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Rosário F, Santos MI, Angus K, Pas L, Ribeiro C, Fitzgerald N. 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; 16:6. [PMID: 33413487 PMCID: PMC7791720 DOI: 10.1186/s13012-020-01073-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 12/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Alcohol is a leading risk factor contributing to the global burden of disease. Several national and international agencies recommend that screening and brief interventions (SBI) should be routinely delivered in primary care settings to reducing patients' alcohol consumption. However, evidence shows that such activities are seldom implemented in practice. A review of the barriers and facilitators mediating implementation, and how they fit with theoretical understandings of behaviour change, to inform the design of implementation interventions is lacking. This study aimed to conduct a theory-informed review of the factors influencing general practitioners' and primary care nurses' routine delivery of alcohol SBI in adults. METHODS A systematic literature search was carried out in four electronic databases (Medline, CINAHL, CENTRAL, PsycINFO) using comprehensive search strategies. Both qualitative and quantitative studies were included. Two authors independently abstracted and thematically grouped the data extracted. The barriers and facilitators identified were mapped to the domains of the Capability-Opportunity-Motivation-Behaviour system/Theoretical Domains Framework (TDF). RESULTS Eighty-four out of the 258 studies identified met the selection criteria. The majority of the studies reported data on the views of general practitioners (n = 60) and used a quantitative design (n = 49). A total of 660 data items pertaining to barriers and 253 data items pertaining to facilitators were extracted and thematically grouped into 46 themes. The themes mapped to at least one of the 14 domains of the TDF. The three TDF domains with the highest number of data units coded were 'Environmental Context and Resources' (n = 158, e.g. lack of time), 'Beliefs about Capabilities' (n = 134, e.g. beliefs about the ability to deliver screening and brief advice and in helping patients to cut down) and 'Skills' (n = 99, e.g. lack of training). CONCLUSIONS This study identified a range of potential barriers and facilitators to the implementation of alcohol SBI delivery in primary care and adds to the scarce body of literature that identifies the barriers and facilitators from a theoretical perspective. Given that alcohol SBI is seldom implemented, this review provides researchers with a tool for designing novel theory-oriented interventions to support the implementation of such activity. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016052681.
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Affiliation(s)
- Frederico Rosário
- Instituto de Medicina Preventiva e Saúde Pública, Faculty of Medicine, Lisbon University, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal. .,Agrupamento de Centros de Saúde Dão Lafões, Av. António José de Almeida - Edíficio MAS, 3514-511, Viseu, Portugal.
| | - Maria Inês Santos
- Hospital Casa de Saúde São Mateus SA, Rua 5 de Outubro 183, 3500-093, Viseu, Portugal
| | - Kathryn Angus
- Institute for Social Marketing & Health (ISMH), Faculty of Health Sciences & Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK
| | - Leo Pas
- Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 33 blok j - box 7001, 3000, Leuven, Belgium
| | - Cristina Ribeiro
- Instituto de Medicina Preventiva e Saúde Pública, Faculty of Medicine, Lisbon University, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Niamh Fitzgerald
- Institute for Social Marketing & Health (ISMH), Faculty of Health Sciences & Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK
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Flentje A, Barger BT, Capriotti MR, Lubensky ME, Tierney M, Obedin-Maliver J, Lunn MR. Screening gender minority people for harmful alcohol use. PLoS One 2020; 15:e0231022. [PMID: 32255781 PMCID: PMC7138294 DOI: 10.1371/journal.pone.0231022] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/13/2020] [Indexed: 01/12/2023] Open
Abstract
This study identifies how to screen for harmful alcohol use among gender minority (e.g., transgender and gender-expansive) people using brief screening methods and identifies which screening methods perform best among gender-expansive, transfeminine, and transmasculine subgroups, as screening recommendations are not currently available. Using 2018 Annual Questionnaire data from The PRIDE Study, area under the curve (AUC) values were compared to identify which screening methods ("4 or more" or "5 or more" drinks on one occasion in the past year, or one or more items from the Alcohol Use Disorders Identification Test [AUDIT]) best predicted (i) harmful alcohol use and (ii) one or more past year alcohol dependence symptoms or consequences. Among 1892 participants, "5 or more" drinks on one occasion (AUC ranges: 0.82-0.86) performed better than "4 or more" drinks (AUC ranges: 0.78-0.81) in predicting harmful drinking. The screening methods "4 or more" drinks, "5 or more" drinks, and the consumption items of the AUDIT (AUDIT-C) using a cutoff score of 3 all maximized sensitivity and specificity to predict alcohol dependence symptoms or consequences in gender minority people overall (AUC: 0.77-0.78). Screening for "5 or more" drinks on one occasion within the past year performed as well as or better than other screening methods to detect both harmful drinking and alcohol dependence-related symptoms or consequences. This single-item screening method can identify if more extensive alcohol use assessment is warranted with gender minority people.
