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Table 2 Characteristics of studies included in the review

From: A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

Study (n = 56)a

Sample size

Strategy

Targets

Main outcomes

CQI elementsc

Patients

Clinicians

Sites

Clin.actionb

Org. level

M/faceted

1

2

3

Randomized controlled trials

WHO collaborative Project (Phase 3)

 Gomel 1998 AUS Alcohol [33]

94,481

Phase 1: 628 Phase 2: 161 (1 per site)

628 161

Phase 1: mailout (c); telemarketing; academic detailing. Phase 2: written guidance (c); training; training + min support; training + ongoing support

S, BI

3,4

Y

Higher uptake if academic detailing or telemarketing; higher screening in training or training + max support cf. other arms; advice significantly higher in max support arms

N

N

N

Hansen et al. 1999 DNK Alcohol [34]

na

143

na

Phase 1 only

S, BI

4

N

Higher uptake if academic detailing or telemarketing. No significant differences control cf. intervention arms

N

N

N

Kaner 1999 GBR Alcohol [39]

11,007

128

128

Phase 2 only (excluding the training + min support arm).

S, BI

4

Y

Increased implementation, screening and intervention in training + support.

N

N

N

Funk 2005 AUS, BEL, DNK, NZ, ESP, GBR Alcohol [32]

60,989

Phase 1: 3436, Phase 2: 727 (1 per site)

3436 727

Phase 1 & 2 (excluding the training + min support arm)

S, BI

3,4

Y

Increased uptake if academic detailing or telemarketing. Increased screening and advice giving if training or training + support.

N

N

N

Anderson 2004 AUS, BEL, ESP, GBR Alcohol [25]

na

Phase 1: 2924; Phase 2: 632 (1 per site)

2924 632

Phase 1 & 2 (excluding the training + min support arm)

S, BI

3,4

Y

Sub-analysis of Funk 2005: Increased screening and BI if physicians secure and committed in working with drinkers

N

N

N

ODHIN

 Anderson 2016 ESP, GBR, NLD, POL, SWE Alcohol [23]

Mean: 1500 consults/site (baseline)

746

120

Country guidelines summary (c); training and support (TS), Financial reimbursement (FR), access to referral to eBI and combinations of these

S, BI

3,4

Y

During 12-week implementation: Increased screening in TS arm and FR arm. Increased intervention (screening or advice) in TS, FR, TSFR and TSFReBI. No effect on giving advice to screen positive pts.

N

N

N

 Bendtsen 2016 ESP, GBR, NLD, POL, SWE Alcohol [26]

As above

350

60

As above

S, BI

3,4

Y

No association between eBI and increase in screening. Increased proportion of screen-positive pts. given BI. Low pt. and provider uptake rates of eBI

N

N

N

 Anderson 2017 ESP, GBR, NLD, POL, SWE Alcohol [24]

As above

746

120

As above

S, BI

3,4

Y

At 9 months follow-up: Increased intervention rates in TS. Reduction of intervention rates in all arms but reduction in TS arm was smaller.

N

N

N

CN SNAP

Chan 2013 AUS Broad prev [28].

na

129

4

Training (5As); Integrating assessment/prompts into initial visits; referral directory; resources including. Guides for nurses, action plans for each risk factor.

S, BI, RT

3,4

Y

Increased self-reported screening at 6 and 12 months (validated scale). No effect on self-reported management or referral.

N

N

N

Harris 2013 AUS Broad prev [35].

804

na

4

As above.

BI, RT

3,4

Y

Increase in pt-reported referrals in intervention group at 3 months cf. baseline. No significant changes in self-reported alcohol consumption.

N

?

N

Other RCTs

 Bonevski 1999 AUS Broad prev [27].

2917

19

na

Computerized feedback system: guidelines, goal setting for GPs, GP feedback on performance in other health screening (not alcohol).

na

4

Y

Although not targeted by intervention, at 3-month follow-up classification of hazardous/harmful drinkers more accurate in intervention arm cf. controls.

N

N

N

 Dubey 2006 CAN Broad prev [30].

1117

38

4

Gender based preventative checklist prompt with evidence-based recommendations.

S

4

N

Significant increase in alcohol history intake between baseline and follow-up in intervention arm. Increase significantly associated with intervention.

