Integrating a brief alcohol intervention with tobacco addiction treatment in primary care: qualitative study of health care practitioner perceptions

Abstract

Background Randomized trials of complex interventions are increasingly including qualitative components to further understand factors that contribute to their success. In this paper, we explore the experiences of health care practitioners in a province wide smoking cessation program (the Smoking Treatment for Ontario Patients program) who participated in the COMBAT trial. This trial examined if the addition of an electronic prompt embedded in a Clinical Decision Support System (CDSS)—designed to prompt practitioners to Screen, provide a Brief intervention and Referral to Treatment (SBIRT) to patients who drank alcohol above the amounts recommended by the Canadian Cancer Society guidelines—influenced the proportion of practitioners delivering a brief intervention to their eligible patients. We wanted to understand the factors influencing implementation and acceptability of delivering a brief alcohol intervention for treatment-seeking smokers for health care providers who had access to the CDSS (intervention arm) and those who did not (control arm). Methods Twenty-three health care practitioners were selected for a qualitative interview using stratified purposeful sampling (12 from the control arm and 11 from the intervention arm). Interviews were 45 to 90 min in length and conducted by phone using an interview guide that was informed by the National Implementation Research Network’s Hexagon tool. Interview recordings were transcribed and coded iteratively between three researchers to achieve consensus on emerging themes. The preliminary coding structure was developed using the National Implementation Research Network’s Hexagon Tool framework and data was analyzed using the framework analysis approach. Results Seventy eight percent (18/23) of the health care practitioners interviewed recognized the need to simultaneously address alcohol and tobacco use. Seventy four percent (17/23), were knowledgeable about the evidence of health risks associated with dual alcohol and tobacco use but 57% (13/23) expressed concerns with using the Canadian Cancer Society guidelines to screen for alcohol use. Practitioners acknowledged the value of adding a validated screening tool to the STOP program’s baseline questionnaire (19/23); however, following through with a brief intervention and referral to treatment proved challenging due to lack of training, limited time, and fear of stigmatizing patients. Practitioners in the intervention arm (5/11; 45%) might not follow the recommendations from CDSS if these recommendations are not perceived as beneficial to the patients. Conclusions The results of the study show that practitioners’ beliefs were reflective of the current social norms around alcohol use and this influenced their decision to offer a brief alcohol intervention. Future interventions need to emphasize both organizational and sociocultural factors as part of the design. The results of this study point to the need to change social norms regarding alcohol in order to effectively implement interventions that target both alcohol and tobacco use in primary care clinics. Trial registration ClinicalTrials.gov NCT03108144. Retrospectively registered 11 April 2017, https://www.clinicaltrials.gov/ct2/show/NCT03108144

The barriers and enablers to the integration of a clinical decision support systems into general practice medical software: A narrative review using a systematic approach

“…Passive prompts provide clinical guidance to the GP end-user without requiring any action on their part, while active prompts are automated clinical actions or alerts, which the user must either accept or override to proceed with their work ow (10). CDSS applications include those for the detection and management of cancer, sepsis, acute pain, hypertension, asthma, diabetes, alcohol and tobacco use, antibiotic prescribing, vaccination, medication adverse events, and pregnancy care (4,5,10,11,12,13,14,15,16,17,18,19,20).…”

“…Other identi ed barriers include costs in time and nances associated with the set up and maintenance of CDSS (3,5,28,30,31), lack of information technology (IT) support (10,25,39), challenges around content delivery and maintenance, concerns relating to information quality, risk of litigation, and the potential use of data by third parties (5,14,31,33,34,35,39). CDSS system mechanisms that also impact on end-user satisfaction include poor interface design, limited system exibility and functionality, hardware reliability and computing network issues, software malfunctions, limitations in end-user's IT literacy, and inadequate IT support and training (3,5,10,15,25,28,29,30,31,32,34,35,36,39,40,41).…”

Referring high-risk individuals for lung cancer screening: A systematic review of interventions with healthcare professionals

“…This result is comparable to findings from the wider health literature. For instance, Minian et al (2021) showed that the addition of an electronic prompt positively influenced the proportion of practitioners delivering a brief intervention relating to alcohol use, with 19/23 practitioners acknowledging the value of adding a validated screening tool to the baseline questionnaire. Participants did advise, however, that organisational and sociocultural factors need to be included as part of an electronic prompt design to increase its diagnostic value and reduce redundant alerts (Minian et al , 2021).…”

“…However, this does not come without its challenges. There is a concurrent need for clinician and societal education without which there is a risk of a lack of prompt engagement or prompt fatigue (Brenner et al ., 2017; Minian et al , 2021).…”

The Impact of a Clinical Decision Support System for Addressing Physical Activity and Healthy Eating During Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial

“…We conducted a pragmatic, hybrid type I effectiveness and implementation trial [ 39 ], which allowed for the simultaneous testing of intervention effectiveness and implementation feasibility in real-world settings. Health care practitioners in primary care settings often report barriers to offering comprehensive preventive health services, including not having enough time, skills, knowledge, or resources [ 40 ]. As a result, it is important to examine the effectiveness of the CDSS on patients’ behavior outcomes, as well as how the CDSS impacts health care practitioners’ ability to provide treatment to their patients.…”