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Affiliation(s)
- Annesa Flentje
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, California, United States of America
- Alliance Health Project, Department of Psychiatry, School of Medicine, University of California, San Francisco, California, United States of America
- The PRIDE Study/PRIDEnet, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Branden T. Barger
- The PRIDE Study/PRIDEnet, School of Medicine, Stanford University, Stanford, California, United States of America
- Office of Diversity and Outreach, University of California, San Francisco, California, United States of America
| | - Matthew R. Capriotti
- Department of Psychology, San Jose State University, San Jose, California, United States of America
| | - Micah E. Lubensky
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, California, United States of America
- The PRIDE Study/PRIDEnet, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Matthew Tierney
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, California, United States of America
| | - Juno Obedin-Maliver
- The PRIDE Study/PRIDEnet, School of Medicine, Stanford University, Stanford, California, United States of America
- Department of Obstetrics and Gynecology, School of Medicine, Stanford University, Stanford, California, United States of America
| | - Mitchell R. Lunn
- The PRIDE Study/PRIDEnet, School of Medicine, Stanford University, Stanford, California, United States of America
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California, United States of America
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White GE, Richardson GA, Mair C, Courcoulas AP, King WC. Do Associations Between Alcohol Use and Alcohol Use Disorder Vary by Weight Status? Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res 2019; 43:1498-1509. [PMID: 31034607 DOI: 10.1111/acer.14071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding whether the associations between alcohol use and alcohol use disorder (AUD) differ by weight status may be useful in screening for AUD in populations where obesity is common. We aimed to determine whether the associations between alcohol use and AUD differ by weight status. METHODS A total of 24,869 adult participants of the National Epidemiologic Survey on Alcohol and Related Conditions-III with a body mass index ≥18.5 kg/m2 who reported past-year alcohol use were included. The AUD and Associated Disabilities Interview Schedule-5 were administered to identify past-year AUD. Logistic regression was used to test the associations between weight status and levels and patterns of alcohol use with AUD; interactions between weight status and alcohol use variables in relation to AUD were examined. Analyses were stratified by gender. RESULTS For males and females, the odds of AUD were higher with greater frequency of any alcohol use and heavy drinking, higher average quantity of drinks per drinking day, and past-year high-risk drinking. Among males, at the same average quantity of drinks per drinking day, frequency of heavy drinking, or presence of high-risk drinking, those with class 3 obesity had higher odds of AUD versus lower classes or no obesity (p for all interactions <0.01). Among females, at the same frequency of any alcohol use, those with healthy weight had the highest odds of AUD, while females with class 3 obesity had the lowest odds of AUD (p for interaction <0.001); interactions between weight status and other alcohol use variables were not significant (p ≥ 0.05). CONCLUSIONS The associations between some measures of alcohol use and AUD differed by weight status, with inconsistent results between males and females. Alcohol use thresholds typically used in AUD screening may be too high in males with class 3 obesity.
