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Objectives To evaluate the 12-month costs and quality-adjusted life years (QALYs) gained to the Italian National Health Service of facilitated access to a website for hazardous drinkers compared with a standard face-to-face brief intervention (BI). Design Randomised 1:1 non-inferiority trial. Setting Practices of 58 general practitioners (GPs) in Italy. Participants Of 9080 patients (>18 years old) approached to take part in the trial, 4529 (49·9%) logged on to the website and 3841 (84.8%) undertook online screening for hazardous drinking. 822 (21.4%) screened positive and 763 (19.9%) were recruited to the trial. Interventions Patients were randomised to receive either a face-to-face BI or access via a brochure from their GP to an alcohol reduction website (facilitated access). Primary and secondary outcome measures The primary outcome is the cost per QALY gained of facilitated access compared with face-to-face. A secondary analysis includes total costs and benefits per 100 patients, including number of hazardous drinkers prevented at 12 months. Results The average time required for the face-to-face BI was 8 min (95% CI 7.5 min to 8.6 min). Given the maximum time taken for facilitated access of 5 min, face-to-face is an additional 3 min: equivalent to having time for another GP appointment for every three patients referred to the website. Complete case analysis adjusting for baseline the difference in QALYs for facilitated access is 0.002 QALYs per patient (95% CI −0.007 to 0.011). Conclusions Facilitated access to a website to reduce hazardous drinking costs less than a face-to-face BI given by a GP with no worse outcomes. The lower cost of facilitated access, particularly in regards to investment of time, may facilitate the increase in provision of BIs for hazardous drinking. Trial registration number NCT01638338;Post-results.

"OBJECTIVES: to identify the differences among patients of general practictioners (GPs) in both Tuscany Region (Central Italy) and Friuli Venezia Giulia (FVG) Region (Northern Italy), which are different for drinking cultures, as to motivation of consultation, hazardous drinking and alcohol dependence, health problems, and use of health services.

OBIETTIVI: identificare i criteri utilizzati dai medici di medicina ge- nerale (MMG) per le diagnosi di alcoldipendenza (AD) e confron- tarli con quelli dell’intervista Composite International Diagnostic Interview (CIDI). DISEGNO: studio correlazionale trasversale. SETTING E PARTECIPANTI: i 55 MMG delle regioni Friuli Venezia Giulia e Toscana che hanno preso parte alla ricerca hanno effettuato una valutazione clinica dei primi 40 pazienti che si presentavano da loro per una visita medica. PRINCIPALI MISURE DI OUTCOME: tassi di alcoldipendenza diagnosti- cati dai MMG e dall’intervista CIDI e loro relazione con le variabili sociodemografi la presenza di altre patologie e il consumo di alcol. RISULTATI: i MMG hanno diagnosticato l’AD nel 5,4% dei casi e l’intervista CIDI nel 4,4% dei casi, con una sovrapposizione del 26% circa. Rispetto al CIDI, i MMG hanno identifi come AD pa- zienti di età più avanzata e affetti da malattie epatiche e ipertensione. CONCLUSIONI: la limitata sovrapposizione tra diagnosi di AD fatte dai MMG e dal CIDI è problematica. I MMG sembrano indivi- duare prevalentemente le forme di AD più gravi, in cui il consu- mo eccessivo di alcol è associato alla presenza di patologie epatiche, mentre il CIDI permette di individuare anche pazienti più giovani che non hanno ancora sviluppato patologie. L’efficacia dell’indivi- duazione dell’AD tra gli assistiti da parte dei MMG potrebbe essere incrementata usando congiuntamente la competenza dei MMG e quella dei questionari standardizzati sul consumo di alcol

Introduction Early identification (EI) and brief interventions (BIs) for risky drinkers are effective tools in primary care. Lack of time in daily practice has been identified as one of the main barriers to implementation of BI. There is growing evidence that facilitated access by primary healthcare professionals (PHCPs) to a web-based BI can be a time-saving alternative to standard face-to-face BIs, but there is as yet no evidence about the effectiveness of this approach relative to conventional BI. The main aim of this study is to test non-inferiority of facilitation to a web-based BI for risky drinkers delivered by PHCP against face-to-face BI. Method and analysis A randomised controlled non-inferiority trial comparing both interventions will be performed in primary care health centres in Catalonia, Spain. Unselected adult patients attending participating centres will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Participants with positive results will be requested online to complete a trial module including consent, baseline assessment and randomisation to either face-to-face BI by the practitioner or BI via the alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 3 months and 1 year using the full AUDIT and D5-EQD5 scale. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. Ethics and dissemination The protocol was approved by the Ethics Commmittee of IDIAP Jordi Gol i Gurina P14/028. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations. Trial registration number ClinicalTrials.gov NCT02082990.

