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

Abstract

Background: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. Methods: We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. Results: Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements.

Financial reimbursement - Irrelevant for GPs' readiness to implement brief intervention to reduce alcohol consumption? A cross-sectional vignette study.

“…Moreover, the vast majority of 91% of French GPs did not use any test to screen for hazardous drinking in comparison to 77% of Swiss GPs. Even more daunting in this context may be the systematic review about strategies to improve the implementation of SBI (28) including results from 13 countries such as USA, Australia, GBR, and Spain showing that none of the tested strategies showed signi cant improvement regarding patient outcomes. We believe hence that the substantial number of barriers reported in previous studies indicates some 'deeper' con ict being rooted in the inherent characteristics of BI and we'd like to ask, is the time ripe now to quit forcing the implementation of BI into routine care?…”

Financial reimbursement - irrelevant for GPs’ readiness to implement brief intervention to reduce alcohol consumption? A cross-sectional vignette study

“…Moreover, the vast majority of 91% of French GPs did not use any test to screen for hazardous drinking in comparison to 77% of Swiss GPs. Even more daunting in this context may be the systematic review about strategies to improve the implementation of SBI [27] including results from 13 countries such as USA, Australia, GBR, and Spain showing that none of the tested strategies showed significant improvement regarding patient outcomes. We believe hence that the substantial number of barriers reported in previous studies indicates some 'deeper' conflict being rooted in the inherent characteristics of BI and we'd like to ask, is the time ripe now to quit forcing the implementation of BI into routine care?…”

Effects of service-wide support on regularity of alcohol screening of clients in Australian Aboriginal and Torres Strait Islander Community Controlled Health Services: a cluster randomised trial

“…These patterns of drinking and harms have roots in ongoing trauma from colonisation [ 8 ]. Other Indigenous peoples who have been colonised have suffered increases in harms from alcohol, however, there are very few studies addressing alcohol screening in Indigenous populations [ 9 ].…”

“…Implementation studies in general primary care aim to increase the absolute number of alcohol screening events or patients screened. A recent systematic review showed that 34 of 44 studies aiming to improve alcohol screening resulted in significant increases in rates [ 9 ]. However, none investigated whether such interventions resulted in appropriate screening frequency or regularity.…”