TO THE EDITOR
Alcohol-associated liver disease (ALD) represents a mounting global health crisis, now standing as the leading indication for liver transplantation in many Western nations[1-3]. This surge is inextricably linked to the pervasive and often untreated burden of alcohol use disorder (AUD), which remains the seventh leading risk factor for global disability and premature mortality[4]. Despite the existence of effective, evidence-based pharmacologic and psychosocial treatments for AUD[5], a profound and persistent treatment gap endures, with utilization rates dismally low in clinical practice[6]. This gap is fueled by a critical, dual challenge: A lack of patient awareness regarding available treatment options, compounded by significant knowledge deficits and discomfort among non-specialist providers in initiating AUD conversations and management[7]. In this issue of the World Journal of Hepatology, the prospective cohort study by Twohig et al[8] confronts this challenge head-on, introducing and evaluating a novel, scalable intervention-an educational video module (EVM)-with the potential to redefine AUD patient education and bridge this costly divide. EVM represents a powerful tool in patient education, leveraging integrated interactive visual and auditory features to create a dynamic and engaging learning experience. Essentially, it is a form of audio-visual psychological education[9], and this multi-sensory approach is designed to enhance comprehension and improve knowledge retention.
A key strength of the EVM lies in its capacity for personalization. By granting patients control over the content, the module adapts to the individual’s learning pace, fostering a sense of ownership and thereby increasing motivation to learn.
UNMET NEED: BRIDGING THE AUD TREATMENT GAP IN HEPATOLOGY
The management of AUD is a cornerstone in the care of patients with ALD, with successful treatment directly linked to reduced hepatic decompensation, improved survival, and lower rates of liver transplantation[10,11]. Hepatologists and gastroenterologists are therefore on the front lines of encountering this disease. However, surveys reveal a troubling reality: A number of gastroenterology and hepatology providers have rarely prescribed United States Food and Drug Administration approved AUD medications[12], and a vast majority express a desire for more formal training[13]. This systemic shortfall creates a scenario where patients hospitalized for ALD-a critical “teachable moment”-often leave the hospital without a clear pathway to address the root cause of their illness.
Patient education is a fundamental pillar of chronic disease management, yet traditional methods can be inconsistent, time-consuming for staff, and difficult to standardize. The EVM developed by Twohig et al[8] offers an elegant solution. By delivering standardized, evidence-based content about AUD epidemiology and treatment options in an interactive, self-paced format, the EVM ensures that every patient receives comprehensive education, irrespective of their primary medical team's expertise in addiction medicine. To maximize accessibility across diverse inpatient populations, future implementations of EVMs should prioritize universal design principles. This includes using plain-language scripts supplemented by pictograms to enhance comprehension for those with varying health literacy levels, and offering multi-modal delivery options (e.g., closed captions, voice-over, adjustable fonts) to accommodate sensory impairments or limited digital proficiency[14,15]. Crucially, low-tech alternatives such as illustrated printed handouts or bedside tablet viewing ensure that patients are not excluded due to connectivity barriers or personal preference. This approach empowers patients with knowledge, demystifies treatment options, and reduces stigma, thereby activating them to become engaged participants in their own recovery. This approach empowers patients with knowledge, demystifies treatment options, and reduces stigma[16], thereby activating them to become engaged participants in their own recovery.
DUAL ROLE OF EDUCATION: EMPOWERING PATIENTS AND REINFORCING CLINICAL CARE
The EVM functions not as a replacement for clinical care, but as a powerful catalyst within a multi-faceted treatment ecosystem. The study by Twohig et al[8] wisely embedded the EVM within a broader intervention that included a brief intervention using motivational interviewing and the provision of resource lists. The EVM primes the patient for these subsequent interactions, effectively “pre-loading” them with a foundational understanding[17]. With a certain knowledge reserve[18], they can make discussions with addiction psychiatrists, hepatologists, and primary care providers more productive and patient-centered. The results are striking. The significant increases in both pharmacologic (50% vs 22%) and psychosocial (73.8% vs 44%). The engagement in treatment after EVM demonstrated the efficacy of this module in motivating the pursuit of healthy behaviors. Perhaps even more compelling for hepatologists is the dramatic reduction in return to alcohol use (7.9% vs 35.6%), a key metric directly tied to liver-related morbidity and healthcare utilization[19]. The fact that 100% of participants would recommend the EVM to others underscores its exceptional acceptability and perceived value from the patient’s perspective.