Many health online resources addressed to the general public lack usability and their content is frequently difficult to understand. This case study evaluates the usability and the effectiveness of information presentation of the “Alcol e Salute” website, using two methods: heuristic evaluation and user testing. The results of the usability testing analysis revealed several key weaknesses with respect both to navigation and information display. These results will be used to revise the website accordingly.

The aim of this study was to analyze possible existing correlations among the three dimensions of the sense of coherence (SOC), as a psychosocial risk factor, and some other cardiovascular risk factors in a group of primary care patients. Seventy-one persons at high cardiovascular risk were identified by their general practitioners and invited to answer the 13 questions included in the Antonovsky's SOC questionnaire. Psychosocial risk evaluation, performed with SOC analysis, may provide an important added value in the identification of behavioral changes and cardiovascular risk reduction.

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Environmental factors are likely to be involved in explaining the wide geographical variation in asthma and atopic diseases that has been documented in many recent epidemiological studies.

Summary Rationale and objectives Response to mailed epidemiological surveys has decreased in recent decades. Since subjects with respiratory symptoms are usually early responders to surveys performed in Southern Europe, this trend could bias prevalence estimates. The present study aimed at evaluating the impact of non-response bias on prevalence estimates of respiratory symptoms and smoking habits. Methods In 9 centres, participating in the Italian Study on Asthma in Young Adults (ISAYA), random samples of people aged 20–45 years were administered a mailed questionnaire between 1998 and 2000. Non-responders were contacted again first by mail and then by phone. Cumulative response percentage was 30.5%, 52.4% and 72.7% (18,873/25,969), respectively, after the 1st, 2nd and 3rd contact. Results The prevalence of self-reported current asthma, asthma-like symptoms, and chronic cough/phlegm was more than halved from the first contact (5.6%, 17.8%, 14.6% respectively) to the third contact (2.7%, 6.4%, 6.9%). This pattern was less pronounced when considering allergic rhinitis and past asthma, whose prevalence decreased, respectively, from 21.5% to 15.6% and from 3.5% to 2.6%. At the same time the proportion of current smokers increased from 29.2% to 38%, while the proportion of ex-smokers decreased from 16.5% to 10.1%. In a multinomial logistic model current asthma, asthma-like symptoms, chronic cough/phlegm and smoking habits, and to a lower extent past asthma and allergic rhinitis, were significant predictors of late response. Conclusions In Italy when response percentage is low, the prevalence of current asthma, chronic cough/phlegm and ex-smokers is overestimated, while the proportion of current smokers is underestimated.

Aims Alcohol use disorders (AUDs) are prevalent in Europe but occurrence in primary care and the proportion of treated cases are understudied. This study reports prevalence of AUDs and their treatment in European primary health care settings and compares them with general population estimates. Procedure We sampled 358 general practitioners (GPs, refusal rate: 56.4%) across six European countries (Germany, Hungary, Italy, Latvia, Poland, and Spain), who assessed 13,003 patients including providing AUD diagnoses. A subsample of 8,476 patients (refusal rate: 17.8%) was interviewed subsequently, assessing DSM-IV AUD diagnoses via the Composite International Diagnostic Interview. Final AUD diagnoses combined GP and patient interview information. Findings Past year AUDs were prevalent with 11.8% (95% CI: 11.2-12.5%) across all regions, which is 1.6 times the European general population AUD estimate. Of those diagnosed with AUDs, 17.7% (95% CI: 15.4-20.0%) received professional help. Compared to general population estimates, AUDs and their treatment were more prevalent in primary care settings in most countries, with disproportionally high AUD rates in Italy and Spain and unexpectedly low AUD rates in Hungary. Conclusions We found higher prevalence and treatment rates of AUDs in primary health care compared to general population surveys, with large variability between the observed countries.

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: s creening for alcohol use and alcohol-related problems, b rief i nterventions for hazardous and in some cases harmful drinking, r eferral to specialized t reatment 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.