N

N

N

 Chossis 2007 Switzerland Alcohol [29]

260

27

2

Training; summary checklist, textbook and pt. education materials.

BI

4

Y

Intervention residents conducted more components of BI: more likely to explain safe drinking limits provide feedback, seek pt. opinions on drinking limits, after training but not at follow-up; no effect on pt. drinking patterns.

N

N

N

 Friedmann 2006 USA Alcohol [31]

164

18

2

Maintenance care training for alcohol problems in remission (5As); follow-up academic detailing; booster training; materials for pts. and clinicians; pt. record prompt (paper).

S, BI, RP, RT

4

Y

Intervention pts. more likely to report clinician took alcohol history. Intervention clinicians who took alcohol history more likely to assess prior and planned alcohol treatment, offer of prescriptions and referral.

N

N

N

 Harris 2015 AUS Broad prev [36].

21,848

122

32

Training of practice staff and QI facilitators; audit and feedback; site visits with goal setting; pt. education and referral materials; implementation support; facilitator support.

S

3,4

Y

At 12 months follow-up increase in odds of alcohol recording of alcohol consumption in the intervention compared to control. No significant change in the level of risk factors based on audit data.

Y

Y

Y

Haskard 2008 USA Broad prev [37].

2196

156

3

Physician training; pt. training.

BI

4,5

Y

Significant upward trend in counselling to quit alcohol at time 6-months post training after initial expected drop at 1-month post training.

N

N

N

Kaner 2003 GBR Alcohol [38]

5541

na

212

Phase 1: mailout (c); telemarketing; academic detailing. Phase 2: written guidance (c); training; training + ongoing support (directed at nurses).

S, BI

 

Y

Increased implementation in training and training + support. Increased BI in training and training + support. Fewer pt. management errors in controls.

N

?

N

Krist 2016 USA Broad prev [40].

2913

156

18

MOHR: self-administered health behaviour questionnaire; MOHR summary and feedback for pts.; a summary of positive MOHR for clinicians; optional training for clinicians; freedom of method of implementation.

S, BI, RT

3,4

Y

Significantly higher screening for alcohol and goal setting to reduce risky drinking in intervention arm compared to control. No significant changes in referrals. No significant changes in alcohol consumption.

N

Y

N

Ornstein 2013 USA Alcohol [43]

26,005

77

20

Pre-intervention visit; electronic screening/intervention prompt and resource template; network meeting to discuss facilitators and barriers and to develop implementation plans; performance feedback; on-site support visits.

S, BI, RP

3,4

Y

Early Intervention (EI) phase: increased odds of screening and BI in EI cf. delayed intervention (DI); performance stable at DI phase. DI phase: increased odds of screening in DI pts. cf. EI phase. Increased prescription of AUD medication in EI pts. at DI phase.

Y

Y

Y

Mertens 2015 USA Alcohol [41]

420,946

554

54

Physician (PCP), Non-physician providers (NPP), Medical Aid (MA) arms. Training: PCP trained in all of SBIRT, MAs trained to ask screening question, NPPs trained to ask weekly drinking questions, AUD screener and BI and RT. All arms: Screening + automated prompts added to electronic health record; implementation support; audit + feedback.

S, BI, RT

3,4

Y

Higher screening rates in NPP, MA and PCP cf. controls. Higher BI and referrals in PCP cf. other arms (No difference between NPP, MA and controls).

N

Y

Y

Navarro 2012 AUS Alcohol [42]

155,170

na

20

Feedback letter to GP: prescription + community dependence rates, information on pharmacotherapies + behavioural interventions; recommendation to increase prescribing to reduce heavy alcohol consumption.

RP

4

N

Increased acamprosate but decreased naltrexone prescribing cf. controls.

N

N

N

Rose 2008 USA Alcohol [44]

27,591

na

22

NIAAA screening guidelines; instructions to develop/adapt screening template in electronic MRs; performance feedback and review; on-site visits with training, development of action plan; network meetings. Screening template (5As with AUDIT-C + question /diagnosis/recording prompts).

S, BI, RT

2,3,4

Y

Screening, counselling odds higher in intervention cf. controls. Improvements over time greater in intervention arm. Reduced PB in pts. given brief counselling or referral but No significant reduction for intervention cf. controls.

Y

Y

Y

Saitz 2003 USA Alcohol [45]

212

41

1

Clinical prompt: Results of CAGE assessment + recommendations attached to pt. record.

BI, RT

4

N

Faculty physicians in intervention arm more likely cf. controls to give advice, discuss associated problems. No significant difference in outcomes for residents in intervention cf. control arm. At 6-months, intervention arm pts. who saw residents had fewer drinks/drinking day but no between group differences.

N

N

N

van Beurden 2012 NLD Alcohol [46]

1502

124

82

3 components targeting: [1] professionals: training, guidelines, reminder cards [2]; organization: feedback report, facilitation of external specialist support, implementation support [3]; Pt-directed: letters, leaflets, self-help booklets, poster, personal feedback based on consumption.

S, BI

3,4,5

Y

No difference in improvement in screening or BI in intervention cf. control.

?

Y

N

Non randomized controlled studies

 Bradley 2002 USA Alcohol [47]

68

34

2

Clinical prompt: pt-specific positive screening result at each visit.

BI

4

N

Intervention group more likely to discuss alcohol use cf. controls.

N

N

N

 Hamilton 2014 GBR Alcohol [48]

211,834

na

30

Pay-for-performance scheme (QOF+) to extend alcohol screening; computer templates; in-practice training.

S, BI, RT

2

Y

Increased screening in eligible and Non-eligible group cf. baseline. Eligible pts. more likely to receive ASBI and full AUDIT than Not eligible.

N

N

N

Harris 2017 USA Alcohol [49]

2952

199

3

3 components targeting [1] Local champion: training + support, monthly teleconferences, access to national champions, website, pt. dashboard [2]; Providers: training + support, website, access to local champions, pt. dashboard, reminder emails [3]; Pt education + activation: mailed materials.

RP

2,3,4,5

Y

Increased odds of filling a prescription during implementation in the three sites, however not significant at one site when stratified by site. No significant changes cf. matched controls.

N

?

N

Khadjesari 2017 GBR Alcohol [50]

261,424

na

na

Pay-for-performance scheme for specific clinical areas.

S

1,2

N

Increase in alcohol recording rate ratio over 13 years in case group cf. control group.

N

N

N

Mason 1997 GBR Alcohol [51]

1417

na

4

Nurse-counsellor providing counselling services to practices + training to physicians.

S, BI, RT

3

Y

Increase in: recording of consumption and identification of problem drinkers (all intervention sites), identification of pts. drinking above recommended limits and advice (2 sites). No increases in referrals.

N

N

N

McElwaine 2014 AUS Broad prev [52].

1989

570

17

Local leadership engagement, electronic MR modification, training, implementation support, audit + feedback.

S, BI, RT

2,3,4

Y

Increase in odds of provision of Brief Advice from baseline to follow-up in intervention cf. controls. No changes in screening or referrals.

Y

?

Y

O’Donnell 2016 GBR Alcohol [53]

106,700

99

16

Two pay-for-performance schemes: National (DES) - for each newly registered pt. screened; Local (LES) - for each new pt. over 16 positive for risky drinking + received BI.

S, BI

1,2

N

Rates of short screening (FAST or AUDIT-C) or AUDIT lowest in non-incentivised and highest in DES. Rates of alcohol intervention lowest in non-incentivised and highest in DES. Significance Not reported.

N

N

N

Onders 2014 USA Broad prev [54].

23,000 visits/year Indigenous

10

1 (cf national service)

Electronic clinical reminders (CR) using PDSA: [1] data-driven ID of need [2]; Pilot test CR [3]; Expand to all providers [4]. audit +feedback [5]; Delegation of CR to other staff.

S

3,4

Y

Increased screening from 35 to 70% cf. IHS (smaller increase 40–48%) cf. other IHS.

Y

Y

Y

Ozer 2005 USA Broad prev [55].

T0 = 226(i), 246(c); T1 = 551(i), 260(c); T2 = 940(i), 405(c) Adolescents

76

4

Clinician training; facilitated implementation of screening and charting forms tailored to local conditions. (Setting: paediatric PHC).

