Cost-effectiveness of strategies to market and train primary health care physicians in brief intervention techniques for hazardous alcohol use.

The cost-effectiveness of strategies to market and train primary care physicians in brief intervention for hazardous alcohol consumption was examined. Physicians were randomly assigned to one of three marketing strategies designed to promote the "uptake" of a brief intervention package for hazardous and harmful alcohol consumption. The strategies were direct mail, tele-marketing, or academic detailing. One hundred and twenty-seven of those physicians who requested the package during the marketing phase (phase 1) and who also agreed to participate in the training and support phase of the project (phase 2) were matched into one of three training and support conditions: training and no support, training and minimal support, training and maximal support. An additional 34 physicians were randomly selected and assigned to a control condition. The ultimate aim of training and support was to maximise physician screening and counselling rates. Tele-marketing was found to be more cost-effective than academic detailing and direct mail in promoting the uptake of the package. For the training and support phase costs and effects increased with the level of support, hence the issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome.

Predictive capacity of the AUDIT questionnaire for alcohol-related harm.

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed to screen for hazardous and harmful alcohol consumption. We examined its ability to predict alcohol-related illness and social problems, hospital admission and mortality over a 2-3-year period. At initial interview, 330 ambulatory care patients were assessed using a detailed interview including the AUDIT questions and laboratory tests. After 2-3 years, 250 (76%) subjects were reassessed and their experience of alcohol-related harm determined. Of those who scored eight or more on AUDIT at initial interview, 61% experienced alcohol-related social problems compared with 10% of those with lower scores (p < 0.0001); they also had a significantly greater experience of alcohol-related medical disorders and hospitalization. AUDIT score was a better predictor of social problems and of hypertension than laboratory markers. Its ability to predict other alcohol-related illnesses was similar to the laboratory tests. However, gamma glutamyltransferase was the only significant predictor of mortality. We conclude that AUDIT should prove a valuable tool in screening for hazardous and harmful alcohol consumption so that intervention can be provided to those at particular risk of adverse consequences.

Prediction of alcohol-related harm by laboratory test results.

We examined the value of laboratory markers of excessive alcohol (ethanol) intake as predictors of mortality, morbidity, and health-care utilization in a cohort of 330 patients attending an acute ambulatory care service. Among men, all four markers examined--gamma-glutamyltransferase (GGT) and aspartate aminotransferase (AST) activities, high-density lipoprotein cholesterol (HDL-C), and mean corpuscular volume (MCV)--were predictive of medical sequelae and health-care utilization over a 3-year period. In contrast, social problems were more closely related to the amount of alcohol consumption at initial assessment than to any biological marker. Serum GGT and AST activities and MCV were predictive of medical sequelae in women. The predictive value of GGT was an independent risk factor and did not merely reflect recent alcohol intake or the presence of chronic liver disease. We conclude that these readily available laboratory tests provide important prognostic information and should be an integral part of the assessment of persons with hazardous alcohol consumption.

A hepatitis B vaccination programme for inner metropolitan Sydney neonates.

UNLABELLED: OBJECTIVE; To review the effectiveness of a hepatitis B vaccination programme for high risk infants within a mobile urban population. DESIGN: A follow-up study of 1429 infants enrolled consecutively in the programme from September 1987 to December 1988. SETTING: The programme was established in early childhood centres within inner metropolitan Sydney, an area where 30% of residents were born in non-English speaking countries and where doubts had previously been expressed about the efficacy of vaccination. PARTICIPANTS: Neonates born to mothers who were surface antigen positive, born in selected countries with a 5% prevalence of surface antigen carriage, Aboriginal or intravenous drug users. OUTCOME MEASURES: Documented vaccination given by early childhood centre nurses. Some adjustment was made for parents' reports of vaccination given elsewhere. RESULTS: Two vaccinations were given to 87% and three to 73% of these infants. If we include vaccinations apparently given elsewhere we estimate that 92% may have been fully protected. CONCLUSION: The programme produced high rates of compliance with vaccinations within a population where the delivery of such a service was thought to be difficult. Experience with the current State policy for hepatitis B vaccination indicates that it may not optimally reduce the pool of surface antigen carriers within our community.

Problem drinking in emergency department patients: the scope for early intervention.

OBJECTIVE: To determine the prevalence of previously undiagnosed problem drinking and thereby to assess the suitability of the emergency department for early intervention. DESIGN: Three hundred and fifty ambulatory care patients were assessed by means of a structured interview schedule, physical examination and blood tests. Alcohol intake and presence of alcohol-related problems were recorded, along with history of past advice on drinking and self-perception of an alcohol problem. SETTING: The ambulatory care section of the emergency department of Royal Prince Alfred Hospital, Sydney. PATIENTS: Three hundred and fifty subjects, aged between 18 and 55 years, were sequentially selected over an 18-month period. RESULTS: Forty-one per cent of subjects (95% confidence interval, 36%-46%), 50% of men and 26% of women, were classified as problem drinkers on the basis of hazardous or harmful levels of alcohol consumption, frequent drinking to intoxication, evidence of dependence, or experience of alcohol-related problems. Of these, 63% had not previously received advice on drinking from a health professional and only 28% perceived they had a problem. Of particular note was that 24% of men and 4% of women were drinking 12 or more drinks (120 g of alcohol or more) in a single session on a weekly or more frequent basis. CONCLUSIONS: Many of the problem drinkers attending the emergency department have not previously received advice about their drinking from a health professional. The emergency department therefore offers considerable potential as a site for early detection and intervention in patients with hazardous and harmful alcohol use and related disorders.

The determination of the incidence of acute myocardial infarction from hospital morbidity records.

A method for estimating the incidence of acute myocardial infarctions (AMI) from routinely collected hospital morbidity records is presented. The method is based on a review of a sample of routinely collected statistics on hospital diagnoses and the subsequent estimation of the "sensitivity" and "positive predictive value" of hospital diagnoses of AMI. The incidence estimate of AMI is a function of the total number of hospital diagnoses of AMI, the "sensitivity", the "positive predictive value", the proportion of cases of AMI treated at home, and the proportion dying prior to hospital admission. Such estimates may be a practical alternative to community registers for monitoring the incidence of AMI.