Background Brief interventions (BIs) delivered in primary care have been shown to be effective in reducing risky drinking, but implementation is limited. Facilitated access to a digital application offers a novel alternative to face-to-face intervention, but its relative effectiveness is unknown. Methods Primary care-based, non-inferiority, randomised controlled trial comparing general practitioner (GP) facilitated access to an interactive alcohol reduction website (FA) with face-to-face BI for risky drinking. Patients screening positive on the short Alcohol Use Disorders Identification Test (AUDIT-C) were invited to participate in the trial. Assessment at baseline, 3 months and 12 months was carried out using AUDIT and EQ-5D-5L questionnaires. Findings 58 participating GPs approached 9080 patients of whom 4529 (49.9%) logged on, 3841 (84.8%) undertook screening, 822 (21.4%) screened positive and 763 (19·9%) were recruited. 347 (45.5%) were allocated to FA and 416 (54.5%) to BI. At 3 months, subjects in FA group with an AUDIT score of ≥8 reduced from 95 (27.5%) to 85 (26.8%) while those in BI group increased from 123 (20.6%) to 141 (37%). Differences between groups were principally due to responses to AUDIT question 10. Analysis of primary outcome indicated non-inferiority of FA compared with BI, and prespecified subgroup analysis indicated benefits for older patients and those with higher levels of computer literacy and lower baseline severity. Additional analyses undertaken to take account of bias in response to AUDIT question 10 failed to support non-inferiority within the prespecified 10% boundary. Interpretation Prespecified protocol-driven analyses of the trial indicate that FA is non-inferior to BI; however, identified bias in the outcome measure and further supportive analyses question the robustness of this finding. It is therefore not possible to draw firm conclusions from this trial, and further research is needed to determine whether the findings can be replicated using more robust outcome measures. Trial registration number NCT01638338; Results

Aim: To provide a description of patients receiving alcohol treatment in eight different European countries, including the level of comorbidities and functional limitations. Methods: Drinking behaviours, DSM-IV alcohol use disorder (AUD), mental and somatic comorbidities, disability and health services utilization of 1767 patients from various specialized treatment settings were assessed as representative for regions of eight European countries. Severity of alcohol dependence (AD) in terms of drinking level was compared with a large representative US sample. Alcohol and Alcoholism, 2015, 1–9 doi: 10.1093/alcalc/agv009 Article © The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved 1 Alcohol and Alcoholism Advance Access published February 25, 2015 Downloaded from by guest on February 25, 2015 Results: Patients in specialized care for AUDs showed high levels of consumption [average level of daily ethanol intake: 141.1 g, standard deviation (SD): 116.0 g], comorbidity [e.g. liver problems: 19.6%, 95% confidence interval (CI): 17.5–21.6%; depression: 43.2%, 95% CI: 40.7–45.8%; anxiety: 50.3%, 95% CI: 47.8–52.9%], disability and health services utilization (average number of nights spent in hospital(s) during the last 6 months: 8.8, SD: 19.5 nights). Severity of AD was similar to the US sample, but European men consumed on average more alcohol daily. Conclusions: High levels of consumption, somatic and mental comorbidities, disability and functional losses were found in this representative treatment sample, indicating that treatment was initiated only at severe stages of AUDs. Earlier initiation of treatment could help avoid some of the health and social burden.

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. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0308-8) contains supplementary material, which is available to authorized users.

BackgroundAlcohol use disorders (AUDs) are highly prevalent in Europe, but only a minority of those affected receive treatment. It is therefore important to identify factors that predict treatment in order to reframe strategies aimed at improving treatment rates.MethodsRepresentative cross-sectional study with patients aged 18–64 from primary health care (PC, six European countries, n = 8476, data collection 01/13–01/14) and from specialized health care (SC, eight European countries, n = 1762, data collection 01/13–03/14). For descriptive purposes, six groups were distinguished, based on type of DSM-IV AUD and treatment setting. Treatment status (yes/no) for any treatment (model 1), and for SC treatment (model 2) were main outcome measures in logistic regression models.ResultsAUDs were prevalent in PC (12-month prevalence: 11.8%, 95% confidence interval (CI): 11.2–12.5%), with 17.6% receiving current treatment (95%CI: 15.3–19.9%). There were clear differences between the six groups regarding key variables from all five predictor domains. Prediction of any treatment (model 1) or SC treatment (model 2) was successful with high overall accuracy (both models: 95%), sufficient sensitivity (model 1: 79%/model 2: 76%) and high specificity (both models: 98%). The most predictive single variables were daily drinking level, anxiety, severity of mental distress, and number of inpatient nights during the last 6 months.ConclusionsVariables from four domains were highly predictive in identifying treatment for AUD, with SC treatment groups showing very high levels of social disintegration, drinking, comorbidity and functional losses. Earlier intervention and formal treatment for AUD in PC should be implemented to reduce these high levels of adverse outcomes.

