Interactive Voice Response Technology Can Deliver Alcohol
Screening and Brief Intervention in Primary Care
Gail L. Rose, PhD, Charles D. MacLean, MD, Joan Skelly, MS, Gary J. Badger, MS,
Tonya A. Ferraro, BA, and John E. Helzer, MD
The University of Vermont, Burlington, VT, USA.
BACKGROUND: Alcohol screening and brief interven-
tion (BI) is an effective primary care preventive service,
but implementation rates are low. Automating BI using
interactive voice response (IVR) may be an efficient way
to expand patient access to needed information and
OBJECTIVE: To develop IVR-based BI and pilot test it
for feasibility and acceptability.
DESIGN: Single-group pre-post feasibility study.
PARTICIPANTS: Primary care patients presenting for
an office visit.
INTERVENTIONS: IVR-BI structured to correspond to
the provider BI method recommended by NIAAA: (1) Ask
about use; (2) Assess problems; (3) Advise and Assist for
change, and (4) Follow up for continued support. Advice
was tailored to patient readiness and preferences.
MEASUREMENTS: Utilization rate, call duration, and
patients’ subjective reports of usefulness, comfort and
honesty with the IVR-BI. Pre-post evaluation of motiva-
tion to change and change in alcohol consumption as
measured by Timeline Follow Back.
RESULTS: Call duration ranged from 3–7 minutes.
Subjective reactions were generally positive or neutral.
About 40% of subjects indicated IVR-BI had motivated
them to change. About half of the patients had dis-
cussed drinking with their provider at the visit. These
tended to be heavier drinkers with greater concerns
about drinking. Patients who reported a provider-
delivered BI and called the IVR-BI endorsed greater
comfort and honesty with the IVR-BI. On average, a
25% reduction in alcohol use was reported two weeks
after the clinic visit.
CONCLUSIONS: Using IVR technology to deliver BI in a
primary care setting is feasible and data suggest
potential for efficacy in a larger trial.
KEY WORDS: alcohol screening; brief intervention; primary care; IVR
J Gen Intern Med 25(4):340–4
© Society of General Internal Medicine 2010
Alcohol screening and brief intervention (BI) is ranked
among the highest priority preventive services by the
National Commission on Prevention Priorities, based on
their index of cost effectiveness and clinically preventable
burden1and is recommended by the US Preventive Services
Task Force2. There is considerable evidence of its efficacy to
reduce alcohol consumption up to four years following the
intervention3–7; however, only about one-third of primary
care patients are screened for substance misuse by their
providers (PCPs)8,9. Furthermore, biases in the delivery of
BI mean that the intervention is more likely to occur with a
narrow spectrum of patients, i.e. those who are male,
unemployed, less educated, and/or earn lower income10–12.
Barriers to routine screening and BI include lack of
established organizational support systems, lack of reim-
bursement for preventive interventions, heavy workloads,
PCP reluctance to address non-acute behavioral problems,
and PCP lack of confidence or skill discussing alcohol
problems9,13,14. While many of these barriers have proven
intractable to targeted training13, there is early evidence that
they may be circumvented through the use of systematic and
automated approaches to screening. For example, web-based
alcohol interventions have been created for a variety of
audiences and have demonstrated user acceptability and
efficacy15,16. An alternative modality for automating BI that
has not been tested to date is telephone interactive voice
response (IVR) technology. IVR has been used successfully for
alcohol use assessment17,18, alcohol self-monitoring19–21,
symptom reporting22–24, post-BI alcohol monitoring and
feedback25; smoking cessation26, and supplemental case
management in substance abuse treatment27.
IVR systems offer cost and other significant advantages for
primary care settings. Importantly, IVR is an auditory inter-
active process that is not hampered by low literacy. Privacy
and anonymity are greater with an IVR than on a computer
screen or written questionnaire because others cannot see or
hear the questions or responses, even if others are present at
the time of the call. Touch tone phones are familiar, easy to
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-009-1233-0) contains supplementary
material, which is available to authorized users.
