Primary care implementation study to scale up early identification and brief intervention and reduce alcohol-related negative outcomes at the community level (PINO): study protocol for a quasi-experimental 3-arm study

Bram Pussig, Lodewijk Pas, Ann Li, Mieke Vermandere, Bert Aertgeerts, Catharina Matheï, Bram Pussig, Lodewijk Pas, Ann Li, Mieke Vermandere, Bert Aertgeerts, Catharina Matheï

Abstract

Background: Primary healthcare-based Early Identification and Brief Intervention (EIBI) for hazardous and harmful alcohol use is both a clinically relevant and cost-effective strategy to reduce heavy drinking. Unfortunately, it remains poorly implemented in daily practice. Multiple studies have shown that training and support (T&S) programs can increase the use of EIBI. Nonetheless, gains have only been modest and short-term at best. Suggestions have been made to rely more on multicomponent programs that simultaneously address several barriers to the implementation of EIBI. The PINO-project aims to evaluate the added value of such a multicomponent program to improve EIBI delivery in daily practice.

Methods/design: A quasi-experimental three-arm implementation study in Flanders (Belgium) will assess the effects of tailored T&S to General Practitioners (GPs) with or without community mobilisation on EIBI delivery in general practice. The study lasts 18 months and will take place in three comparable municipalities. In municipality 1 and 2, GPs receive a tailored T&S program. The T&S is theoretically founded and tailored to the GPs' views, needs and practice characteristics. Furthermore, community actions will be embedded within municipality 1 providing additional, contextual, support. In municipality 3, GPs are offered a minimal intervention to facilitate data collection. The primary outcome is the proportion of adult patients screened for hazardous and harmful alcohol use at the end of an 18-month implementation period. The secondary outcome is the scaling up activity at municipal level in screening rates, as assessed every 3 months, and the proportion of patients who received an additional brief intervention when necessary. Furthermore, the correlation between the opinions and needs of the GP's, their practice organisation and their EIBI performance will be explored.

Discussion: The PINO-project addresses the gap between what is theoretically possible and the current practice. This is an innovative study combining T&S at GP level with community actions. At the same time, it implements and evaluates practice T&S based on the theoretical domains framework.

Trial registration: This trial was approved by the Ethics Committee for Research of UZ/KU Leuven (reference number s63342 and G-2020-2177-R2(MAR)) and is registered on clinicaltrials.gov ( NCT04398576 ) in May 2020.

Keywords: Community action; EIBI; Harmful use of alcohol; Hazardous alcohol use; Heavy drinking; Implementation; Primary healthcare; Scaling-up; Training and support.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Timeline of the study

