Psychosomatics 45:220-223, June 2004
© 2004 The Academy of Psychosomatic Medicine
Developing a Brief Monitoring Procedure for Alcohol-Dependent Liver Graft Recipients
Thomas P. Beresford, M.D.,
Brandon Martin, B.A., and
Julie Alfers, B.A.
Received Feb. 27, 2003; revision received July 7, 2003; accepted July 29, 2003. From the Department of Veterans Affairs Medical Center, Denver; and the University of Colorado Health Sciences Center, Denver. Address reprint requests to Dr. Beresford, Denver VA Medical Center (151), 1055 Clermont St., Denver, CO 80220; thomas.beresford{at}uchsc.edu (e-mail).
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ABSTRACT
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To address the occurrence of deaths in later postoperative years among alcohol-dependent liver graft recipients, the authors developed the Brief Active Focused Follow-Up protocol as an instrument for monitoring alcohol use following liver transplant. In this preliminary study, patient receptiveness to its use was tested and its ability to identify patient drinking was noted. Alcohol-dependent liver transplant recipients (N=24) and alcohol-dependent nontransplant patients (N=25) were asked to rate their receptiveness to the Brief Active Focused Follow-Up in three areas. Subjects used a five-point scale for which 5 indicated the highest positive response. Liver transplant recipients responded positively to the Brief Active Focused Follow-Up, with mean responses of 4.92, 4.08, and 4.63 with regard to clarity, usefulness, and ease of completion, respectively. Nontransplant subjects responded similarly, with mean responses of 4.88, 4.12, and 4.52. The two groups were not significantly different in their receptiveness to the Brief Active Focused Follow-Up interview. The Brief Active Focused Follow-Up identified alcohol use within the last 30 days: 8% (N=2 of 24) in the transplant group, and 56% (N=14 of 25) in the nontransplant group. These results suggest that 1) this manualized, brief monitoring technique is well received by alcohol-dependent liver transplant patients, and 2) the Brief Active Focused Follow-Up's "user friendliness" makes it a potentially appropriate instrument for long-term monitoring of alcohol use among alcohol-dependent liver graft recipients.
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INTRODUCTION
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Long-term outcome reports have raised concern regarding the frequency of deaths in later postoperative years among alcohol-dependent patients receiving liver transplants.1–3 Our group4 found a 12% frequency of deaths in later postoperative years (N=4 of 34) resulting from a return to alcohol use in alcohol-dependent liver graft recipients. These deaths occurred between 2 and 6 years following liver transplant. A return to high-risk behavior—drinking in the context of alcohol dependence—can elude routine clinical surveillance, which lessens in frequency with time after transplant. There is still much debate regarding how best to prevent deaths in later postoperative years in a way that is time efficient, effective, and well received by patients.5
One attempt, described as unsuccessful by its authors,6 noted the reluctance of liver graft recipients to accept time-intensive interventions and to agree to interventions that presented a risk of graft injury, such as naltrexone treatment. In that report, only five of 31 subjects who were approached agreed to participate in a study of naltrexone and behavioral treatment, and of those five, none completed more than 4 months of the 6-month course. This study identifies, by their absence, the necessary characteristics for monitoring alcohol-dependent liver transplant recipients. First, the process must be acceptable to those for whom it is targeted. Second, its format must be brief and potentially repeatable over time. Third, it must carry no risk to the health of the alcohol-dependent patient, especially with reference to the liver.
In the absence of an instrument with these characteristics designed for use in the posttransplant population, we developed a monitoring protocol that would assess alcohol use and that liver transplant patients would accept. Inspired by the simplicity of the brief intervention approach in other medical settings,7–13 we developed the Brief Active Focused Follow-Up protocol. Like most brief interventions,13 we designed the Brief Active Focused Follow-Up to be concise and efficiently administered by clinicians. Unlike the brief intervention approach, however, the Brief Active Focused Follow-Up was not designed as a therapeutic instrument. Rather, it is a monitoring tool aimed at early identification of alcohol-dependent liver graft recipients who may return to drinking. Early recognition of a patient's return to alcohol use allows a greater window of opportunity in which to intervene clinically, which in turn may reduce the number of deaths in later postoperative years resulting from alcohol use.
Because of this population's reported history of refusing posttransplant interventions,6 we felt that the necessary first step in developing this instrument was assessing subject receptiveness to its use. We therefore evaluated receptiveness both in 1) a group of liver transplant recipients with histories of alcohol dependence and 2) a comparison group of alcohol-dependent subjects who had not undergone liver transplantation. By comparing these two groups, we sought to highlight concerns specific to the liver transplant group. We hypothesized, however, that subjects in both groups would be receptive to the Brief Active Focused Follow-Up because of its brevity and clarity.
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METHOD
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We enrolled two subject groups: first were liver transplant recipients (N=24) with alcohol dependence, as diagnosed according to DSM-IV criteria by the consultant psychiatrist to the transplant team. These subjects were recruited randomly from the Liver Transplant Clinic at the University of Colorado Health Sciences Center. The second group consisted of 25 subjects receiving treatment for alcohol dependence in a local Department of Veterans Affairs (VA) outpatient substance abuse program. This group was recruited consecutively after routine evaluation; diagnosis of DSM-IV alcohol dependence in these subjects was assigned by VA clinicians. Twenty-five percent of transplant subjects and 36% of nontransplant subjects reported past abuse of other substances in addition to the alcohol. Subjects were excluded from this research only if they refused to give informed consent; two subjects—both liver transplant patients—refused participation. One subject cited time limitations, and the other asked to postpone involvement until the next clinic visit.
Each subject was informed that his or her participation in this institutional review board-approved study was voluntary. Each was informed that the interview took approximately 10 to 20 minutes to complete, and that it was intended for eventual use with alcohol-dependent patients who had recently received a liver transplant. Each gave informed consent, answered basic demographic questions, and agreed to undergo on one occasion the Brief Active Focused Follow-Up interview (available from the first author upon request). A research assistant, independent of any clinical care team, administered the Brief Active Focused Follow-Up and all other assessments; the research assistant was not the author of the Brief Active Focused Follow-Up. Of the 49 interviews completed, 43 were performed in person, and six were conducted over the telephone; all telephone interviews were conducted with subjects from the liver transplant group.
Immediately following completion of the Brief Active Focused Follow-Up, subjects were asked four questions about their experience with the instrument. The first three questions assessed clarity, usefulness, and duration of interview. These questions were answered using a five-point Likert-type scale where "1" represented a negative response and "5" indicated a positive experience with the Brief Active Focused Follow-Up. The research assistant then asked subjects whether they preferred an intervention that was either more or less intensive. As part of the Brief Active Focused Follow-Up, all subjects were queried regarding their recent drinking (past 30 days) as well as their pattern of drinking pretransplant.
Mean values were compared using standard t tests for variables such as age, education, and Brief Active Focused Follow-Up satisfaction responses. Goodness of fit tests were used to compare variables such as ethnic distribution and frequency of recent alcohol use. Corrected chi-square analyses were used when all cells contained five or more subjects, and Fisher's exact test was used when any cell contained less than five cases.
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RESULTS
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The transplant group included 15 male and nine female subjects with a mean age of 50.4 years (SD=8). The nontransplant group consisted of only male subjects with a mean age of 48.1 years (SD=7). The two groups varied by gender but did not significantly differ with respect to age (t=1.07, df=47, p=0.30). Ethnic distribution was Caucasian (67%, N=16) and Hispanic (33%, N=8) in the transplant group and Caucasian (76%, N=19), African American, and Hispanic (12%, N=3) in the nontransplant group. Given the small number of subjects in each ethnic group, the two cohorts were collapsed into Caucasian and non-Caucasian groups; compared in this way, the groups were not significantly different ( 2=0.52, df=1, p=0.52). The average number of education years completed did not distinguish the two groups: 12.6 (SD=3.8) in the transplant group and 12.9 (SD=1.6) in the nontransplant group.
The average length of abstinence (from all substances) in the transplant group was 2243 days (SD=2061), with 8% (N=2 of 24) reporting abstinence for less than 6 months. In the nontransplant group, the average length of abstinence was 344 days (SD=725), with 76% (N=19 of 25) reporting abstinence for less than 6 months. The groups differed significantly by length of sobriety (t=4.34, df=47, p<0.001). Sixty-seven percent of transplant subjects (N=16) had been treated for alcohol or drug dependence in the past versus 76% (N=19) in the nontransplant group, a nonsignificant difference (2=0.52, df=1, p=0.52). Alcohol use within the past 30 days identified 8% (N=2 of 24) of the transplant group and 56% (N=14 of 25) of the nontransplant group; this difference was statistically significant (p<0.001, Fishers exact test). Of note, neither of the transplant patients had been suspected of using alcohol previous to this encounter, and both described dependence symptoms. Comparison of all subjects who reported drinking in the previous 30 days with those reporting abstinence for the same period revealed no significant difference in any of the three main study variables.
Regarding receptiveness, the transplant subjects responded positively to the Brief Active Focused Follow-Up, with mean responses of 4.9 (SD=0.4) for clarity, 4.1 (SD=1.2) for content usefulness, and 4.6 (SD=1.0) for ease of use. Nontransplant subjects responded similarly, with mean responses of 4.9 (SD=0.3), 4.1 (SD=1.0), and 4.5 (SD=1.0), respectively.
