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Abstract

The aim of this study was to compare the effectiveness between an automated bilingual computerized alcohol screening and intervention (AB-CASI) digital health tool versus standard care for reduction of ROH consumption in US adult Latino population affected by unhealthy drinking at the ED. According to the World Health Organization, “alcohol-related visits to EDs increased by 61.6%, including increases of more than 51% for acute alcohol-related visits and more than 75% for chronic alcohol-related visits” from 2006 to 2014 (World Health Organization, 2018) . Screening and counseling programs inside the emergency department like the ED-SBIRT (ED screening, brief intervention, and referral to treatment) has been linked to reductions of ROH consumption and adverse consequences. This randomized clinical study analysed the effectiveness of AB-CASI versus standard care among 840 self-identified adult Latino patients in the ED with unhealthy drinking habits from 2014 to 2020 at the ED of a major tertiary care center in the US. The AB-CASI group received alcohol screening and a brief negative interview (BNI) in their preferred language while the standard care group received standard emergency medical care with information concerning recommended follow-up. The AB-CASI group showed a significant reduction (3.2; 95% CI, 2.7-3.8) compared to the standard care group (4.0; 95% CI, 3.4-4.7) at 12 months in number of drinking episodes within the last 28 days at 12 months after randomization.

Background

In the United States, about one-third of all adults will meet the diagnostic of alcohol use disorder (AUD) in the Diagnostic and Statistical Manual for Mental Disorders, 5 th edition (DSM-5) in their lifetime. Furthermore, it is estimated that around 15.1 million US adults meet these criteria in the previous 12 months (Witkiewitz et al., 2019) . In the United States, the Latino population represents the largest minority group with over 60 million people and are considered the fastest growing population in the country, second to Asian Americans. Many articles have described the risk factors present in the Latino population (psychological, social, cultural) leading to alcohol and substance misuse. The literature also shows a link between ethnic discrimination and higher risk of alcohol use disorder. In fact, Kcomt et al. demonstrates that ethnic discrimination is associated with past-year AUD in the Latino population and the association is even greater in sexual minority Latino adults experiencing ethnic and sexual discrimination concomitantly (Kcomt et al., 2023) . Pathological alcohol use worsens the global burden of disease and a correlation has been established between alcohol consumption and over 200 health conditions (World Health Organization, 2018) . In a large retrospective population study conducted in Canada, the increase in rates of ED consultations linked to alcohol use was 4.4 times greater than the increase in rates of overall ED visits between 2003 and 2016 (Myran et al., 2019) . With the increase in alcohol related consultations in emergency rooms, it is important to educate and equip ourselves to better take care of our patients presenting with alcohol-related complaints. At present, few tools are used in the ED to screen patients for alcohol use. In a recent study, Uong et al. showed that no greater than 1 in 6 emergency department physicians screened their patients for excessive alcohol usage (Uong et al., 2022) . The current research aim was to “compare the effectiveness of an automated bilingual computerized alcohol screening and intervention (AB-CASI) digital health tool with standard care for the reduction of alcohol consumption among US adult Latino emergency department (ED) patients with unhealthy drinking” (Vaca et al., 2023) . The authors hypothesized that at 12 months, the AB-CASI group would experience less binge drinking episodes than the standard care group. They also hypothesized that the AB-CASI group would have a reduced mean number of weekly standard drinks over the last 28 days.

Methods

This study utilized an unblinded parallel-group randomized controlled trial (RCT) conducted in both English and Spanish languages. It aimed to evaluate the efficacy of AB-CASI in reducing alcohol use among adult Latino ED patients compared to standard care. The study included self- identified adult Latino ED patients with unhealthy drinking habits. Exclusion criteria encompassed current enrollment in treatment programs, pregnancy and conditions that hindered interview use (psychotic, homicidal or suicidal thoughts). The AB-CASI intervention comprised an AUDIT assessment, brief negotiation interview (BNI) and culturally-tailored components. Participants received personalized plans and counseling referrals in their language. Participants in the standard care group received conventional emergency medical care, which included an informational sheet and the possibility of a social worker consultation.

The study procedure involved obtaining consent and a health quiz from ED patients self-identifying as Latino ethnicity with unhealthy drinking habits. Assessments were conducted at baseline, 1 month, 6 months and 12 months. These assessments included the Alcohol Use Disorders Identification Test (AUDIT), timeline follow-back (TLFB), injury assessment, problem inventory, brief event data report and treatment services review, all administered by trained research assistants. The primary outcome measure was self-reported binge drinking episodes over the past 28 days at the 12-month mark. Secondary outcomes encompassed the mean weekly standard drinks and alcohol-related adverse health behaviors and consequences. Statistical analyses adhered to the intention-to-treat principle and were performed using version 9.4 of the SAS software.

A repeated-measures generalized linear mixed model (GLMM) was employed with a negative binomial distribution to estimate the primary outcome differences between the AB-CASI and standard care groups. This GLMM simultaneously modeled the number of binge drinking episodes at baseline, 1 month, 6 months and 12 months. It adjusted the estimates of treatment effects based on the baseline number of binge drinking episodes. Fixed effects included intervention, time and their interaction, along with baseline covariates like sex, preferred language and alcohol dependence status. The analysis included all randomized participants and assumed that missing data occurred randomly. Linear contrasts were used to estimate intervention group differences at 1, 6 and 12 months with a significance level of 2-sided p = .05. Relative differences (RD) between groups, represented as the ratio of the mean number of binge drinking episodes in the last 28 days in the AB-CASI group to the standard care group were reported with 95% confidence intervals. Similar mixed-model analyses were conducted for secondary outcomes. To control inflated type 1 errors from multiple significance testing, the significance level for secondary outcomes was set at 2-sided p = .01. Subgroup analyses based on baseline factors, such as age, sex, biculturalism score and primary reason for ED visit, assessed the heterogeneity of treatment effects on the primary outcome. Biculturalism scores which measured levels of Hispanicism and Americanism were determined using the Bicultural Involvement Questionnaire – Short Version. These scores represented an approximation of different levels of acculturation.’

