Preben Bendtsen

Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review.

Objective. To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. Key question. To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful? Method. Literature search from Medline, Cinahl, PsychLIT, Cochrane. Setting. Primary healthcare. Material. A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 “non-physicians” from Europe, the USA, and Australia. Main outcome measures. Material utilization, screening, and brief intervention rates. Answer. Intervention effectiveness (material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers.

Alcohol consumption is associated with progression of hepatic fibrosis in non-alcoholic fatty liver disease.

Objective. Moderate alcohol consumption has been reported to be inversely associated with cardiovascular disease and total mortality. The importance of non-alcoholic fatty liver disease (NAFLD) is increasing and many NAFLD patients suffer from cardiovascular disease. In these patients, moderate alcohol consumption could be beneficial. The aim of this study was to investigate whether low alcohol intake, consistent with the diagnosis of NAFLD, is associated with fibrosis progression in established NAFLD. Material and methods. Seventy-one patients originally referred because of chronically elevated liver enzymes and diagnosed with biopsy-proven NAFLD were re-evaluated. A validated questionnaire combined with an oral interview was used to assess weekly alcohol consumption and the frequency of episodic drinking. Significant fibrosis progression in NAFLD was defined as progression of more than one fibrosis stage or development of endstage liver disease during follow-up. Results. Mean follow-up (SD) was 13.8 (1.2) years between liver biopsies. At follow-up, 17 patients (24%) fulfilled the criteria for significant fibrosis progression. The proportion of patients reporting heavy episodic drinking at least once a month was higher among those with significant fibrosis progression (p=0.003) and a trend towards higher weekly alcohol consumption was also seen (p=0.061). In a multivariate binary logistic regression analysis, heavy episodic drinking (p<0.001) and insulin resistance (p<0.01) were independently associated with significant fibrosis progression. Conclusions. Moderate alcohol consumption, consistent with the diagnosis of NAFLD to be set, is associated with fibrosis progression in NAFLD. These patients should be advised to refrain from heavy episodic drinking.

Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory

BackgroundBridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.MethodsA qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.ResultsThe theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.ConclusionWhen implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.

Attitudes of swedish general practitioners and nurses to working with lifestyle change, with special reference to alcohol consumption

AIMS To explore the attitudes of Swedish general practitioners (GPs) and nurses to secondary alcohol prevention (early identification of, and intervention for, alcohol-related problems) and compare it to their attitudes to other important lifestyle behaviours such as smoking, stress, exercise, and overweight. METHODS An adjusted version of The WHO Collaborative Study Questionnaire for General Practitioners was posted to all GPs and nurses in the County of Skaraborg, Sweden; 68 GPs and 193 nurses responded. RESULTS The importance of drinking alcohol moderately, counselling skills on reducing alcohol consumption and perceived current effectiveness in helping patients change lifestyle behaviours ranked lower than working with all the other lifestyle behaviours. The nurses rated their potential effectiveness in helping patients change lifestyle higher than that of GPs for all the lifestyle behaviours. Nurses receiving more alcohol-related education had more positive attitudes than nurses with less education. For alcohol, the GPs assessed their role adequacy, role legitimacy and motivation higher than that of the nurses. The main obstacles for the GPs to carry out alcohol intervention were lack of training in counselling for reducing alcohol consumption, time constraints, and the fact that the doctors did not know how to identify problem drinkers who have no obvious symptoms of excess consumption. CONCLUSION GPs and the nurses estimated their alcohol-related competence as lower than working with many other health-related lifestyles. These results can be explained by lack of practical skills, lack of training in suitable intervention techniques, and unsupportive working environments. All these elements must be considered when planning secondary alcohol prevention programs in primary health care.

Health related quality of life in Crohn's proctocolitis does not differ from a general population when in remission

Objective  All treatment in Crohns disease, although palliative, aims at restoring full health. The objective of this study was to compare health‐related quality of life and psychosocial conditions in patients with Crohns proctocolitis with a general population.

Does a physical activity referral scheme improve the physical activity among routine primary health care patients

Physical activity referral (PAR) schemes or concepts occur in varying forms. Because few physical activity intervention studies have been carried out in routine health care settings, it is difficult to translate research findings into daily practice. The aim of this study was to analyze the effectiveness of a PAR scheme implemented in routine primary health care. The study did not include a control group and was based on the ordinary staffs work efforts and follow‐up measures. During a 2‐year period, 6300 PARs were issued. Effectiveness was measured by an increase in self‐reported physical activity. Half of the patients reached reported increased physical activity both at 3 months (49%) and at 12 months (52%). The proportion of inactive patients decreased from 33% at baseline to 17% at 3 months and 20% at 12 months. The proportion of patients who were physically active on a regular basis increased from 22% at baseline to 33% at 3 months and 32% at 12 months. Neither the patients age nor the profession of the prescriber was associated with differences in effectiveness. The patients activity level at baseline, the type of physical activity as well as the reason for the prescription were associated with increased physical activity.

Alcohol use among university students in Sweden measured by an electronic screening instrument

BackgroundElectronic-based alcohol screening and brief interventions for university students with problem drinking behaviours forms an important means by which to identify risky drinkers.MethodsIn this study an e-SBI project was implemented to assess drinking patterns, and to provide personalised feedback about alcohol consumption and related health problems, to students in a Swedish university. In this study, third semester university students (n = 2858) from all faculties (colleges) at the University were invited to participate in e-SBI screenings. This study employed a randomised controlled trial, with respondents having a equal chance of being assigned to a limited, or full-feedback response.ResultsThe study shows that high risk drinkers tend to underestimate their own consumption compared to others, and that these high risk drinkers experience more negative consequences after alcohol intake, than other respondents. There was a strong belief, for both high- and low-risk drinkers, that alcohol helped celebrations be more festive. This study also confirms findings from other study locations that while males drank more than females in our study population; females reached the same peak alcohol blood concentrations as males.ConclusionObtaining clear and current information on drinking patterns demonstrated by university students can help public health officials, university administration, and local health care providers develop appropriate prevention and treatment strategies.