A two-tailed t test of the mean scores of these items showed no statistical difference. Length of sobriety was not associated with subjects' receptiveness to the Brief Active Focused Follow-Up on any of the measures in either group.
Eighty-seven percent of transplant subjects (N=21) were satisfied with the brevity of the interview. The remaining 13% (N=3) would have preferred a more extensive session. Similarly, 76% of nontransplant subjects (N=19) were satisfied, and 24% (N=6) preferred a lengthier protocol. The two groups were not statistically different on this variable, and when they were collapsed together, 82% were satisfied with the brevity of the Brief Active Focused Follow-Up.
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DISCUSSION
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Although brief contact strategies have been shown to assist patients with varying alcohol use disorders in different clinical environments,7–13 previous research has not focused on patient satisfaction with these strategies in the setting of alcohol-dependent liver transplant recipients. Testing patient receptiveness, such as that reported here, is critical for implementing a brief contact interview in this population. Demonstration that a monitoring protocol is acceptable to its target group, alcohol-dependent transplant recipients in this case, is essential before any attempt at implementation.
The brevity of our monitoring protocol addresses this concern and supports its ease of repeated use in long-term care. Specifically, 87% of transplant subjects preferred our brief contact monitoring instrument—a higher frequency than the nontransplant subjects—although this difference did not reach statistical significance. Furthermore, the non-accusatory script of the Brief Active Focused Follow-Up should be acceptable to those patients who deny or minimize problematic alcohol use, a difficulty that Weinrieb and coworkers cited as interfering with their subject recruitment.6 We interpret the patients' comments for a longer interview as an indication of the Brief Active Focused Follow-Up's ease of use as a systematic method of staff contact.
Our results suggest that this manualized brief monitoring procedure is well received by alcohol-dependent patients for whom liver transplant indicates abstinence as the most appropriate goal. The positive response by the two groups, one of which averaged about 1 year of abstinence and the other which averaged nearly 6 years of abstinence, implies that the Brief Active Focused Follow-Up will be well received by patients in both the early and late stages of alcohol-dependent recovery. As the Brief Active Focused Follow-Up is eventually intended for use over the course of many years following transplant, it may be more effective than standard posttransplant care, which tends to diminish during and after the first postoperative year.14 Its simplicity of language and directed algorithm style of inquiry, resulting in ease of learning to administer the instrument, were both designed for ready, practical use by non-mental health personnel such as physicians and nurses in a busy transplant clinic. It is this continued monitoring by means of the Brief Active Focused Follow-Up interview that we believe will ultimately alert clinicians of "return to drinking" in time to intervene clinically and thereby reduce the number of deaths in later postoperative years resulting from a return to uncontrolled drinking.
With regard to the Brief Active Focused Follow-Up's ability to recognize subject drinking, we found 8% (two subjects) of liver transplant subjects had returned to drinking posttransplant and had both been drinking within the last 30 days. Remarkably, in this pilot exercise, the Brief Active Focused Follow-Up identified two potential candidates for deaths in later postoperative years due to a return to alcohol use and whose current drinking was unknown to their transplant clinic caregivers. The frequency of active drinking in the transplant group (8%) approached that of death in later postoperative years (12%) in our previous report.
The possibility exists that the two patients who refused participation in this research may have returned to drinking as well, and the Brief Active Focused Follow-Up may or may not have captured this. The refusal to participate may be indicative of the social disruption that uncontrolled drinking causes. In this study, the lack of a proxy report on subject drinking made it impossible to verify patient reports of recent drinking or abstinence. Our data on the Brief Active Focused Follow-Up is therefore limited to the accuracy of patient report. At the same time, however, we note that DiMartini and associates15 found patient report to be the most effective method of identifying drinking posttransplant when compared with the Timeline Follow Back questionnaires, proxy reports, and carbohydrate-deficient transferrin levels. Any study of the Brief Active Focused Follow-Up's effectiveness must include these other sources of data as well.
The current study presents an encouraging first step toward developing an effective tool in monitoring the possible return to pathological alcohol use in patients following liver transplant. While the experience reported here encourages our enthusiasm, a controlled, randomly applied clinical trial of this protocol will be necessary to establish its effectiveness in monitoring abstinence and ultimately reducing posttransplant morbidity and mortality in alcohol-dependent liver recipients.
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ACKNOWLEDGMENTS
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This work was supported by the Department of Veterans Affairs (Dr. Beresford) and a grant from the National Institute on Alcohol Abuse and Alcoholism (AA-12095).
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REFERENCES
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ABSTRACT
INTRODUCTION