S, BI

3,4

Y

Increased screening and counselling post implementation both elements (intervention cf. controls). Increases associated with post training. No additional increases post tool implementation.

N

?

N

Thomas 2014 SWE Broad prev [56].

T1 = 888 T2 = 994

T1 = 120 T2 = 132

6

Implementing screening for risky behaviour + BI and referrals to in-house multidisciplinary team; compulsory components: multidisciplinary teams + managers, meetings, in-house referral workflows.

S, BI

3,4

Y

No difference in alcohol consumption discussion rates in intervention cf. control at 3 years. Significantly higher alcohol discussion rates in control cf. intervention at 5 years.

N

?

N

Wiggers 2017 AUS Broad prev [57].

5369

~ 1400

56

Policy + leadership engagement; modifying information systems; training; audit and feedback; implementation support, information and resources.

S, BI, RT

2,3,4

Y

Increased alcohol consumption assessment and advice cf. control (stepped wedge). No increases in referrals.

Y

Y

Y

Wilson 1992 GBR Broad prev [58].

4471

16

10

Increased consultation booking time from 6 to 10 min per pt.

na

3

N

Increased recording of alcohol education and in pt-reported discussion about alcohol.

N

N

N

Before/after and other designs

Healthy Habits

 Seale 2005a USA Alcohol [77]

3387

35

1

Formation of lead committee (monitoring + recommendations); strategy development, modification of pt. record + workflows to include SBI; clinician training.

S, BI, RT

3,4

Y

Increased screening + intervention. Clinicians intervened more often when prompted with AUDITs. Periodic evaluation resulted in modifications, which resulted in progressive increases in screening.

Y

Y

Y

 Seale 2005b USA Alcohol [76]

1052

38

1

Formation of leading committee (monitoring + recommendations); strategy development, modification of pt. record + workflows to include SBI; clinician training.

S, BI

4

Y

No significant differences in problem drinking (PD) identification before and after intervention. After training, greater increase in advice giving in residents cf. faculty.

Y

Y

Y

 Johnson 2013 USA Alcohol [69]

288

na

1

SBI workflow additions to protocols implemented above: Single Alcohol Screening Question (SASQ); checkbox in pt. record for BI; booster training.

S, BI

3,4

Y

Screening rates using AUDIT-C plus SASQ exceeded 90% but no significant changes. Increased identification of UAU at 6 weeks and 6 months.

?

?

?

VA program

Lapham 2012 USA Alcohol [70]

6788

na

na

Health system-wide incentives-linked performance measure (PM) + BI electronic clinical reminder (CR); freedom of adaptation but core PM components required; BI clinician training optional.

BI

2,3,4

Y

Recording of advice increased continuously from baseline year, after PM announcement, PM implementation, and CR dissemination.

N

Y

N

Chavez 2016 USA Alcohol [62]

225,912

na

na

As above.

BI

2,3,4

Y

Increased pt-reported advice to pts. with moderate-severe alcohol misuse from baseline with plateau in two final years.

N

Y

N

ABCD

 Si 2007 AUS Broad prev [78].

360 Indigenous

na

12

Single intervention cycle includes: initial systems audit + records audit; identify priorities + design improvement strategy; audit + feedback to monitor + identify new priorities.

BI

3

Y

Alcohol counselling/advice increased significantly at Year 2 audit.

Y

Y

Y

 Gibson-Helm 2016 AUS Broad prev [65].

2220 (Indigenous Pregnant women)

na

50

As above.

S, BI

3,4

Y

Increased odds of screening and BI with each cycle. Evidence of a trend in increased number of CQI cycles and increase in BI.

Y

Y

Y

Other

 Aalto 2003 Finland Alcohol [59]

1449

24

2

Collaborative BI implementation development; training; implementation support; reminders in local and professional publications; distribution of AUDIT to all households.

S, BI

2,3,4,5

Y

No statistically significant differences.

N

?

N

 Aspy 2008 USA Broad prev [60].

600

30

9

Audits + feedback; training; practice facilitation/support; meetings between participating practice teams; Nurses, medical assistants, trained in screening and very brief interventions (VBI) e.g. referrals and handouts. Clinicians trained in BI.