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Affiliation(s)
- Gretchen E White
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gale A Richardson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Christina Mair
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Anita P Courcoulas
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Wendy C King
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Lafata JE, Shay LA, Brown R, Street RL. Office-Based Tools and Primary Care Visit Communication, Length, and Preventive Service Delivery. Health Serv Res 2015; 51:728-45. [PMID: 26256283 DOI: 10.1111/1475-6773.12348] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The use of physician office-based tools such as electronic health records (EHRs), health risk appraisal (HRA) instruments, and written patient reminder lists is encouraged to support efficient, high-quality, patient-centered care. We evaluate the association of exam room use of EHRs, HRA instruments, and self-generated written patient reminder lists with patient-physician communication behaviors, recommended preventive health service delivery, and visit length. RESEARCH METHODS Observational study of 485 office visits with 64 primary care physicians practicing in a health system serving the Detroit metropolitan area. Study data were obtained from patient surveys, direct observation, office visit audio-recordings, and automated health system records. Outcome measures included visit length in minutes, patient use of active communication behaviors, physician use of supportive talk and partnership-building communication behaviors, and percentage of delivered guideline-recommended preventive health services for which patients are eligible and due. Simultaneous linear regression models were used to evaluate associations between tool use and outcomes. Adjusted models controlled for patient characteristics, physician characteristics, characteristics of the relationship between the patient and physician, and characteristics of the environment in which the visit took place. RESULTS Prior to adjusting for other factors, visits in which the EHR was used on average were significantly (p < .05) longer (27.6 vs. 23.8 minutes) and contained fewer preventive services for which patients were eligible and due (56.5 percent vs. 62.7 percent) compared to those without EHR use. Patient written reminder lists were also significantly associated with longer visits (30.0 vs. 26.5 minutes), and less use of physician communication behaviors facilitating patient involvement (2.1 vs. 2.6 occurrences), but more use of active patient communication behaviors (4.4 vs. 2.6). Likewise, HRA use was significantly associated with increased preventive services delivery (62.1 percent vs. 57.0 percent). All relationships remained significant (p > .05) in adjusted models with the exception of that between HRA use and preventive service delivery. DISSEMINATION AND IMPLEMENTATION IMPLICATIONS Office-based tools intended to facilitate the implementation of desired primary care practice redesign are associated with both positive and negative cost and quality outcomes. Findings highlight the need for monitoring both intended and unintended consequences of office-based tools commonly used in primary care practice redesign.
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Affiliation(s)
- Jennifer Elston Lafata
- Department of Social and Behavioral Health, School of Medicine, and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA
| | - L Aubree Shay
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, San Antonio, TX
| | - Richard Brown
- Department of Social and Behavioral Health, School of Medicine, and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, TX
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Yip BHK, Chung RY, Chung VCH, Kim J, Chan IWT, Wong MCS, Wong SYS, Griffiths SM. Is Alcohol Use Disorder Identification Test (AUDIT) or its shorter versions more useful to identify risky drinkers in a Chinese population? A diagnostic study. PLoS One 2015; 10:e0117721. [PMID: 25756353 PMCID: PMC4355485 DOI: 10.1371/journal.pone.0117721] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 12/29/2014] [Indexed: 11/30/2022] Open
Abstract
Objective To examine the diagnostic performance of shorter versions of Alcohol Use Disorder Identification Test (AUDIT), including Alcohol Consumption (AUDIT-C), in identifying risky drinkers in primary care settings using conventional performance measures, supplemented by decision curve analysis and reclassification table. Study design and Setting A cross-sectional study of adult males in general outpatient clinics in Hong Kong. The study included only patients who reported at least sometimes drinking alcoholic beverages. Timeline follow back alcohol consumption assessment method was used as the reference standard. A Chinese translated and validated 10-item AUDIT (Ch-AUDIT) was used as a screening tool of risky drinking. Results Of the participants, 21.7% were classified as risky drinkers. AUDIT-C has the best overall performance among the shorter versions of Ch-AUDIT. The AUC of AUDIT-C was comparable to Ch-AUDIT (0.898 vs 0.901, p-value = 0.959). Decision curve analysis revealed that when the threshold probability ranged from 15–30%, the AUDIT-C had a higher net-benefit than all other screens. AUDIT-C improved the reclassification of risky drinking when compared to Ch-AUDIT (net reclassification improvement = 0.167). The optimal cut-off of AUDIT-C was at ≥5. Conclusion Given the rising levels of alcohol consumption in the Chinese regions, this Chinese translated 3-item instrument provides convenient and time-efficient risky drinking screening and may become an increasingly useful tool.