Results

Primary Outcomes

In both the AB-CASI group and the standard care group, the mean number of binge drinking episodes within the last 28 days was 7.7 (95% CI, 6.9-8.7 for both groups) at baseline. In the AB-CASI group, this number decreased to 3.5 (95% CI, 3.0-4.2) at 1 month, 3.4 (95% CI, 2.9-4.1) at 6 months and 3.2 (95% CI, 2.7-3.8) at 12 months. Conversely, the standard care group showed a decrease to 3.9 (95% CI, 3.3-4.6) at 1 month, 3.1 (95% CI, 2.6-3.7) at 6 months and 4.0 (95% CI, 3.4-4.7) at 12 months. The number of binge drinking episodes within 28 days at 12 months after randomization was significantly lower in the AB-CASI group compared to the standard care group (RD, 0.79; 95% CI, 0.64-0.99). The Relative Difference (RD) of 0.79 shows that the mean number of binge drinking episodes within the last 28 days in the AB-CASI group was 79% of the mean number in the standard care group.

Secondary Outcomes

In the AB-CASI group, the mean number of weekly standard drinks revealed a decrease from 22.8 (95% CI, 20.8-25.1) at baseline to 12.4 (95% CI, 10.8-14.1) at 1 month, 11.6 (95% CI, 10.1-13.4) at 6 months and 10.0 (95% CI, 8.6-11.5) at 12 months. In contrast, the standard care group recorded a mean number of weekly standard drinks of 22.8 (95% CI, 20.8-25.1) at baseline, which then dropped to 12.2 (95% CI, 10.7-13.9) at 1 month, 10.5 (95% CI, 9.1-12.1) at 6 months and 12.3 (95% CI, 10.7-14.1) at 12 months. At the 12-month mark, the mean number of weekly standard drinks in the AB-CASI group was 19% lower than in the standard care group (RD, 0.81; 99% CI, 0.64-1.02). However, this difference did not attain statistical significance. Additionally over the course of 12 months, the study found no substantial differences in alcohol-related adverse health behaviors and consequences between the two groups.

Exploratory Subgroup Analyses

The influence at 12 months of AB-CASI on the number of binge drinking episodes within the last 28 days was subject to modifications based on the participants age and the primary reason for their ED visit. Among those aged 25 years or older, binge drinking episodes were 30% lower in the AB-CASI group compared to those 25 years or younger (RD, 0.70; 95% CI, 0.54-0.89).

For the latter group, the point estimate for binge drinking episodes was 40% higher (RD, 1.40;95% CI, 0.85-2.31; P = .01 for interaction) in the AB-CASI group compared to the standard care group. However, the 95% confidence intervals had large variability due to small size of the subgroup aged 25 or younger (n = 176).

Additionally, the magnitude of the reduction associated with AB-CASI was more pronounced in participants whose ED visit was primarily related to alcohol issues (RD, 0.18; 95% CI, 0.04-0.86) as compared to those with primary medical-related reasons (RD, 0.83; 95% CI, 0.67-1.05) or primary psychiatric-related reasons (RD, 0.34; 95% CI, 0.05-2.18; P = .04 for interaction).

Conclusion

This study is the first US randomized controlled trial of Emergency Department Screening, Brief Intervention, and Referral to Treatment (ED-SBIRT) using an automated bilingual digital health tool. The research question aimed to compare the effectiveness of an automated bilingual computerized alcohol screening and intervention (AB-CASI) digital health tool with standard care for reducing alcohol consumption among US adult Latino emergency department (ED) patients with unhealthy drinking habits.

AB-CASI emerged as a more effective intervention, outperforming standard care by reducing the average number of binge drinking episodes within 28 days by 21%. This 21% reduction equals to almost a full episode which is clinically significant given the adverse effects of binge drinking on end organs.

The study’s limitations include its confinement to a single ED in the US with a study population primarily of Puerto Rican descent therefore lacking heterogeneity in the studied population. Subjects’ unavailability for follow-up creates attrition bias which can modify the results of the study. Furthermore, the use of DSM-IV criteria for AUD instead of the DSM-V criteria is a notable limitation with the updated version of the DSM being used today.

However, the results of this study hold substantial significance. They underscore the burden of Alcohol Use Disorder (AUD) in the United States and reveal critical alcohol-related health disparities within the Latino community, the country’s largest ethnic minority group. The AB-CASI tool offers a quick and cost-effective means to address these disparities, especially among unilingual individuals. Implementing adapted ED-SBIRT within emergency departments also proves to be a more cost-effective approach compared to delivering SBIRT in other outpatient medical settings.

In summary, this study sheds light on the effectiveness of ED-SBIRT using AB-CASI in reducing alcohol consumption among Latino ED patients with unhealthy drinking habits. It carries implications for public health by demonstrating a feasible, efficient and cost-effective approach to addressing AUD and its associated disparities within the Latino population, while also serving as an example for bilingual, digital health interventions in emergency care.

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