Targeting alcohol problems among patients of rural Australian emergency departments: establishing an evidence base

It is recognised that emergency department (ED)-based programs have potential to substantially contribute to reducing alcohol-related harm, but it is not known whether this is true in rural Australia, where alcohol misuse and the associated burden is disproportionately high. In order to address this uncertainty, this thesis measured the prevalence of alcohol problems in rural ED patients, critically examined the evidence for the cost-effectiveness of ED-based brief alcohol interventions (BAIs), and evaluated the cost-efficacy of an ED-based BAI in reducing alcohol consumption among patients of rural EDs.Self reported alcohol consumption and clinician judgement of alcohol intoxication were used in Chapter 2 to identify alcohol-related ED presentations. Nine percent of presentations were identified as alcohol-related, with elevated rates among defined subgroups of patients.ED patients and the general population in the same rural communities were assessed for risky alcohol consumption in Chapter 3. Relative to the general population, the ED sample demonstrated higher rates of risky drinking across multiple measures. According to the Alcohol Use Disorders Identification Test (AUDIT), for example, 39% of patients engaged in risky alcohol consumption, compared to 20% of the general population. Rates of risky drinking were elevated in the majority of patient subgroups examined.In Chapter 4, a systematic review of published evaluations of ED-based BAIs found that although their outcome measures were inconsistent and the reporting of effect size information inadequate, they were sufficiently methodologically rigorous for their results to be meaningfully interpreted. Meta-analyses revealed that ED-based BAIs can be efficacious in reducing alcohol-related injuries, under certain conditions, but these conditions have not yet been identified sufficiently. The randomised controlled trial conducted in Chapter 5 found mailed personalised feedback to be associated with a reduction in alcohol consumption among risky drinking rural ED patients with alcohol-involved ED presentations. It was also found to have superior cost-efficacy and lower absolute cost than an ED-based BAI consisting of brief motivational counselling. Together, the findings from this thesis suggest the prevalence of alcohol problems is sufficiently high to warrant ED-based alcohol interventions in rural Australia, for which mailed feedback is a promising candidate