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Affiliation(s)
- Benjamin H. K. Yip
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Roger Y. Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Vincent C. H. Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
- * E-mail:
| | - Jean Kim
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Iris W. T. Chan
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Martin C. S. Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Samuel Y. S. Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Sian M. Griffiths
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China
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Mitchell AJ, Bird V, Rizzo M, Hussain S, Meader N. Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis. Br J Gen Pract 2014; 64:e408-18. [PMID: 24982493 PMCID: PMC4073726 DOI: 10.3399/bjgp14x680497] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 03/25/2014] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There is much interest in ultra-short alcohol screening in primary care that may support brief alcohol interventions. Brief screening consisting of one or two questions might be used alone or in combination with longer tests as recommended by the Primary Care Service Framework. AIM To investigate whether a simple one and two question screening might prove an accurate and acceptable screening method in primary care. DESIGN AND SETTING A systematic literature search, critical appraisal and meta-analysis were conducted. METHOD A comprehensive search identified 61 analyses of single questions to detect alcohol problems including 17 that took place in primary care, using a robust interview standard. Despite focusing alcohol-use disorder in primary care settings, heterogeneity remained high, therefore random effects and bivariate meta-analyses were used. RESULTS After adjustments, diagnostic accuracy of a single-question approach was given by a sensitivity of 54.5% (95% CI = 43.0% to 65.5%) and a specificity of 87.3% (95% CI = 81.5% to 91.5%) using meta-analytic weighting. Two questions had a sensitivity of 87.2% (95% CI = 69.9% to 97.7%) and specificity of 79.8% (95% CI = 75.7% to 83.6%). Looking at each question individually, the most successful single question was a modification of the Single Alcohol Screening Question (SASQ) namely, 'How often do you have six or more drinks on one occasion?'. The optimal approach appears to be two questions followed by the CAGE questionnaire, which achieved an overall accuracy of 90.9% and required only 3.3 questions per attendee. CONCLUSION Two brief questions can be used as an initial screen for alcohol problems but only when combined with a second-step screen. A brief alcohol intervention should be considered in those individuals who answer positively on both steps.
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Affiliation(s)
- Alex J Mitchell
- Leicestershire Partnership NHS Trust and honorary senior lecturer in liaison psychiatry, Department of Cancer and Molecular Medicine, Leicester Royal Infirmary, Leicester
| | - Victoria Bird
- National Collaborating Centre for Mental Health, London
| | - Maria Rizzo
- National Collaborating Centre for Mental Health, London
| | | | - Nick Meader
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research Unit, London and CORE, University College London, Research Department of Clinical, Educational and Health Psychology, London
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Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. Br J Psychiatry 2012; 201:93-100. [PMID: 22859576 DOI: 10.1192/bjp.bp.110.091199] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clinicians have considerable difficulty identifying and helping those people with alcohol problems but no previous study has looked at this systematically. AIMS To determine clinicians' ability to routinely identify broadly defined alcohol problems. METHOD Data were extracted and rated by two authors, according to PRISMA standard and QUADAS criteria. Studies that examined the diagnostic accuracy of clinicians' opinion regarding the presence of alcohol problems as well as their written notation were evaluated. RESULTS A comprehensive search identified 48 studies that looked at the routine ability of clinicians to identify alcohol problems (12 in primary care, 31 in general hospitals and 5 in psychiatric settings). A total of 39 examined alcohol use disorder, 5 alcohol dependence and 4 intoxication. We separated studies into those using self-report and those using interview. The diagnostic sensitivity of primary care physicians (general practitioners) in the identification of alcohol use disorder was 41.7% (95% CI 23.0-61.7) but alcohol problems were recorded correctly in only 27.3% (95% CI 16.9-39.1) of primary care records. Hospital staff identified 52.4% (95% CI 35.9-68.7) of cases and made correct notations in 37.2% (95% CI 28.4-46.4) of case notes. Mental health professionals were able to correctly identify alcohol use disorder in 54.7% (95% CI 16.8-89.6) of cases. There were limited data regarding alcohol dependency and intoxication. Hospital staff were able to detect 41.7% (95% CI 16.5-69.5) of people with alcohol dependency and 89.8% (95% CI 70.4-99.4) of those acutely intoxicated. Specificity data were sparse. CONCLUSIONS Clinicians may consider simple screening methods such as self-report tools rather than relying on unassisted clinical judgement but the added value of screening over and above clinical diagnosis remains unclear.
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Affiliation(s)
- Alex J Mitchell
- Leicester General Hospital, Leicester Partnership Trust, Leicester, UK.
