Mandana Khalili, MD, discusses how baseline motivation predicted alcohol reduction in a stepped treatment trial for liver disease patients.
Baseline motivation to reduce drinking, measured separately as patients' self-rated importance of cutting back and their confidence in being able to do so, was significantly associated with better outcomes among patients with
The trial missed its primary endpoint — so why did researchers still call it a success? See the full results on drinking reduction, abstinence rates, and how SAT stacked up against usual care.
Higher baseline confidence predicted a 43% increase in the odds of achieving less-than-moderate alcohol use, the trial's primary endpoint (Odds Ratio [OR] 1.43 per point), while higher baseline importance predicted a 40% increase in the odds of 30-day abstinence at 6 months (OR 1.40 per point). Notably, patients assigned to SAT, which centers on motivational interviewing, also saw significantly greater reductions in weekly drinking compared with those receiving usual care.
"One of the strongest predictors we found for successful alcohol reduction was patients' baseline motivation, and also their confidence and emphasis on the importance of reducing alcohol use," said senior author Mandana Khalili, MD, Chief of Clinical Hepatology and Director of Clinical and Translational Research in Hepatology at Zuckerberg San Francisco General Hospital, and Professor of Medicine at UCSF, in an interview with HCPLive. "This to me highlights that motivation is not just a patient characteristic. It's really something that clinicians can actively help strengthen."
In the SAT model, motivational interviewing took the form of 3 telehealth sessions over 6 weeks, including an initial 45-minute visit followed by 2 20-minute follow-ups, conducted by clinical psychologists familiar with the effects of alcohol on liver disease.
"It's built around helping patients explore the reasons for change," said Khalili. "That is beyond just letting them know that it's important to stop drinking."
While hepatology visits tend to emphasize protecting liver health, she noted that patients often raise other motivations just as readily, such as improving their sleep, their mood, their relationships with family, their finances, or simply feeling healthier overall.
"Helping patients connect alcohol reduction with the goals that are personally meaningful to them increases their motivation," she said, "and it's much more effective in sustaining behavioral change."
That same logic extended to how the trial structured escalation of care. Patients who did not reduce their drinking after the initial motivational interviewing sessions were referred to addiction medicine specialists for more intensive treatment, including pharmacotherapy.
"The advantage of the step care model is that it's designed to meet patients where they're at," she said.
Patients with less severe alcohol use, she explained, may respond to motivational interviewing alone, while those with more severe alcohol use disorder, or who don't respond initially, can step up to more intensive services.
The study also noted that the reduction in drinks per week associated with SAT was significantly greater among women than men (interaction estimate −0.94; P = .046). When asked, Khalili was quick to caveat the finding.
"This study was not designed necessarily or powered to look at subgroup analysis, so we have to be cautious about that," she said. "We also saw that women benefited strongly, and this sort of raises a hypothesis that potentially integrating alcohol [treatment] into the hepatology setting can also be beneficial to them and reduce some of those barriers."
Khalili also pointed to where the trial was conducted as part of its significance. Of the 3 participating sites, 2 were Veterans Affairs medical centers and 1, Zuckerberg San Francisco General Hospital, is a safety-net hospital serving a population with comparatively fewer resources.
"This may be not as much in a Veterans Affairs healthcare system, they have additional resources accessible to them, but in particular in safety-net settings, it's quite challenging," she said.
She called the fact that the model could be delivered successfully in that setting "a testament to the fact that we could potentially replicate these models in other healthcare settings."
That question of replication, Khalili said, comes down largely to workforce, not infrastructure. Most hepatology clinics don't have behavioral health specialists on staff, but she argued that shouldn't be a barrier to adopting a model like SAT.
"Motivational interviewing is a skill that can be taught to hepatologists and other members of a healthcare team," she said, adding that wider telehealth adoption has made delivery logistically feasible even in systems that previously lacked access to this kind of integrated care. Close coordination with addiction medicine specialists remains essential for the smaller subset of patients who need to step up to more intensive treatment.
Editor’s Note: Khalili reports relevant disclosures with Gilead, GSK, Resolution, and Intercept.