Received July 21, 2009
Revised December 3, 2009
Accepted December 14, 2009
Published online February 2, 2010
use, and more widely available than computers. Furthermore,
the hardware and software of a centrally-housed IVR system
can support multiple clinic sites and thus there are no on-site
installation costs beyond telephone access.
The goal of this study was to develop an IVR-based BI (IVR-BI)
and pilot test it for feasibility and patient acceptability.
Participants and Procedures
Recruitment took place in a suburban, university-affiliated
primary care internal medicine office with eight providers.
This busy office was short staffed at the time of recruit-
ment, so it was not possible to invite every clinic patient to
participate. In designing a process to identify the subset of
patients who would be candidates for the study, the
following were the primary considerations: (1) to avoid bias
in selection of participants and (2) to minimize the effect of
the study on the flow of patients through the office. The
procedures were as follows: the evening before each clinic
day, the practice supervisor selected a priori the subset of
patients who would be invited to participate the following
day. Certain visit types/ patients were excluded from the
recruitment pool: new patient visits, acute illness visits,
severe mental health disorder follow-ups, patients (very
limited in number) who were known to be belligerent who
would refuse and might cause a disturbance in the waiting
area, and very elderly patients or those with impaired
vision. Additionally, four patients per half-day were select-
ed, each of whom was scheduled to see a different provider.
Otherwise, the selection of patients was random. The clinic
supervisor marked on the schedule which patients were to
be invited, and the receptionist followed a protocol for
inviting them. All selected patients were invited to make a
brief call using a dedicated waiting room phone to answer
five screening questions (the IVR-screen) in preparation for
the office visit. Patients were told that they and their PCP
would receive a printout of their answers before the
examination, and that participation was voluntary.
The IVR-screen (See online Appendix) was developed by the
authors, pilot-tested on a sample of 119 patients, and revised
for use in this study. Alcohol use was assessed with two
items, either one of which qualified the respondent for the
IVR-BI. The question, “In general, do you feel you drink more
than you should?” was asked first because the PCPs at the
clinic site were accustomed to this as a general question
regarding readiness to engage on the topic of alcohol use.
Responses of “yes” or “not sure” were scored positive. The
second question, “How often do you have five (four for women)
or more drinks on one occasion?” is taken directly from the
World Health Organization’s Alcohol Use Disorders Identifi-
cation Test28, as revised by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA) to reflect standard drink sizes
in the United States29. Any response other than “never” was
scored positive, in accordance with NIAAA guidelines.
At the end of the IVR-screen, those who screened positive
heard the following: “The amount of alcohol you are drinking
can affect your health and interfere with some medical
treatments.” The IVR then alerted them that in the privacy
of the examination room the Medical Assistant (MA) would
invite them to test a “Health Information Line” (the IVR-BI)
that provides information and advice about drinking and
health. In the exam room, the MA obtained written informed
consent, provided a card with the toll free IVR-BI number, and
asked the subjects to call within 48 hours. The MA explained
this was voluntary and, whether or not they called the IVR-BI,
a member of the research team would be contacting them to
ask follow-up questions. The patient then remained in the
exam room for the PCP. The PCPs received a printout of
screening items, but they otherwise were neither encouraged
to nor discouraged from conducting an in-office BI with study
participants. All study procedures were approved by the
University of Vermont Institutional Review Board.
The IVR-BI begins with an introductory description of the
program and its purpose, a reminder that it is part of a
research project, assurance of privacy and confidentiality, and
a request for callers to enter the personal ID number given by
the MA. The IVR-BI content is based on NIAAA29recommenda-
tions for an alcohol brief intervention by a PCP (see Fig. 1). The
NIAAA guidelines for low risk drinking
Advice to cut down
Set a goal
Develop a plan
Do you feel you drink too much?
Exceed 5 (4) drinks per occasion?