ORAL PRESENTATION Open Access A randomized controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): preliminary results Pierluigi Struzzo1,2*, Roberto Della Vedova1, Donatella Ferrante2, Nicholas Freemantle3, Charilaos Lygidakis4, Francesco Marcatto2, Emanuele Scafato5, Francesca Scafuri1, Costanza Tersar1, Paul Wallace6 From INEBRIA 12th Congress, Atlanda, GA, USA. 24-25 September 2015 Background The effectiveness of brief interventions for risky drinkers by GPs is well documented [1]. However, implementa-tion levels remain low. Facilitated access to an alcohol reduction website offers an alternative to standard face-to-face intervention, but it is unclear whether it is as effective [2]. This study evaluates whether online brief intervention, through GP facilitated access to an alcohol reduction website for risky drinkers, is not inferior to the face-to-face brief intervention conducted by GPs. Material and methods In a northern Italy region participating GPs actively encouraged all patients age 18 attending their practice, to access an online screening website based on AUDIT-C [3]. Those screening positive underwent a baseline assessment with the AUDIT-10 [4] and EQ-5D [5] ques-tionnaires and subsequently, were randomly assigned to receive either online counselling on the alcohol reduc-tion website (intervention) or face-to-face intervention based on the brief motivational interview [6] by their GP (control). Follow-up took place at 3 and 12 months and the outcome was calculated on the basis of the pro-portion of risky drinkers in each group according to the AUDIT-10. Results More than 50% (n= 3974) of the patients who received facilitated access logged-on to the website and com-pleted the AUDIT-C. Just under 20% (n = 718) screened positive and 94% (n= 674) of them completed the base-line questionnaires and were randomized. Of the 310 patients randomized to the experimental Internet inter-vention, 90% (n = 278) logged-on to the site. Of the 364 patients of the control group, 72% (263) were seen by their GP. A follow-up rate of 94% was achieved at 3 months. Conclusions The offer of GP facilitated access to an alcohol reduc-tion website appears to be an effective way of identifying risky drinkers and enabling them to receive brief intervention. A randomized controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): preliminary results. Available from: https://www.researchgate.net/publication/282849260_A_randomized_controlled_non-inferiority_trial_of_primary_care-based_facilitated_access_to_an_alcohol_reduction_website_%28EFAR-FVG%29_preliminary_results#full-text [accessed Oct 15, 2015].

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 ini- tiating 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 indepen- dently 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 over- lap between cases identified. Alcohol-dependent patients identified by a physi - cian were older, had higher rates of physicial comorbidity (liver disease, hyper- tension), 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 alco- hol-dependent patients with severe comorbidities seemed to be missed in this assessment.

Alcohol; Brief interventions; Health system Alcohol; Intervencions breus; Sistema sanitari Alcohol; Intervenciones breves; Sistema sanitario Alcohol-related health problems are important public health issues and alcohol remains one of the leading risk factors of chronic health conditions. In addition, only a small proportion of those who need treatment access it, with figures ranging from 1 in 25 to 1 in 7. In this context, screening and brief interventions (SBI) have proven to be effective in reducing alcohol consumption and alcohol-related problems in primary health care (PHC) and are very cost effective, or even cost-saving, in PHC. Even if the widespread implementation of SBI has been prioritized and encouraged by the World Health Organization, in the global alcohol strategy, the evidence on long term and population-level effects is still weak. This review study will summarize the SBI programs implemented by six European countries with different socio-economic contexts. Similar components at health professional level but differences at organizational level, especially on the measures to support clinical practice, incentives, and monitoring systems developed were adopted. In Italy, cost-effectiveness analyses and Internet trials shed new light on limits and facilitators of renewed, evidence-based approaches to better deal with brief intervention in PHC. The majority of the efforts were aimed at overcoming individual barriers and promoting health professionals' involvement. The population screened has been in general too low to be able to detect any population-level effect, with a negative impact on the acceptability of the program to all stakeholders. This paper will present a different point of view based on a strategic broadening of the implemented actions to real inter-sectoriality and a wider holistic approach. Effective alcohol policies should strive for quality provision of health services and the empowerment of the individuals in a health system approach.

Item does not contain fulltext AIMS: To document the attitudes of general practitioners (GPs) from eight European countries to alcohol and alcohol problems and how these attitudes are associated with self-reported activity in managing patients with alcohol and alcohol problems. METHODS: A total of 2345 GPs were surveyed. The questionnaire included questions on the GP's demographics, reported education and training on alcohol, attitudes towards managing alcohol problems and self-reported estimates of numbers of patients managed for alcohol and alcohol problems during the previous year. RESULTS: The estimated mean number of patients managed for alcohol and alcohol problems during the previous year ranged from 5 to 21 across the eight countries. GPs who reported higher levels of education for alcohol problems and GPs who felt more secure in managing patients with such problems reported managing a higher number of patients. GPs who reported that doctors tended to have a disease model of alcohol problems and those who felt that drinking was a personal rather than a medical responsibility reported managing a lower number of patients. CONCLUSION: The extent of alcohol education and GPs' attitudes towards alcohol were associated with the reported number of patients managed. Thus, it is worth exploring the extent to which improved education, using pharmacotherapy in primary health care and a shift to personalized health care in which individual patients are facilitated to undertake their own assessment and management (individual responsibility) might increase the number of heavy drinkers who receive feedback on their drinking and support to reduce their drinking.