References

    1. GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2018;392(10152):1015–1035. doi: 10.1016/S0140-6736(18)31310-2.
    1. Vlaams expertise centrum voor Alcohol en andere Drugs (VAD) Factsheet alcohol. 2019.
    1. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373(9682):2223–2233. doi: 10.1016/S0140-6736(09)60746-7.
    1. Maertens De Noordhout C, Van Oyen H, Speybroeck N, et al. Changes in health in Belgium, 1990-2016: A benchmarking analysis based on the global burden of disease 2016 study. BMC Public Health. 2018;18(1):1–3. doi: 10.1186/s12889-018-5708-y.
    1. Anderson P, O’Donnell A, Kaner E. Managing alcohol use disorder in primary health care. Curr Psychiatry Rep. 2017;19(11):79. doi: 10.1007/s11920-017-0837-z.
    1. Sassi F (ed.).Tackling harmful alcohol use: economics and public health policy. In: Organisation for Economic Co-opertation and Development (OECD). Paris: OECD Publishing; 2015. 10.1787/9789264181069-en.
    1. Kaner EF, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2:CD004148.
    1. Miller WR, Wilbourne PL. Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction. 2002;97(3):265–277. doi: 10.1046/j.1360-0443.2002.00019.x.
    1. Rapley T, May C, Frances KE. Still a difficult business? Negotiating alcohol-related problems in general practice consultations. Soc Sci Med. 2006;63(9):2418–2428. doi: 10.1016/j.socscimed.2006.05.025.
    1. Mistriaen P, Kohn L, Mambourg F, et al. Reduction of the treatment gap for problematic alcohol use in Belgium. 2016.
    1. Johnson M, Jackson R, Guillaume L, et al. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Bangkok) 2010;33(3):412–421. doi: 10.1093/pubmed/fdq095.
    1. Rosário F, Santos MI, Angus K, et al. Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and theoretical domains framework. Implement Sci. 2021;16(1):1–25. doi: 10.1186/s13012-020-01073-0.
    1. Seale JP, Shellenberger S, Clark DC. Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum. BMC Med Educ. 2010;10(1):33. doi: 10.1186/1472-6920-10-33.
    1. Keurhorst M, Anderson P, Spak F, et al. 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 rando. Implement Sci. 2013;8(1):11. doi: 10.1186/1748-5908-8-11.
    1. Keurhorst M, van de Glind I, Bitarello DO, Amaral-Sabadini M, et al. Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis. Addiction. 2015;110(12):1877–1900. doi: 10.1111/add.13088.
    1. Korsen N. Understanding variation in practice. J Fam Pract. 2002;51(5):472–4.
    1. Anderson P, Laurant M, Kaner E, Wensing M, Grol R. Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol. 2004;65(2):191–199. doi: 10.15288/jsa.2004.65.191.
    1. Anderson P, Bendtsen P, Spak F, et al. Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial. Addiction. 2016;111(11):1935–1945. doi: 10.1111/add.13476.
    1. Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients’ care. Lancet. 2003;362:1225–1230. doi: 10.1016/S0140-6736(03)14546-1.
    1. World Health Organization‎. WHO Collaborative Project on Identification and Management of Alcohol-Related Problems in Primary Health Care: report on phase IV: development of country-wide strategies for implementing early identification and brief intervention in primary health care/edited by Nick Heather. World Health Organization; 2006. .
    1. El-Guebaly N, Toews J, Lockyer J, et al. Medical education in substance-related disorders: components and outcome. Addiction. 2000;95(6):949–957. doi: 10.1046/j.1360-0443.2000.95694911.x.
    1. Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992;268(9):1111–1117. doi: 10.1001/jama.1992.03490090053014.
    1. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274(9):700–705. doi: 10.1001/jama.1995.03530090032018.
    1. Carlfjord S, Lindberg M, Andersson A. Staff perceptions of addressing lifestyle in primary health care: a qualitative evaluation 2 years after the introduction of a lifestyle intervention tool. BMC Fam Pract. 2012;13(1):99. doi: 10.1186/1471-2296-13-99.
    1. Jané-Llopis E, Anderson P, Piazza M, O'Donnell A, Gual A, Schulte B, Pérez Gómez A, de Vries H, Natera Rey G, Kokole D, V Bustamante I, Braddick F, Mejía Trujillo J, Solovei A, Pérez de León A, Kaner EFS, Matrai S, Manthey J, Mercken L, López-Pelayo H, Rowlands G, Schmidt C, Rehm J. Implementing primary healthcare-based measurement, advice and treatment for heavy drinking and comorbid depression at the municipal level in three Latin American countries: final protocol for a quasiexperimental study (SCALA study) BMJ Open. 2020;10(7):e038226. doi: 10.1136/bmjopen-2020-038226.
    1. Varsi C, Ekstedt M, Gammon D, Ruland CM. Using the consolidated framework for implementation research to identify barriers and facilitators for the implementation of an internet-based patient-provider communication Service in Five Settings: a qualitative study. J Med Internet Res. 2015;17(11):e262. doi: 10.2196/jmir.5091.
    1. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi: 10.1186/1748-5908-6-42.
    1. Statistieken van bevolking - Bevolking - IBZ Instellingen en Bevolking. (2021); Available from:
    1. Michels J, Hoeck S, Dom G, et al. Problematisch alcoholgebruik aanpak door de huisarts. 2011.
    1. Hoge Gezondheidsraad. Risico’s van alcoholgebruik. Brussel: HGR; 2018. Advies nr. 9438.
    1. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJC, Crone MR. Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implement Sci. 2014;9(1):33. doi: 10.1186/1748-5908-9-33.
    1. Keurhorst M, Heinen M, Colom J, Linderoth C, Müssener U, Okulicz-Kozaryn K, Palacio-Vieira J, Segura L, Silfversparre F, Słodownik L, Sorribes E, Laurant M, Wensing M. Strategies in primary healthcare to implement early identification of risky alcohol consumption: why do they work or not? A qualitative evaluation of the ODHIN study. BMC Fam Pract. 2016;17(1):70. doi: 10.1186/s12875-016-0461-8.
    1. Gual A, Anderson P, Segura L, et al. Alcohol and primary health care: training Programme on identification and brief interventions. Dep Health Gov Catalonia Barcelona. 2005.
    1. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM, Lawton R, Michie S. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. doi: 10.1186/s13012-017-0605-9.
    1. Pussig B, Van Nuland M, Pas L, et al. Community involvement for early identification of alcohol problems in general practice: a nominal group study. EJGP. 10.1080/13814788.2021.1936493.
    1. Singh M, Gmyrek A, Hernandez A, Damon D, Hayashi S. Sustaining screening, brief intervention and referral to treatment (SBIRT) services in health-care settings. Addiction. 2017;112:92–100. doi: 10.1111/add.13654.
    1. Vendetti J, Gmyrek A, Damon D, Singh M, McRee B, del Boca F. Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration. Addiction. 2017;112:23–33. doi: 10.1111/add.13652.
    1. De Visser RO. Personalized feedback based on a drink-pouring exercise May improve knowledge of, and adherence to, government guidelines for alcohol consumption. Alcohol Clin Exp Res. 2015;39(2):317–323. doi: 10.1111/acer.12623.
    1. Anderson P, Coulton S, Kaner E, Bendtsen P, Kłoda K, Reynolds J, Segura L, Wojnar M, Mierzecki A, Deluca P, Newbury-Birch D, Parkinson K, Okulicz-Kozaryn K, Drummond C, Gual A. Delivery of brief interventions for heavy drinking in primary care: outcomes of the ODHIN 5-country cluster randomized trial. Ann Fam Med. 2017;15(4):335–340. doi: 10.1370/afm.2051.
    1. Delvaux N, Aertgeerts B, van Bussel JC, et al. Health data for research through a Nationwide privacy-proof system in Belgium: design and implementation. JMIR Med Inform. 2018;6(4):e11428. doi: 10.2196/11428.
    1. Anderson P, Clement S. The AAPPQ Revisited: the measurement of general practitioners' attitudes to alcohol problems. Addiction. 1987;82 (7):753-759
    1. Schweizer ML, Braun BI, Milstone AM. Research methods in healthcare epidemiology and antimicrobial stewardship - quasi-experimental designs. Infect Control Hosp Epidemiol. 2016;37(10):1135–1140. doi: 10.1017/ice.2016.117.
    1. Chan A-W, Tetzlaff JM, Altman DG, et al. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Ann Intern Med. 2013;158(3):207. doi: 10.7326/0003-4819-158-3-201302050-00583.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe