CLINICIAN’S CAPSULE
What is known about the topic?
Emergency department (ED) visits for adolescent alcohol-related concerns offer the opportunity for early intervention; however, the underlying alcohol problem generally remains unaddressed.
What did this study ask?
What are ED physicians’ perceptions regarding adolescent alcohol use and ED-based intervention? What are their current intervention practices?
What did this study find?
While the majority of ED physicians feel the responsibility to address problematic adolescent alcohol use, interventional practices are unstandardized and lacking.
Why does this study matter to clinicians?
This study identifies the resources needed by ED physicians to deliver appropriate adolescent alcohol-related care.
INTRODUCTION
Problematic adolescent alcohol use is prevalent in Canada and associated with harmful and hazardous consequences.1 Emergency department (ED) visits for alcohol-related morbidities offer an opportunity to screen for problematic alcohol use and provide brief intervention, referral to treatment (SBIRT), or both to those adolescents who screen positive.Reference Newton, Dong and Mabood2 Despite the benefitsReference Cunningham, Chermack and Ehrlich3, Reference Walton, Chermack and Shope4 and recommendations to use5 SBIRT for adolescent ED patients, limited time, knowledge, and resources hinder the performance of SBIRT in the ED.Reference Chun, Spirito, Rakowski, D’Onofrio and Woolard6
To date, there are no available reports on alcohol intervention practices in Canadian EDs to inform recommendations for SBIRT training and implementation. This study explored perceptions of adolescent alcohol use and ED-based treatment and SBIRT practices among Canadian pediatric emergency physicians.
METHODS
Study design and population
Physicians in the Pediatric Emergency Research Canada (PERC) database, which included approximately 53% of physicians working across 15 Canadian pediatric EDs, were surveyed (n=245). Our calculated sample size was 81 participants (see Supplementary File 1).Reference Bartlett, Kotrlik and Higgins7 The University of Alberta Research Ethics Board approved this study.
Survey development
We developed a 35-item questionnaire with five domains: demographics (seven items), training (three items), attitudes and beliefs about adolescent drinking and treatment (seven items), SBIRT practices (seven items), and technology acceptance (11 items) (see Supplementary File 2). The questionnaire was tested for content and face validity.
Recruitment
From October 2016 to January 2017, we recruited PERC physicians using a modified Dillman approach.Reference Dillman, Smyth, Christian and Dillman8 Physicians received pre-notice email invitations to participate and three subsequent emails with a unique participant hyperlink to the survey. Paper-based questionnaires were mailed to non-respondents. Data were collected and managed using Research Electronic Data Capture (REDCap). All responses were anonymized, and no identifying information was collected.
Statistical analysis
We summarized responses with frequencies and proportions with 95% confidence intervals and used a chi-square test to explore associations between physician characteristics and reported SBIRT practices. We used the Jonckheere-Terpstra trend test to explore the directionality of associations. All tests were two-sided, and p-values less than 0.05 were considered significant. Analyses were performed using STATA (version 14.0; StataCorp, College Station, TX).
RESULTS
Respondent characteristics
The response rate was 67.8% (166 of 245 physicians; 46.4% male). On average, the physicians were 43.6 years old (standard deviation [SD]=8.8) with 13.5 years of professional experience (SD=9.1). Most physicians held clinical appointments as pediatric emergency physicians (83.0%); 64.5% completed pediatric emergency medicine fellowships. Almost one-half, 42.8%, of the physicians indicated personally knowing a family relation with an alcohol problem.
Most physicians reported feeling comfortable discussing alcohol use with adolescents (72.9%), recognized problematic use as addressable in the ED (65.1%), and indicated feeling responsible for intervening (85.6%). However, many indicated low confidence in knowledge of (75.3%) and ability to conduct (62.1%) SBIRT. Perceptions of the treatability of problematic alcohol use in the ED varied (see Supplementary File 3). Physicians who indicated not feeling responsible for intervening (14.5%) most commonly identified general practitioners and family members as responsible.