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Chou SP, Chun S, Smith S, Ruan J, Li TK, Grant BF. Episodic heavy drinking, problem drinking and injuries - results of the WHO/NIAAA collaborative emergency room study in South Korea. Alcohol 2012; 46:407-13. [PMID: 22579122 DOI: 10.1016/j.alcohol.2012.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/15/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
Alcohol is the 5th leading risk factor to the global disease burden and disability and about half of the global alcohol burden was attributable to injuries. Despite a large body of evidence documenting the associations between alcohol and injuries, data from Asian countries including South Korea are sparse. The aim of this study was to investigate the associations between episodic heavy past-year drinking, problem drinking symptomatic of alcohol dependence and alcohol-related and intentional injuries. Data from 1989 injured patients recruited for the WHO/NIAAA Collaborative Study on Alcohol and Injury in South Korea were analyzed with respect to the prevalence rates and associations between injuries and frequency of past-year episodic heavy drinking and problem drinking. In estimating the odds ratios (ORs) and the associated 95% confidence intervals between alcohol intake and injuries multivariable logistic models were employed to adjust for sociodemographic characteristics and selected drinking variables. All analyses were conducted using the SAS 9.2 software. Findings of this study were consistent with prior studies that the risk of alcohol-related or intentional injury was positively associated with the frequency of episodic heavy drinking. The magnitudes of the associations were larger with frequent consumption of 5+ drinks (OR=4.0 approximately) than with frequent consumption of 12+ drinks (OR=3.1). Strong associations were also noted between RAPS4-assessed alcohol dependence and alcohol-related and intentional injuries. Further, the prevalence of intentional injury and its association with alcohol increased sharply once the acute alcohol intake exceeded 90 ml. Our results were consistent with prior studies that episodic heavy consumption, acute intoxication and problem drinking are pervasive among emergency room patients. Results of our study also lent support for administering a single-item screener querying consumption of 5+ drinks at a sitting in the past 12 months as a triage tool in Korea.
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Shires DA, Stange KC, Divine G, Ratliff S, Vashi R, Tai-Seale M, Lafata JE. Prioritization of evidence-based preventive health services during periodic health examinations. Am J Prev Med 2012; 42:164-73. [PMID: 22261213 PMCID: PMC3262983 DOI: 10.1016/j.amepre.2011.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 09/20/2011] [Accepted: 10/14/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND Delivery of preventive services sometimes falls short of guideline recommendations. PURPOSE To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs). METHODS Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011. RESULTS Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50-80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient-physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months. CONCLUSIONS A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.
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Affiliation(s)
- Deirdre A Shires
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
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Hamilton MD, Cola PA, Terchek JJ, Werner JJ, Stange KC. A novel protocol for streamlined IRB review of Practice-based Research Network (PBRN) card studies. J Am Board Fam Med 2011; 24:605-9. [PMID: 21900445 PMCID: PMC4331110 DOI: 10.3122/jabfm.2011.05.110034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The "card study," in which clinicians record brief information about patient visits during usual clinical care, has long been a rapid method for conducting descriptive studies in practice-based research networks. Because an increasingly stringent regulatory environment has made conducting card studies difficult, we developed a streamlined method for obtaining card study institutional review board (IRB) approval. METHODS We developed a protocol for a study of the card study method, allowing new card study proposals of specific research questions to be submitted as addenda to the approved Card Study Protocol. RESULTS Seven card studies were proposed and approved under the Card Study Protocol during the first year after implementation, contrasted with one-card study proposed in the previous year. New card study ideas submitted as addenda to an approved protocol appeared to increase IRB comfort with the card study as a minimal risk method while reducing the hurdles to developing new study ideas. CONCLUSIONS A Card Study Protocol allowing new study questions to be submitted as addenda decreases time between idea generation and IRB approval. Shortened turn-around times may be useful for translating ideas into action while reducing regulatory burden.