Advice to abstain
Talk to your doctor
Call the IVR-BI again any time
Gauge readiness to change
Figure 1. Content and branching structure of interactive voice
response brief intervention (IVR-BI). AUDIT-C: Alcohol Use Disorders
Identification Test-Consumption. NIAAA: National Institute of Alco-
hol Abuse and Alcoholism. AA: Alcoholics Anonymous.
Rose et al.: Automated Alcohol Screening and BI
“Ask” element was accomplished with the two alcohol items in
the IVR-screen that the patient completed in the waiting room;
the remaining 3 elements are covered in the IVR-BI. The
“Assess” phase is accomplished using the three AUDIT-C
questions about quantity, frequency and heavy episodic con-
sumption of alcohol30. The “Advise/Assist” section first gives
the NIAAA safe-drinking guidelines of no more than 14 drinks
per week and fewer than 5 drinks on one occasion for men,
and the corresponding 7 per week, fewer than 4 per occasion for
women. This section then assesses the caller’s readiness to
change their drinking and offers three “Readiness Suggestions”
to those who are not currently ready to change. Callers who
endorse readiness to change can then choose to hear guidance
and suggestions for either cutting down or for stopping alcohol
consumption. Advice for cutting down includes goal-setting,
planning for urges and high-risk situations, proactive avoid-
ance of triggers, self-monitoring, and other strategies. The
advice is voiced by different characters speaking in the first
person so as to maintain the listener’s interest. Advice to
abstain describes treatment and mutual-help models common-
ly used to achieve abstinence, and includes information on local
support and treatment resources. For all callers, the IVR-BI
ends with a section on “Follow-up Support”: callers are
encouraged to talk with their PCP about their alcohol use and
to call the IVR-BI again at any time. The full text of the IVR-BI
can be obtained from the authors.
Two follow-up telephone assessments were conducted at
approximately one and two weeks following the clinic visit by
a research assistant (RA) who was not involved with patient
care. The RA employed a structured interview that was
developed by the research team and tested in a pilot study. It
included a mixture of question formats. The interviewer
recorded participant responses verbatim, and each response
was coded according to a scheme developed after the pilot test
that reflected possible respondent options.
The first call elicited feedback about the patient’s visit with
the PCP as well as their subsequent call to the IVR-BI. The RA
ascertained patients’ recollections of whether or not they had
discussed their drinking with their PCPs during the office visit.
If so, the patient was asked whether the conversation was
initiated by the provider or by the patient, and whether it made
them more aware of how much they drink. On this basis, we
classified patients as either having or not having a brief
intervention by the provider (i.e., PCP-BI). Patients were also
asked to compare the PCP-BI with the IVR-BI in terms of
personal usefulness, comfort with the process, and their
honesty in answering questions. Patients who did not discuss
drinking with their PCP were asked to hypothetically evaluate
the expected usefulness, comfort, and honesty with a PCP-BI
compared with the IVR-BI. The interviewer also assessed
patients’ general reactions to the IVR-BI, the personal rele-
vance of the information it contained, the impact of the
information on their drinking-related attitudes or behavior,
and suggestions for improvements in the IVR-BI.
The first follow-up interview also included a timeline follow
back (TLFB)31assessment of daily alcohol consumption cover-
ing the period of time from 2 weeks prior to the clinic visit up
through the day before the telephone interview. The second
follow-up interview, conducted an average of 16 days following
the clinic visit, consisted of a second TLFB assessment
covering the period of time from the clinic visit through the
day before the second telephone interview.
Analyses were primarily descriptive to assess subject experi-
ence with the IVR-BI. Inferential analyses were based on chi
square tests for categorical variables and paired t-tests to
evaluate changes in self-reported drinking.