S, BI

2,3,4

Y

No significant changes in alcohol screening or VBI or BI cf. baseline. Pts less likely to screen positive for UAU at end of study cf. baseline. Screening increased if alcohol was the target in first two cycles. Addition of more than two target behaviours appeared to negatively impact previous targets.

Y

Y

Y

Bobb 2017 USA Alcohol [61]

53,133

na

3

3 strategies: [1] Enabling teams: recruitment + CQI training of site champions, development + implementation support, regular education on CQI, SBI + AUD treatment, information sharing between sites [2]. Support via electronic health record: screening, BI, AUD prompts [3]; Monitoring + feedback: PDSA; meetings.

S, BI, RP, RT

2,3,4

Y

Increased screening and assessment post-implementation cf. baseline. Effects sustained 1 year later + increased new AUD diagnoses. Increased treatment within 30- and 90-days post diagnosis (driven mainly by one site).

Y

Y

Y

Clifford 2013 AUS Alcohol [63]

9322

na

4

Training; treatment guidelines; electronic assessment tool; implementation support

S, BI

3,4

Y

Increased records of screening. Increased records of BI overall but Not significant in individual ACCHS.

N

Y

N

Cowan 1994 USA Alcohol [64]

910

11

1

Clinician training.

Y

S

4

N

Significant increase in recording of drinking histories.

N

N

N

Gilkes 2017 AUS Broad prev [66].

2608

35

na

Clinical audit + feedback by medical students to GP supervisors.

S

4

N

Increased record of alcohol consumption.

N

N

Y

Gowin 2012 POL Broad prev [67].

1060

106

na

Regional training program.

S

2,4

N

Increased screening.

N

N

N

Holtrop 2009 USA Broad prev [68].

1965

na

20

Record audits + practice assessment; choice of improvement plan based on 5As, priority risk behaviour or both; support in planning + implementation; audit + feedback at end of study.

S, BI

3,4

Y

No practice chose alcohol as target. However, increased alcohol screening but non-significant when adjusted for clustering.

Y

Y

?

Lawner 1997 USA Alcohol [71]

297

15

1

Training of faculty members to give performance feedback to residents with a feedback form.

S

4

N

Increased record of alcohol consumption. Increased use of CAGE.

N

N

N

Lustig 2001 USA Broad prev [72].

532 (Adolescents)

63

3

Clinician training (Setting: paediatric PHC).

S, BI

4

N

Increased screening.

N

N

N

Marco-Garcia 1999 ESP Broad prev [73].

(1500–2000/doctor, 42 doctors)

84

3

Formation of task force; collaborative program development; consensus on indicators + evaluation criteria; regular audit; action in response to audit.

S

3,4

Y

Increased recording of alcohol consumption.

Y

Y

Y

Olfson 1992 USA Alcohol [74]

884

110

1

Clinical prompt: addition of CAGE to health form completed by first-time pts. prior to first consult.

S

4

N

Alcohol problem detection (either problem drinking or abuse) increased cf. baseline.

N

N

N

Seale 2015 USA Alcohol [75]

1318

na

4

Partial funding for coordinator; coordinator + clinician training; implementation committees; implementation guide + freedom to adapt to local setting; progress feedback.

S, BI, RP, RT

3,4

Y

Increased record of any screening or validated screening. Increased identification of risky users. Increased record of BI.

?

Y

?

  1. aAuthor, year, country (as three-letter ISO 3166 country codes), focus and citation are given; bsignificant positive result for clinical action is indicated in bold; Y – Yes, N – No; S – screening; BI – brief intervention; RP – relapse prevention medicines; PT – psychosocial therapies; RT – referral to treatment; Strategy targets: Clin. Action – clinical action, Org. level – organisational level (1 = National, 2 = Health System, 3 = Practice, 4 = Clinician, 5 = Patient), M/faceted – multifaceted; cCQI elements: 1- Using ‘systematic data guided activities’ to identify problems and achieve improvement; 2 - ‘designing with local conditions in mind’ i.e. adapting and or designing strategies to fit the special characteristics of the local setting; 3 - using an ‘iterative development and testing process’; na – not available in article; (c) – control; (i) – intervention; pt. – patient; MR – medical record, eMR electronic medical record,.? – unclear; cf. – compared with