Aims To test if training and support of primary health care providers (PHCP), financial reimbursement to PHCP for screening and brief advice, and option for PHCP to refer screen positive patients to an internet-based method of giving advice (eBI) increases PHCP's delivery of screening and advice to heavy drinkers, compared to a control group of PHCPs.Design Cluster randomized factorial trial with 12-week implementation measurement period.Setting Primary health care units (PHCU) in different locations throughout Catalonia, England, Netherlands, Poland and Sweden.Participants 120 PHCU, 24 in each of Catalonia, England, Netherlands, Poland and Sweden.Interventions PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR), and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI.Outcome measures Primary outcome measures is proportion of eligible patients screened during a 12-week implementation period. Secondary outcome measures are proportion of screen positive patients advised; and, proportion of consulting adult patients given an intervention (screening and advice to screen positives) during the same 12-week implementation period.Results During a 4-week baseline measurement period, 5.9 (95% CI 3.4 to 8.4)per 100 adult patients consulting per PHCU were screened for their alcohol consumption. Based on the factorial design, PHCU that received TS had a 1.48 (95% CI 1.13 to 1.95)relatively higher proportion of patients screened during the 12-week implementation period than PHCU that did not receive TS; PHCU that received FR had a 2.00 (95% CI 1.56 to 2.56) relatively higher proportion than no FR. The option of referral to eBI did not have a higher proportion. A combination of TS plus FR had a 2.34 (95% CI 1.77 to 3.10) relatively higher proportion of patients screened than no TS plus FR. A combination of TS plus FR plus eBI had a 1.68 (95% CI 1.11 to 2.53) relatively higher proportion of patients screened than no TS plus FR plus eBI.Conclusions Training and support of PHCP, and financial reimbursement to PHCP for screening and brief advice increase the proportion of adult patients screened for their alcohol consumption, at least in the short term. Trial registration ClinicalTrials.gov. Trial identifier: NCT015015523

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.

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.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 Internetbased 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. METHODSWe 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. INTRODUCTIONA lcohol consumption is partly or entirely the cause of more than 200 diseases, injuries, and other health conditions with 3-digit International Classification of Diseases 10th Revision (ICD-10) codes, 1 and alcohol is the sixth most important risk factor for ill health and premature death at the global level.2 Heavy drinkers who reduce consumption decrease their risk of mortality when compared with those who continue to drink heavily.3,4 Systematic reviews demonstrate that primary health care-based screening and brief advice programs are effective in reducing alcohol consumption and related harm. [5][6][7] Many national and international guidelines recommend routine screening for heavy drinking in primary care and the offering of advice to screen-positive patients. [8][9][10] In many settings, however, there is a large gap between need and provision of advice. Elsewhere, we have shown that only 11 per 1,000 eligible patients consulting their primary care clinician over a 4-week period were screened for heavy drinking and, if screen-positive, subsequently advised to reduce their alcohol consumption (average across Catalonia, England, Netherlands, Poland, and Sweden). 11It is possible to increase the proportion of eligible patients screened and advised for heavy drinking. 13 During the implementation period, practitioners were asked to screen all consulting adult patients-regardless of the reason for their visit-for heavy drinking using the Alcohol Use Disorders Identification...

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