Researchers at the Yale School of Medicine have developed a standardized checklist that evaluates the success of techniques emergency department physicians use when administering brief interventions to patients. These brief interventions aim to remedy patient misuse of alcohol, and the newly developed tool is the first of its kind to measure their effectiveness. Inspired by an earlier study regarding the effectiveness of brief intervention, Michael V. Pantalon, a research scientist in Emergency Medicine at Yale and lead author of the study, spoke with the News on Tuesday afternoon.
Q: First off, congratulations on the development of this new tool. Can you briefly describe the findings of the study?
A: After finding out that our brief intervention works for ER patients, we wanted to make sure that we had a way for people to implement the brief intervention in the way that it was meant to be implemented. The only way to do that with counseling intervention was to develop a checklist that people can use to rate someone else’s implementation and make sure they were doing it correctly. And so based on our data in a prior study where we studied the effectiveness of the brief intervention, we developed a scale that captured the essence of the intervention and rated the several hundred audiotapes. After analyzing all that data, we boiled it down to an eight item version that captured the heart, the essence, of the intervention, such that if doctors or nurses or TAs were doing those eight things, that they were hitting the heart of it and would like to get the intervention to be as effective as the ones in our prior study.
Q: What sort of things are on this checklist?
A: The intervention that we were measuring with the checklist is called the Brief Negotiation Interview, and it has four simple steps to it and the checklist items for step one, for example, would be: ‘Did the practitioner ask for the patient’s permission to talk about alcohol?’ It might seem like a simple item on the checklist, but we’ve found over and over again that since it’s such a sensitive issue, if you ask people permission to talk about it, they’re much more likely to open up. That was one item. Another item is, it may sound slightly counter intuitive, but we asked people to rate how ready they were to cut down on their drinking on a scale of one to 10 — where one means not at all, and 10 means totally — and they would give us their rating. Let’s say they said only a four, for example. The next question would be ‘Did the doctor ask the patient why he or she did not pick a lower number?’, which everybody sort of does a double take on. But that question is the heart of this intervention where we’re asking people why they have any motivation to cut down on their drinking, versus the more traditional and ineffective question, which is ‘Why aren’t you more ready to cut down on your drinking?’ That does not work. So the key checklist question was asking people why they were not less ready to cut down.
Q: What was the research process like for figuring this out? Were there any significant challenges faced?
A: It’s important to know that this was sort of a study within a study. The development of the new tool was a study within a larger study that was evaluating the effectiveness of the intervention. So the effectiveness of the intervention, that happened, and was published several months prior to this. And then the checklist was developed within that process. This was a study that recruited almost 900 patients in a very busy, chaotic emergency department. One challenge was to convince physicians and TAs at Yale, New Haven and New York that they were equipped to do yet another thing. They always counsel patients about alcohol, but here was a new way to do it briefly and to get at those people who are not already alcoholics. So the first challenge was to get real world practitioners onboard and convince them that we can train them well. But with this checklist it really made it much, much easier. People were able to see exactly what we were looking for and they said, “Oh we can do that. All we have to do is say the things on this laminated card that you give us?” And we said yes. It was challenging to recruit patients, to train practitioners, but with a manualized approach and a checklist to show them that they can really easily figure out what they need to do, it went much smoother.
Q: How would you describe your role as “lead author” of the study?
A: I’m sort of your quality control in counseling intervention, if you will. I’ve done this for 15 years now at Yale and so I’ve become an expert in tracking and supervising people who are implementing counseling interventions in randomized controlled trials. For me it was a bit of a change to do this within the emergency room, but it was really exciting to be able to find that something as quick as 7 minutes really works. It was even more exciting to find out that we can disseminate it broadly because anyone who wants to do this now will know how well they’re actually doing it and how likely they are to get good results. That’s what this new tool gives us.
Q: What sort of effect do you predict the study will have?
A: Well, that’s a great question. For a number of years — say, in the last five to seven years — we’ve had really good evidence that brief interventions around substance abuse, done by physicians, work. So we’ve known brief interventions work, but we have not yet had any kind of validated scale or tool like this one that will tell people whether or not they are doing it correctly. Sure, if the counseling intervention works, that’s great, but it can only be broadly disseminated if people know how well they’re doing it. That’s what the effectiveness rests on. It’s different than when you study a medication. You know what compound is in that tablet, and you know it’s going to work when you give it to people; you don’t need the same sort of quality control. So my prediction for the impact here is that now physicians more broadly — especially in the ER — wil be more likely to do brief intervention because this checklist will show exactly what is expected of them, and it makes it much easier to implement it when you know it’s effective and you know exactly what you need to do to make it effective.
Q: Do you have any further research plans in this topic?
A: Yes, so we are now going to apply this tool to brief interventions done in emergency rooms that have to do with opiate-dependent patients, as well as people who are smokers who are trying to quit with brief intervention. So the new tool will be adapted for those two populations and broadly disseminated to other investigators. That’s the key here. Before this study, we didn’t have a scale like this that was validated. Now that we do, our hope is to broadly disseminate it to other brief intervention researchers so that we can all know how well people need to do the intervention in order for it to be effective.