “If we better prepare people with more limited resources to manage the types of stress they have in their lives, we’d get better results. “

The research was funded by National Institutes of Health National Cancer Institute (R03 CA141995–01A1) and the National Center for Research Resources (RR 020146). The treatment program was funded by the Arkansas Department of Health.

January 22nd, 2012  in Tobacco No Comments »