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Affiliation(s)
- Michelle D Hamilton
- Department of Family Medicine, Research Division, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Nehlin C, Fredriksson A, Jansson L. Brief alcohol screening in a clinical psychiatric population: special attention needed. Drug Alcohol Rev 2011; 31:538-43. [PMID: 21726312 DOI: 10.1111/j.1465-3362.2011.00333.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND AIMS Abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT) and single-item screeners show promising results but have not previously been investigated in a clinical psychiatric setting. The aim of the present study was to investigate the capacity of three brief screening methods to detect hazardous drinking in a psychiatric treatment-seeking population. DESIGN AND METHODS Data were collected from consecutive patients (n = 1811) visiting a general psychiatric clinic. The screening capacity of the heavy episodic drinking (HED) screener, AUDIT item # 3 (AUDIT-3) and the three consumption items of AUDIT (AUDIT-C) was compared to the result of the full 10-item AUDIT with cut-off points 6 for women and 8 for men. RESULTS The HED screener and AUDIT-3 with recommended cut-offs captured low rates of hazardous drinkers when compared to the full AUDIT. Lowering the cut-offs created rates far above those of the full AUDIT. AUDIT-C with recommended cut-off limits categorised nearly the same rates of men as the full AUDIT but much higher rates of women. Raising the cut-off for women approached the detection rate of AUDIT-C closely to that of the full AUDIT. DISCUSSION AND CONCLUSIONS The findings of this study suggest that the HED screener is not sensitive enough in the clinical psychiatric setting. When designing alcohol screening measures to be used all over health-care organisations, special attention should be paid to psychiatric patients. If a somewhat more extensive screening tool is used, the full AUDIT is recommended.
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Affiliation(s)
- Christina Nehlin
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
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Westfall JM, Zittleman L, Staton EW, Parnes B, Smith PC, Niebauer LJ, Fernald DH, Quintela J, Van Vorst RF, Dickinson LM, Pace WD. Card studies for observational research in practice. Ann Fam Med 2011; 9:63-8. [PMID: 21242563 PMCID: PMC3022048 DOI: 10.1370/afm.1199] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODS We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTS Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked. CONCLUSIONS Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.
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Affiliation(s)
- John M Westfall
- Department of Family Medicine, University of Colorado, Denver School of Medicine, Aurora, CO, USA.
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Collaborative depression treatment in older and younger adults with physical illness: pooled comparative analysis of three randomized clinical trials. Am J Geriatr Psychiatry 2010; 18:520-30. [PMID: 20220588 PMCID: PMC2875343 DOI: 10.1097/jgp.0b013e3181cc0350] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There have been few comparisons of the effectiveness of collaborative depression care between older versus younger adults with comorbid illness, particularly among low-income populations. DESIGN Intent-to-treat analyses are conducted on pooled data from three randomized controlled trials that tested collaborative care aimed at improving depression, quality of life, and treatment receipt. SETTINGS Trials were conducted in oncology and primary care safety net clinics and diverse home healthcare programs. PARTICIPANTS Thousand eighty-one patients with major depressive symptoms and cancer, diabetes, or other comorbid illness. INTERVENTION Similar intervention protocols included patient, provider, sociocultural, and organizational adaptations. MEASUREMENTS The Patient Health Questionnaire (PHQ)-9 depression, Short-Form Health Survey-12/20 quality of life, self-reported hospitalization, ER, intensive care unit utilization, and antidepressant, psychotherapy treatment receipt are assessed at baseline, 6, and 12 months. RESULTS There are no significant differences in reducing depression symptoms (p ranged 0.18-0.58), improving quality of life (t = 1.86, df = 669, p = 0.07 for physical functioning at 12 months, and p ranged 0.23-0.99 for all others) patients aged between >/=60 years versus 18-59 years. Both age group intervention patients have significantly higher rates of a 50% PHQ-9 reduction (older: Wald chi[df = 1] = 4.82, p = 0.03; younger: Wald chi[df = 1] = 6.47, p = 0.02), greater reduction in major depression rates (older: Wald chi[df = 1] = 7.72, p = 0.01; younger: Wald chi[df = 1] = 4.0, p = 0.05) than enhanced-usual-care patients at 6 months and no significant age group differences in treatment type or intensity. CONCLUSION Collaborative depression care in individuals with comorbid illness is as effective in reducing depression in older patients as younger patients, including among low-income, minority patients. Patient, provider, and organizational adaptations of depression care management models may contribute to positive outcomes.