Feasibility of Screening
A total of 188 patients completed the IVR-screen, and 83 (44%)
of them screened positive for at-risk drinking. Of the 83
subjects who endorsed either of the screening questions, 82
were positive on the frequency of five (four) or more drinks
question and just 19 were positive on the “feel you drink more
than you should” item. All but one of the 19 were also
identified by the frequency question, but those who endorsed
that they “feel they drink more than they should” were more
likely than those who did not to later call the IVR-BI [12/19
(63%) vs 21/63 (33%), χ2=5.4, p=.02].
Utilization of IVR-BI
Of the 83 who screened positive, 61 (73%) consented to the
IVR-BI study. Of those consenting, 34 (56%) completed the
IVR-BI. Participants called The IVR-BI at varying times
throughout the day, except between 2 AM and 7 AM. One-
third of all calls were made outside of regular clinic hours.
Call duration ranged from 3 to 7 minutes depending on the
number of features the subject chose. Eight of the 34
subjects endorsed interest in changing their drinking habits.
These patients proceeded to the “Advice” section where they
could choose to hear information about cutting down and/or
quitting. Five elected to hear the cut down information and
two elected to hear the quit information. One caller listened to
IVR-BI and PCP-BI
Thirty patients (17 male/13 female) with mean age 43 years
completed the IVR-BI and both follow-up interviews. The
following analyses are based on data from these subjects.
About 45% (n=13) of the 30 respondents stated they had
discussed drinking with their PCP during the office visit, with 9
of the 13 noting that the PCP had initiated the discussion. We
compared those who had received PCP-BI with those who had
not, although PCP-BI occurred in a non-random fashion.
Regardless of PCP-BI, all 30 subjects completed the IVR-BI
and both follow-up interviews. Heavier drinkers were more
likely to report they had a PCP-BI [Mantel-Haenszel χ2=19.2,
p<0.001]; all ten patients who indicated they drank more than
5(4) drinks per occasion on either a daily or weekly basis
reported having a BI from the PCP, whereas just one of 15 (7%)
who endorsed this quantity “less than monthly” received a
Rose et al.: Automated Alcohol Screening and BI
PCP-BI. All patients who endorsed drinking more than they
should (n=8) received a PCP-BI.
About half of those who had a PCP-BI (7/13) said the
discussion made them more aware of how much they drink,
whereas 82% of those who did not have PCP-BI said the IVR-BI
made them more aware of how much they drink. Five subjects
said the discussion with the PCP was more useful than the
IVR-BI, 5 said the reverse was true, and 3 were not sure. We
asked respondents about their comfort level for receiving the
information by phone versus their PCP. Of those who had a
PCP-BI, 50% were more comfortable with the IVR-BI, 25% were
more comfortable with the PCP-BI, and 25% were equally
comfortable. Regarding honesty of responses, 83% reported
they were equally honest with IVR or PCP and 17% said they
were more honest with the IVR. None said they were more
honest with their PCP. For those who did not report receiving a
PCP-BI (n=17), 53% hypothetically said they would be more
honest with the IVR, while 12% said they would be more
honest with their PCP. The remaining 35% said equal or not
Change in Alcohol Consumption
In the assessment section of the IVR-BI, 24% of participants
indicated they were interested in changing their drinking
habits. However, at the first follow-up interview, 40% said the
IVR-BI had motivated them to make a change in their drinking.
Overall, the TLFB data show mean drinks per week decreased
25%, from 8.7 (SD=12.1) before to 6.5 (SD=10.6) two weeks
after the office visit (paired-t=1.63, p=0.11). TLFB data for the
17 individuals who did not receive a PCP-BI (i.e., IVR-BI only)
showed a decrease from 4.3 (SD=8.2) drinks per week before
the visit to 2.5 (SD=2.6) drinks per week after (42% reduction,
paired-t=0.9, p=0.40) Those who received a PCP-BI and an
IVR-BI (n=13) decreased from 14.4 (SD=14.3) drinks per week
before the visit to 11.7 (SD=14.5) drinks per week after (19%
reduction, paired t=1.75, p=0.10).
