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GPs talked to fewer patients about alcohol after incentive scheme ended, study finds

BMJ 2019; 367 doi: (Published 10 October 2019) Cite this as: BMJ 2019;367:l5920

Rapid Response:

Axing financial incentives on alcohol screening and brief advice: good news?

The bitter comment about the publication from the Universities of Newcastle and Sheffield and University College London concluding “Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision.”(1,2) should have been balanced, questioning if axing the financial incentive was good news.

First, there is no evidence yet on the effectiveness of Pay-for-Performance (P4P) programmes on relevant outcomes.(3) Further, why pay when quality is not present? The healthcare industry is an exception, operating under a strict “No Refunds” policy.

Second, there is no evidence yet for effectiveness of the “brief advice” mantra. Could this vague term be a wolf in sheep's clothing to avoid confessing “I have too little time for implementing motivational interviewing, even more as I have not being trained for it despite a decade at the university”? Why do health care systems from rich countries, which can offer futile but expensive treatments, deny adequate care for vulnerable victims of alcohol? Happily, no promotion of brief interventions for patients with type II diabetes. However, misconceptions may be the issue. Indeed, the US National Institute on Alcohol Abuse and Alcoholism recently funded a randomized controlled trial aiming to reduce intimate partner violence and heavy drinking: Women (mostly poor, single, black, and unemployed) were treated by 20 to 30 minutes counselling or by usual care (i.e. no care) during an Emergency Department visit. At least the negative result allows questioning of the hypothesis: dealing with individual bad habits and these women only met the wrong guy.(4)

As a second line clinician caring for victims of alcohol I am fond of Rehm and colleagues’ paradigm shift for targeting “situations where there is a co-morbidity with alcohol being a potential cause (such as hypertension, insomnia, depression or anxiety disorders)”.(5) Depression deserves specific comment as pilling, almost a reptilian reflex (6,7), is not only missing the forest for the trees but also a double penalty (8): antidepressants have modest, if any, useful effects on mood even more in depressed drinkers but they may paradoxically aggravate drinking outcomes to produce pathological intoxication characterized by marked loss of control, memory impairment, and occasionally serious violence, even homicide.(9)

However, the real issue is a comprehensive alcohol control policy, minimum unit pricing on alcohol purchases as in Scotland being one of the measures,(10) otherwise caring for victims of alcohol will remain a Sisyphean task.

1 Mahase E. GPs talked to fewer patients about alcohol after incentive scheme ended, study finds. BMJ 2019;367:l5920.

2 O’Donnell A, Colin A, Hanratty B, et al. Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time series analysis. Addiction 2019. 10.1111/add.14778.

3 Mooney H. Incentives paid to GPs to improve healthcare have no effect on mortality, study finds. BMJ 2016;353:i2882.

4 Braillon A, Taiebi F. Treatment of Alcohol Use Disorders: Benchmarking Houston, Texas, and Philadelphia, Pennsylvania. Clin Gastroenterol Hepatol 2016;14:487.

5 Rehm J, Anderson P, Manthey J et al. Alcohol Use Disorders in Primary Health Care: What Do We Know and Where Do We Go? Alcohol Alcohol 2016;51:422-7.
6 Chick J. Unhelpful Prescribing in Alcohol Use Disorder: Risk and Averting Risk. Alcohol Alcohol 2019;54:1-4

7 Braillon A, Lexchin J, Blumsohn A, Hengartner MP. The "pharmaceuticalisation" of life. BMJ 2019;365:l1972.

8 Braillon A. Alcohol Use Disorders and the Barrel of the Danaids. Alcohol Alcohol 2016;5:774.

9 Menkes DB. Alcohol and serious harms of antidepressant treatment. BMJ 2016;352:i892.

10 O'Donnell A, Anderson P, Jané-Llopis E, Manthey J, Kaner E, Rehm J. Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. BMJ 2019;366:l5274.

Competing interests: No competing interests

16 October 2019
alain braillon
senior consultant
Avenue René LaënnecUniversity hospital. 80000 Amiens. France.