CONTEXTUAL FACTORS AND FUTURE IMPLICATIONS
The success of this intervention must be viewed within its context. The study was conducted in a hospitalized population, a “captive audience” that may be more receptive to education during a health crisis[20]. Furthermore, the cohort consisted of patients motivated enough to consent to the study, potentially excluding those in the pre-contemplative stage of change[21]. This highlights an ongoing challenge and an area for future research: How to effectively engage the most resistant patients. To address this, proactive strategies are needed. Embedding brief, structured screening prompts during admission (e.g., “How do you prefer to learn about your health?”) can help clinical teams quickly identify individual needs related to health literacy, language, or technological access[22]. This information then allows for the tailoring of educational delivery, such as automatically providing a literacy-appropriate version of the EVM or a printed summary. Following the intervention, employing the evidence-based “teach-back” method, where patients are asked to explain the concepts in their own words, can verify understanding and reinforce key messages, making the education more effective and patient-centered[23]. Those suffer from AUDs and anxiety disorders at the same time may be less willing to seek or participate in treatment[24]. In addition, this study also has certain limitations, such as its single-center design, moderate sample size, and 30-day follow-up. The impressive short-term outcomes now demand validation through multi-center, randomized controlled trials. Future studies must also assess the durability of these effects at 90 days and 180 days, and, crucially, evaluate the impact of this intervention on hard hepatic outcomes such as rates of decompensation, transplant-free survival, and overall healthcare costs. In order to translate these promising findings into widespread practice, several steps are essential. First, the EVM itself should be evaluated for efficacy across diverse healthcare settings (e.g., community hospitals, outpatient hepatology clinics) and patient demographics. Second, scientific research needs to be carried out to determine which standard treatments to combine EVM with for better clinical outcomes and to promote the formulation of standard clinical workflows. Finally, exploring the synergy between EVMs and other innovative approaches, such as telehealth-based AUD treatment and peer support programs, could create a comprehensive, patient-centered ecosystem of care that extends from the hospital into the community[25].
For EVMs to be successfully scaled and equitably implemented, careful attention must be paid to their design and delivery process. This involves adopting a universal design framework from the outset, ensuring content is available in plain language and multiple formats (e.g., digital with accessibility features, printed) to cater to diverse health literacy levels and sensory abilities. A key operational step is the integration of a brief needs assessment into the admission workflow, allowing clinicians to identify and match the appropriate educational modality to each patient. Finally, confirming comprehension through techniques like teach-back is critical to transitioning from mere information delivery to meaningful patient education[26]. Future research should not only validate the efficacy of EVMs in broader trials but also explicitly evaluate the impact of these tailored implementation strategies on patient engagement and outcomes.
While the findings by Twohig et al[8] are encouraging, their interpretation warrants caution due to several methodological considerations. First, the intervention was conducted at a single center with a modest sample size and assessed only short-term (30-day) outcomes, which limits the generalizability of the results and the certainty regarding their long-term durability[27]. Second, the significant benefits associated with the intervention may be partly attributable to the study’s context: The participants were inpatients-a “teachable moment” during a health crisis-who proactively consented to participate[28]. This may introduce selection bias by excluding less motivated patients (e.g., those in the “pre-contemplative stage” of change), potentially overestimating the real-world effectiveness in a broader ALD population. Furthermore, the EVM was tested as part of a bundled intervention that included motivational interviewing and resource provision; consequently, the observed benefits cannot be solely attributed to the video module itself[7]. Therefore, these findings should be regarded as a strong, preliminary proof-of-concept. They provide a clear rationale for future validation through multicenter randomized controlled trials to confirm the independent efficacy of the EVM, the durability of its effects (e.g., at 90 days and 180 days), and its impact on hard liver-specific endpoints.
CONCLUSION
The work by Twohig et al[8] provides a compelling proof-of-concept that a standardized EVM is a feasible, acceptable, and highly effective tool for closing the AUD treatment gap in patients with ALD. By directly addressing the critical barrier of knowledge, this low-cost, scalable intervention empowers patients and standardizes a core component of high-quality care. As the global burden of ALD continues to escalate, the hepatology community must expand its role from treating the damaged liver to actively addressing its primary cause. The integration of innovative, patient-centered educational tools like the EVM into every inpatient and outpatient care pathway for ALD is not just an enhancement-it is an ethical and clinical imperative. This study marks a significant stride toward a future where comprehensive, compassionate, and effective AUD care is accessible to all patients with ALD.
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A
Novelty: Grade A
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Yao YT, Associate Professor, Chief Physician, China S-Editor: Liu JH L-Editor: A P-Editor: Wang CH