Physician SBIRT practices
Twenty-five percent of physicians reported that they had never conducted SBIRT, primarily citing limited time and resources as reasons. Only 1.2% reported conducting SBIRT consistently clinically. Among physicians who reported conducting SBIRT (n=125), 59.6% performed screening, 57.8% provided brief intervention, and 51.2% had made referrals to treatment. Less than one-half of those who conducted screening used a validated tool (40.4%).
Factors associated with physician SBIRT practices
Table 1 presents the associations between physician-specific characteristics and SBIRT practices. Indications of more alcohol education received during professional training and more alcohol counselling experience were associated with increased performance of SBIRT. Positive responses for comfort in addressing alcohol use, confidence in SBIRT knowledge, and confidence in the ability to conduct SBIRT demonstrated a similar pattern. SBIRT practice was also associated with beliefs of ED suitability to address adolescent alcohol use, treatability of problematic alcohol use, and clinical responsibility to intervene.
The relationship between current SBIRT practices and physician-specific factors
CME=continuing medical education; PEM=pediatric emergency medicine; SBIRT=Screening, Brief Intervention, and Referral to Treatment.
* Using a standardized Jonckheere-Terpstra test. The chi-square and Jonckheere-Terpstra tests both demonstrated significant associations, p<0.05, for the same variables.
† Indicates a negative test statistic (i.e., variables increased in opposite directions).
‡ Medical school, residency, and fellowship.
DISCUSSION
To our knowledge, this is the first study to describe the perceptions and practices of Canadian pediatric emergency physicians regarding adolescent alcohol-related ED presentations. In this study, physicians recognized the importance of and their responsibility to address problematic adolescent alcohol use. However, they lacked confidence in their knowledge of and ability to conduct SBIRT, and one-quarter reported never performing SBIRT for alcohol-related presentations.
Educational initiatives for trainees in SBIRT do result in skills and competency to address alcohol problems.Reference D’Onofrio, Nadel and Degutis9, Reference Bernstein, Bernstein and Feldman10 We found that conducting SBIRT was associated, in part, with the amount of alcohol education received during professional training, but not during continuing medical education (CME). Translating these findings into practical recommendations for training Canadian physicians, offering a SBIRT curriculum early in professional learning may be of value. As many physicians who reported conducting SBIRT did not necessarily follow SBIRT recommendations, training could impact both confidence in and quality of its performance.
Underutilization of SBIRT among emergency physicians has been prevalent in the past and remains unchanged. A commonly cited reason for not practising SBIRT is the belief that SBIRT may not impact patient outcomes.Reference Broderick, Kaplan, Martini and Caruso11 In our study, physicians who doubted that problematic alcohol use was treatable in the ED reported less SBIRT use. While efficacy studies have demonstrated reduced alcohol-related consequences following SBIRT in the ED,Reference Cunningham, Chermack and Ehrlich3, Reference Walton, Chermack and Shope4 establishing a strong evidence base for effectiveness is critical for SBIRT implementation.
This study had several limitations. First, although our sample size was statistically sufficient, we could not determine whether systematic differences existed between respondents and non-respondents, leaving the potential for nonresponse bias in the results. Second, our findings reflect only physician beliefs and clinical practices. To assess the performance of SBIRT comprehensively in the ED, the beliefs and practices of other ED clinicians including nurses and mental health care providers is necessary. Finally, despite precautions, this study was susceptible to social desirability bias, as the physicians were not blinded to the study objective and might have responded in perceived favourable directions.
CONCLUSIONS
Although SBIRT is recommended for adolescent ED patients with alcohol-related concerns, physicians in this study reported limited and unstandardized practices of SBIRT for these visits. Strategies to enhance educational initiatives regarding SBIRT among physician trainees is important as is maturing the evidence base for SBIRT effectiveness.
Competing interests
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. While conducting the study, Ms. Jun was supported by a University of Alberta Medical Science Graduate Scholarship, and Dr. Newton was supported by a New Investigator Award from the Canadian Institutes of Health Research. Dr. Plint holds a University of Ottawa Research Chair in Pediatric Emergency Medicine. None declared.
SUPPLEMENTARY MATERIAL
To view supplementary material for this article, please visit https://doi.org/10.1017/cem.2018.390