Role of preexisting disease in patients' perceptions of health-related quality of life after intensive care.

Objectives:To find out how patients perceive their health-related quality of life after they have been treated in an intensive care unit and whether preexisting disease influenced their perception. Design:Follow-up, quantitative, dual-site study. Setting:Combined medical and surgical intensive care units of one university and one general hospital in Sweden. Patients:Among the 1,938 patients admitted, 562 were considered eligible (>24 hrs in the intensive care unit, and age >18 yrs). The effect of preexisting disease was assessed by use of a large reference group, a random sample (n = 10,000) of the main intake area of the hospitals. Interventions:None. Measurements and Main Results:During 2000–2002, data were collected from the intensive care unit register and from a questionnaire mailed to the patients 6 months after their discharge from hospital. Subjects in the reference group were sent postal questionnaires during 1999. Of the patients in the intensive care unit group, 74% had preexisting diseases compared with 51% in the reference group. Six months after discharge, health-related quality of life was significantly lower among patients than in the reference group. When comparisons were restricted to the previously healthy people in both groups, the observed differences were about halved, and when we compared the patients in the intensive care unit who had preexisting diseases with subjects in the reference group who had similar diseases, we found little difference in perceived health-related quality of life. In some dimensions of health-related quality of life, we found no differences between patients in the intensive care unit and the subjects in the reference population. Conclusions:Preexisting diseases significantly affect the extent of the decline of health-related quality of life after critical care, and this effect may have been underestimated in the past. As most patients who are admitted to an intensive care unit have at least one preexisting disease, it is important to account for these effects when examining outcome.

Physical activity referrals in Swedish primary health care - prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.

BackgroundOver the past decade, practitioners in primary health care (PHC) settings in many countries have issued written prescriptions to patients to promote increased physical activity or exercise. The aim of this study is to describe and analyse a comprehensive physical activity referral (PAR) scheme implemented in a routine PHC setting in Östergötland County. The study examines characteristics of the PARs recipients and referral practitioners, identifies reasons why practitioners opted to use PARs with their clients, and discusses prescribed activities and prescriptions in relation to PHC registries.MethodsProspective prescription data were obtained for 90% of the primary health care centres in Östergötland County, Sweden, in 2004 and 2005. The study population consisted of patients who were issued PARs after they were deemed likely to benefit from increased physical activity, as assessed by PHC staff.ResultsDuring the two-year period, a total of 6,300 patients received PARs. Two-thirds of the patients were female and half of the patients were 45–64 years. Half of the patients (50.8%) who received PARs were recommended a home-based activity, such as walking. One third (33%) of the patients issued PARs were totally inactive, reporting no days of physical activity that lasted for 30 minutes, and 29% stated that they reached this level 1–2 days per week.The number of PARs prescribed per year in relation to the number of unique individuals that visited primary health care during one year was 1.4% in 2004 and 1.2% in 2005. Two-thirds of the combined prescriptions were issued by physicians (38%) and nurses (31%). Physiotherapists and behavioural scientists issued the highest relative number of prescriptions. The most common reasons for issuing PARs were musculoskeletal disorders (39.1%) and overweight (35.4%), followed by high blood pressure (23.3%) and diabetes (23.2%).ConclusionÖstergötland Countys PAR scheme reached a relatively high proportion of physically inactive people visiting local PHC centres for other health reasons. PAR-related statistics, including PAR-rates by individual PHC centres and PAR- rates per health professional category, show differences in prescribing activities, both by patient categories, and by prescribing professionals.

Brief interventions in routine health care: a population‐based study of conversations about alcohol in Sweden

AIMS To investigate how brief alcohol interventions are delivered in routine practice in the Swedish health-care system. DESIGN, SETTING AND PARTICIPANTS A cross-sectional sample of 6000 individuals representative of the adult population aged 18-64 years registered in the Swedish total population register was drawn randomly. Data were collected in 2010 by means of a mail questionnaire. The response rate was 54%. MEASUREMENTS The questionnaire consisted of 27 questions, of which 15 variables were extracted for use in this study. Whether alcohol had been discussed and the duration, contents, experiences and effects of any conversations about alcohol, as reported by patients themselves, were assessed. FINDINGS Sixty-six per cent of the respondents had visited health-care services in the past 12 months and 20% of these had had one or more conversations about alcohol during these visits (13% of the population aged 18-64 years). The duration of the conversations was generally brief, with 94% taking less than 5 minutes, and were not experienced as problematic. The duration, contents, experiences and effects of these conversations generally varied between abstainers, moderate, hazardous and excessive drinkers. Twelve per cent of those having a conversation about alcohol reported that it led to reduced alcohol consumption. Reduced alcohol consumption was more likely when conversations lasted for 1-10 minutes rather than less than 1 minute and included advice on how to reduce consumption. CONCLUSIONS Population survey data in Sweden suggest that when health-care professionals give brief advice to reduce alcohol consumption, greater effects are observed when the advice is longer and includes advice on how to achieve it.