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Introduction and Objective: The ODHIN trial found that training and support and financial reimbursement increased the proportion of patients that were screened and given advice for their heavy drinking in primary health care. However, the impact of these strategies on professional accuracy in delivering screening and brief advice is underresearched and is the focus of this paper., Method: From 120 primary health care units (24 in each jurisdiction: Catalonia, England, the Netherlands, Poland, and Sweden), 746 providers participated in the baseline and the 12-week implementation periods. Accuracy was measured in 2 ways: correctness in completing and scoring the screening instrument, AUDIT-C; the proportion of screen-negative patients given advice, and the proportion of screen-positive patients not given advice. Odds ratios of accuracy were calculated for type of profession and for intervention group: training and support, financial reimbursement, and internet-based counselling., Results: Thirty-two of 36 711 questionnaires were incorrectly completed, and 65 of 29 641 screen-negative patients were falsely classified. At baseline, 27% of screen-negative patients were given advice, and 22.5% screen-positive patients were not given advice. These proportions halved during the 12-week implementation period, unaffected by training. Financial reimbursement reduced the proportion of screen-positive patients not given advice (OR = 0.56; 95% CI, 0.31-0.99; P < .05)., Conclusion: Although the use of AUDIT-C as a screening tool was accurate, a considerable proportion of risky drinkers did not receive advice, which was reduced with financial incentives., (© 2017 John Wiley & Sons, Ltd.)

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.

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., Competing Interests: Conflicts of interest: Dr Gual reports grants and personal fees from Lundbeck and D&A Pharma, grants from Teva, and personal fees from AbbVie, outside the submitted work. The other authors report having no conflicts of interest., (© 2017 Annals of Family Medicine, Inc.)

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.

Background: Brief 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., Methods: In 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., Results: Data 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., Conclusions: The 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 Registration: ClinicalTrials.gov: NCT01501552.

Aims: To analyze the current paradigm and clinical practice for dealing with alcohol use disorders (AUD) in primary health care., Methods: Analyses of guidelines and recommendations, reviews and meta-analyses., Results: Many recommendations or guidelines for interventions for people with alcohol use problems in primary health care, from hazardous drinking to AUD, can be summarized in the SBIRT principle: screening for alcohol use and alcohol-related problems, brief interventions for hazardous and in some cases harmful drinking, referral to specialized treatment for people with AUD. However, while there is some evidence that these procedures are effective in reducing drinking levels, they are rarely applied in clinical practice in primary health care, and no interventions are initiated, even if the primary care physician had detected problems or AUD. Rather than asking primary health care physicians to conduct interventions which are not typical for medical doctors, we recommend treatment initiation for AUD at the primary health care level. AUD should be treated like hypertension, i.e. with regular checks for alcohol consumption, advice for behavioral interventions in case of consumption exceeding thresholds, and pharmaceutical assistance in case the behavioral interventions were not successful. Minimally, alcohol consumption should be screened for in all situations where there is a co-morbidity with alcohol being a potential cause (such as hypertension, insomnia, depression or anxiety disorders)., Conclusions: A paradigm shift is proposed for dealing with problematic alcohol consumption in primary health care, where initiation for treatment for AUD is seen as the central element., (© The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Background: Alcohol dependence (AD) in Europe is prevalent and causes considerable health burden. Recognition by general practitioners (GPs) and provision of or referral to treatment may contribute to reduce this burden. This paper studied AD prevalence in varying European primary care settings and examined who received treatment., Methods: In a cross-sectional multi-centre study in six European countries, 358 general practitioners assessed 13,003 primary care patients between January 2013 and January 2014, of which 8,476 patients were interviewed, collecting information on socio-demographics, physical and mental problems, and on alcohol use, problems and treatment. AD diagnoses were determined by GPs' clinical judgement and a standardized interview. A wide definition for AD treatment included individual and group interventions provided by different health professionals. Descriptive as well as inferential statistics were employed., Results: AD was prevalent among patients in European primary health care settings (8.7 %, 95 % confidence interval (CI): 8.1-9.3 %). Treatment rates were low (22.3 % of all AD cases, 95 % CI: 19.4-25.2 %). For both prevalence and treatment utilization, considerable country variations were observed. AD was associated with a number of socio-economic disadvantages (e.g. higher unemployment rate) and higher physical (e.g., liver disease, hypertension) and mental comorbidities (e.g., depression, anxiety). Liver problems, mental distress and daily amount of alcohol used were higher among treated versus untreated male patients with AD., Conclusion: A minority of people identified as having AD received treatment, showing heavier drinking patterns and a higher level of co-morbidity. Different types of treatment, depending on severity of AD, should be considered.

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., (© The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Purpose: Although alcohol dependence causes marked mortality and disease burden in Europe, the treatment rate is low. Primary care could play a key role in reducing alcohol-attributable harm by screening, brief interventions, and initiating or referral to treatment. This study investigates identification of alcohol dependence in European primary care settings., Methods: Assessments from 13,003 general practitioners, and 9,098 interviews (8,476 joint number of interviewed patients with a physician's assessment) were collected in 6 European countries. Alcohol dependence, comorbidities, and health service utilization were assessed by the general practitioner and independently using the Composite International Diagnostic Interview (CIDI) and other structured interviews. Weighted regression analyses were used to compare the impact of influencing variables on both types of diagnoses., Results: The rate of patients being identified as alcohol dependent by the CIDI or a general practitioner was about equally high, but there was not a lot of overlap between cases identified. Alcohol-dependent patients identified by a physician were older, had higher rates of physicial comorbidity (liver disease, hypertension), and were socially more marginalized, whereas average consumption of alcohol and mental comorbidity were equally high in both groups., Conclusion: General practitioners were able to identify alcohol dependence, but the cases they identified differed from cases identified using the CIDI. The role of the CIDI as the reference standard should be reexamined, as older alcohol-dependent patients with severe comorbidities seemed to be missed in this assessment., (© 2015 Annals of Family Medicine, Inc.)