Jillian Reynolds

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN) : study protocol for a cluster randomized factorial trial

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study

AIMS To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Social costs of illegal drugs, alcohol and tobacco in the European Union: A systematic review

ISSUES Drug use accounts for one of the main disease groups in Europe, with relevant consequences to society. There is an increasing need to evaluate the economic consequences of drug use in order to develop appropriate policies. Here, we review the social costs of illegal drugs, alcohol and tobacco in the European Union. APPROACH A systematic search of relevant databases was conducted. Grey literature and previous systematic reviews were also searched. Studies reporting on social costs of illegal drugs, alcohol and tobacco were included. Methodology, cost components as well as costs were assessed from individual studies. To compare across studies, final costs were transformed to 2014 Euros. KEY FINDINGS Forty-five studies reported in 43 papers met the inclusion criteria (11 for illegal drugs, 26 for alcohol and 8 for tobacco). While there was a constant inclusion of direct costs related to treatment of substance use and comorbidities, there was a high variability for the rest of cost components. Total costs showed also a great variability. Price per capita for the year 2014 ranged from €0.38 to €78 for illegal drugs, from €26 to €1500 for alcohol and from €10.55 to €391 for tobacco. IMPLICATIONS AND CONCLUSIONS Drug use imposes a heavy economic burden to Europe. However, given the high existing heterogeneity in methodologies, and in order to better assess the burden and thus to develop adequate policies, standardised methodological guidance is needed. [Barrio P, Reynolds J, García-Altés A, Gual A, Anderson P. Social costs of illegal drugs, alcohol and tobacco in the European Union: A systematic review. Drug Alcohol Rev 2017;00:000-000].

Attitudes and Learning through Practice Are Key to Delivering Brief Interventions for Heavy Drinking in Primary Health Care: Analyses from the ODHIN Five Country Cluster Randomized Factorial Trial

In this paper, we test path models that study the interrelations between primary health care provider attitudes towards working with drinkers, their screening and brief advice activity, and their receipt of training and support and financial reimbursement. Study participants were 756 primary health care providers from 120 primary health care units (PHCUs) in different locations throughout Catalonia, England, The Netherlands, Poland, and Sweden. Our interventions were training and support and financial reimbursement to providers. Our design was a randomized factorial trial with baseline measurement period, 12-week implementation period, and 9-month follow-up measurement period. Our outcome measures were: attitudes of individual providers in working with drinkers as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire; and the proportion of consulting adult patients (age 18+ years) who screened positive and were given advice to reduce their alcohol consumption (intervention activity). We found that more positive attitudes were associated with higher intervention activity, and higher intervention activity was then associated with more positive attitudes. Training and support was associated with both positive changes in attitudes and higher intervention activity. Financial reimbursement was associated with more positive attitudes through its impact on higher intervention activity. We conclude that improving primary health care providers’ screening and brief advice activity for heavy drinking requires a combination of training and support and on-the-job experience of actually delivering screening and brief advice activity.

Delivery of Brief Interventions for Heavy Drinking in Primary Care: Outcomes of the ODHIN 5-Country Cluster Randomized Trial

PURPOSE We aimed to test whether 3 strategies—training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice—have a longer-term effect on primary care clinicians’ delivery of screening and advice to heavy drinkers operationalized with the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) tool. METHODS We undertook a cluster randomized factorial trial with a 12-week implementation period in 120 primary health care units throughout Catalonia, England, Netherlands, Poland, and Sweden. Units were randomized to 8 groups: care as usual (control); training and support alone; financial reimbursement alone; electronic brief advice alone; paired combinations of these conditions; and all 3 combined. The primary outcome was the proportion of consulting adult patients (aged 18 years and older) receiving intervention—screening and, if screen-positive, advice—at 9 months. RESULTS Based on the factorial design, the ratio of the log of the proportion of patients given intervention at the 9-month follow-up was 1.39 (95% CI, 1.03–1.88) in units that received training and support as compared with units that did not. Neither financial reimbursement nor directing screen-positive patients to electronic brief advice led to a higher proportion of patients receiving intervention. CONCLUSIONS Training and support of primary health care units has a lasting, albeit small, impact on the proportion of adult patients given an alcohol intervention at 9 months.

Implementing referral to an electronic alcohol brief advice website in primary healthcare: results from the ODHIN implementation trial

Objectives The objective of the present study was to explore whether the possibility of offering facilitated access to an alcohol electronic brief intervention (eBI) instead of delivering brief face-to-face advice increased the proportion of consulting adults who were screened and given brief advice. Design The study was a 12-week implementation study. Sixty primary healthcare units (PHCUs) in 5 jurisdictions (Catalonia, England, the Netherlands, Poland and Sweden) were asked to screen adults who attended the PHCU for risky drinking. Setting A total of 120 primary healthcare centres from 5 jurisdictions in Europe. Participants 746 individual providers (general practitioners, nurses or other professionals) participated in the study. Primary outcome Change in the proportion of patients screened and referred to eBI comparing a baseline 4-week preimplementation period with a 12-week implementation period. Results The possibility of referring patients to the eBI was not found to be associated with any increase in the proportion of patients screened. However, it was associated with an increase in the proportion of screen-positive patients receiving brief advice from 70% to 80% for the screen-positive sample as a whole (p<0.05), mainly driven by a significant increase in brief intervention rates in England from 87% to 96% (p<0.01). The study indicated that staff displayed a low level of engagement in this new technology. Staff continued to offer face-to-face advice to a larger proportion of patients (54%) than referral to eBI (38%). In addition, low engagement was seen among the referred patients; on average, 18% of the patients logged on to the website with a mean log-on rate across the different countries between 0.58% and 36.95%. Conclusions Referral to eBI takes nearly as much time as brief oral advice and might require more introduction and training before staff are comfortable with referring to eBI. Trial registration number NCT01501552; Post-results.

Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial

BackgroundBrief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation.MethodsIn a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design.ResultsData from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups.ConclusionsThe extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners’ attitudes, their actual behaviour and care improvement strategies to enhance implementation science.Trial registrationClinicalTrials.gov: NCT01501552

Impact of practice, provider and patient characteristics on delivering screening and brief advice for heavy drinking in primary healthcare: Secondary analyses of data from the ODHIN five-country cluster randomized factorial trial

Abstract Background: The implementation of primary healthcare-based screening and advice that is effective in reducing heavy drinking can be enhanced with training. Objectives: Undertaking secondary analysis of the five-country ODHIN study, we test: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such characteristics found at baseline. Methods: A cluster randomized factorial trial involving 120 practices, 746 providers and 46 546 screened patients from Catalonia, England, the Netherlands, Poland, and Sweden. Practices were randomized to receive training or not to receive training. The primary outcome measures were the proportion of adult patients screened, and the proportion of screen-positive patients advised. Results: Nurses tended to screen more patients than doctors (OR = 3.1; 95%CI: 1.9, 4.9). Screen-positive patients were more likely to be advised by doctors than by nurses (OR = 2.3; 95%CI: 1.4, 4.1), and more liable to be advised the higher their risk status (OR = 1.9; 95%CI: 1.3, 2.7). Training increased screening and advice giving, with its impact largely unrelated to practice, provider or patient characteristics. Training diminished the differences between doctors and nurses and between patients with low or high-risk status. Conclusions: Training primary healthcare providers diminishes the negative impacts that some practice, provider and patient characteristics have on the likelihood of patients being screened and advised. Trial registration ClinicalTrials.gov. Trial identifier: NCT01501552

Editorial: Brief Interventions for Risky Drinkers

The Editorial on the Research Topic Brief Interventions for Risky Drinkers Alcohol consumption is a wholly or contributory cause for more than 200 diseases, injuries, and other health conditions with three-digit ICD-10 codes (1). Globally, alcohol is the fifth most important risk factor for ill-health and premature death (2). Risky alcohol use can be defined as a quantity or pattern of alcohol use that places individuals at risk for adverse health and social outcomes (3). Harmful use, in turn, can be defined as alcohol use that results in physical, psychological, or social harm (3). Using a threshold of an average of 60 g of alcohol/day for a man and 40 g/day for a woman (4), about one in four Europeans aged 15–64 years use alcohol in a risky fashion (5). And, using a threshold of an average of 100 g of alcohol/day for a man and 60 g/day for a woman, about one in eight of Europeans aged 15–64 years use alcohol in a harmful fashion (5). Harmful use causes comorbid illnesses such as liver disease, depression, and raised blood pressure (6). Risky and harmful alcohol use and their comorbid illnesses are frequently detected in primary health care, emergency departments, and other non-specialized clinical settings. Brief advice emerged in the 1980s (7–9) and progressed during the three following decades as a strategy to reduce risky and harmful alcohol use in non-specialized clinical settings (10). This article provides an update of the state-of-the art of brief advice.

The ODHIN assessment tool: a tool to describe the available services for the management of hazardous and harmful alcohol consumption at the country and regional level

Optimizing Delivery of Health care Interventions (ODHIN) is an ongoing European project (EC, FP7) involving research institutions from 9 European countries using the implementation of Early Identification and Brief Intervention (EIBI) programmes for Hazardous and Harmful Alcohol Consumption (HHAC) in Primary Health Care (PHC) as a case study to better understand how to translate the results of clinical research into everyday practice. The Italian National Health Service (ISS) is the project leader of the Work Package 6 assessment tool. The aim of the ODHIN assessment tool is to formalise, operationalise and test the questionnaire developed under the PHEPA project in order to produce an update instrument to assess the extent of implementation of EIBIs for HHAC throughout PHC settings. The ODHIN assessment tool has been conceived as a semi-structured questionnaire for the identification of the state of the art, gaps and areas in the country that need further work and strengthening; to monitor the adequacy of brief intervention programmes for HHAC in order to provide recommendations to improve and optimize delivery of health care interventions. It analyses 24 questions distributed across 7 key sections. Data have been collected from 9 ODHIN collaborating countries (Catalonia, Czech Republic, Italy, Poland, Portugal, Slovenia, Sweden, The Netherlands and United Kingdom) and from other 14 European countries who have agreed to share their national experience with the ODHIN partners (Belgium, Croatia, Cyprus, Estonia, Finland, Fyrom-Yugoslav Republic of Macedonia, Germany, Greece, Iceland, Ireland, Latvia, Malta, Romania, and Switzerland). Preliminary data on the state of the art of the implementation and the extent of EIBI for HHAC throughout PHC settings across 23 European participating countries will be presented. Identified areas where services require development or strengthening across the participating countries as well as examples of good practices between countries will be also discussed.