This pilot study demonstrated that an IVR-based screening
and brief intervention system for at-risk drinking was both
feasible in a busy primary care office setting and acceptable to
patients. Compared with a PCP-BI, the IVR-BI was perceived to
be at least as useful, and patients reported being at least as
comfortable and as honest with the IVR-BI as they were with
Patient willingness to complete the IVR-BI was particularly
important because fewer than half of patients who screened
positive for possible alcohol misuse received a brief interven-
tion from their PCP during the clinic visit. Furthermore, one-
third of the calls to IVR-BI were made outside of clinic hours.
Clearly, the IVR-BI produced greater exposure to needed
advice and information than would have occurred otherwise.
The strengths of the IVR-BI approach are that it can be
accomplished in a way that is minimally disruptive to the office
workflow, can prompt patient and PCP to act, is scalable to
large populations, and once it is developed is inexpensive to
deploy. In this study, the IVR was programmed by a commer-
cial vendor for an initial set-up fee then hosted for a monthly
fee thereafter. Calls to the toll-free number can be received
from any location so theoretically the same IVR system can
support an infinite number of practices. Interference with
clinic routine could be avoided altogether if the IVR-screen and
IVR-BI were completed prior to the visit, for example at the
time of pre-registration or appointment reminder call. If this
were to occur, relevant IVR data could be merged with an
electronic medical record or other pre-visit paperwork process,
and the information from the IVR-BI made available to the PCP
at the time of the visit to facilitate further discussion.
This study has some limitations. Since this was designed as a
feasibility study, the sample was drawn from a single clinic and
there was no control group. Recruitment to the study required
clinic staff to spend extra time to explain the study; thus the
number of patients who could participate was limited. Certain
patients were excluded from the recruitment pool because of the
reason for the visit or their own physical/ cognitive limitations,
which affects the generalizability of findings to the entire clinic
population or to other settings or populations. The impact of
volunteer bias on the results is not known.
Among this sample of patients who completed the IVR-BI and
two follow-up interviews, 45% reported they had discussed their
drinking with the PCP during the visit. We do not interpret this
to mean that 45% of screen-positive patients received PCP-BI (a
much higher rate than that reported in the literature) because
our sample of 30 patients only represents 16% of patients
screened for the study. However, it is possible that the provider
intervention rate for this study was higher than it might have
been because providers were aware that the study was going on.
As part of the study, patients were screened and results of the
screen were prominently displayed on the patients’ charts. Also,
the providers in this clinic all had received training in BI within
the past 6 years.
The study was not designed or powered to evaluate the
impact of the IVR-BI on alcohol consumption. However, we do
have some evidence of a possible therapeutic effect. First, 40% of
respondents indicated in the exit interview that the IVR-BI had
motivated them to change their drinking. Second, we observed a
substantial but non-significant decline in consumption during
the two weeks after the clinic visit in subjects who did and did
not receive a BI from their PCP. These results suggest a larger
controlled trial is warranted.
Screening and brief intervention using interactive voice re-
sponse technology is feasible in a primary care setting. Given
that this pilot has shown acceptability and feasibility, our next
goal is to examine clinical efficacy of the IVR-BI. If an IVR-BI
proves efficacious, it is conceivable that it would be accepted as
a reimbursable service.
Acknowledgements: We gratefully acknowledge the assistance of
Megan Malgeri in gathering the IVR-screen pre-test data.
We also would like to thank Dee Scheidel and all the staff at
Given Essex for collaborating on this study.
An abstract of this study was presented at a poster session at
the Society of General Internal Medicine annual meeting, Miami, FL,
May, 2009. This research was also presented as part of a
symposium at the Research Society on Alcoholism annual meeting,
San Diego, CA, June, 2009.
Rose et al.: Automated Alcohol Screening and BI
Conflict of Interest: None disclosed.
Corresponding Author: Gail L. Rose, PhD; UHC mail stop
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