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A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department. J Emerg Med 2010; 38:115-21. [DOI: 10.1016/j.jemermed.2007.09.042] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 09/10/2007] [Accepted: 09/12/2007] [Indexed: 11/19/2022]
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Dawson DA, Pulay AJ, Grant BF. A Comparison of Two Single-Item Screeners for Hazardous Drinking and Alcohol Use Disorder. Alcohol Clin Exp Res 2010; 34:364-74. [DOI: 10.1111/j.1530-0277.2009.01098.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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ELL KATHLEEN, KATON WAYNE, CABASSA LEOPOLDOJ, XIE BIN, LEE PEYJIUAN, KAPETANOVIC SUAD, GUTERMAN JEFFRY. Depression and diabetes among low-income Hispanics: design elements of a socioculturally adapted collaborative care model randomized controlled trial. Int J Psychiatry Med 2009; 39:113-32. [PMID: 19860071 PMCID: PMC3387981 DOI: 10.2190/pm.39.2.a] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This article describes design elements of the Multifaceted Depression and Diabetes Program (MDDP) randomized clinical trial. The MDDP trial hypothesizes that a socioculturally adapted collaborative care depression management intervention will reduce depressive symptoms and improve patient adherence to diabetes self-care regimens, glycemic control, and quality-of-life. In addition, baseline data of 387 low-income, 96% Hispanic, enrolled patients with major depression and diabetes are examined to identify study population characteristics consistent with trial design adaptations. METHODS The PHQ-9 depression scale was used to identify patients meeting criteria for major depressive disorder (1 cardinal depression symptom + a PHQ-9 score of > or = 10) from two community safety net clinics. Design elements included sociocultural adaptations in recruitment and efforts to reduce attrition and collaborative depression care management. RESULTS Of 1,803 diabetes patients screened, 30.2% met criteria for major depressive disorder. Of 387 patients enrolled in the clinical trial, 98% had Type 2 diabetes, and 83% had glycated hemoglobin (HbA1c) levels > or = 7%. Study recruitment rates and baseline data analyses identified socioeconomic and clinical factors that support trial design and intervention adaptations. Depression severity was significantly associated with diabetes complications, medical comorbidity, greater anxiety, dysthymia, financial worries, social stress, and poorer quality-of-life. CONCLUSION Low-income Hispanic patients with diabetes experience high prevalence of depressive disorder and depression severity is associated with socioeconomic stressors and clinical severity. Improving depression care management among Hispanic patients in public sector clinics should include intervention components that address self-care of diabetes and socioeconomic stressors.
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Affiliation(s)
| | | | | | - BIN XIE
- University of Southern California, Los Angeles
| | | | | | - JEFFRY GUTERMAN
- University of Southern California, Los Angeles, and Los Angeles County Department of Health Services
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Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ. Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. J Clin Oncol 2008; 26:4488-96. [PMID: 18802161 DOI: 10.1200/jco.2008.16.6371] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the effectiveness of the Alleviating Depression Among Patients With Cancer (ADAPt-C) collaborative care management for major depression or dysthymia. PATIENTS AND METHODS Study patients included 472 low-income, predominantly female Hispanic patients with cancer age >or= 18 years with major depression (49%), dysthymia (5%), or both (46%). Patients were randomly assigned to intervention (n = 242) or enhanced usual care (EUC; n = 230). Intervention patients had access for up to 12 months to a depression clinical specialist (supervised by a psychiatrist) who offered education, structured psychotherapy, and maintenance/relapse prevention support. The psychiatrist prescribed antidepressant medications for patients preferring or assessed to require medication. RESULTS At 12 months, 63% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline as assessed by the Patient Health Questionnaire-9 (PHQ-9) depression scale compared with 50% of EUC patients (odds ratio [OR] = 1.98; 95% CI, 1.16 to 3.38; P = .01). Improvement was also found for 5-point decrease in PHQ-9 score among 72.2% of intervention patients compared with 59.7% of EUC patients (OR = 1.99; 95% CI, 1.14 to 3.50; P = .02). Intervention patients also experienced greater rates of depression treatment (72.3% v 10.4% of EUC patients; P < .0001) and significantly better quality-of-life outcomes, including social/family (adjusted mean difference between groups, 2.7; 95% CI, 1.22 to 4.17; P < .001), emotional (adjusted mean difference, 1.29; 95% CI, 0.26 to 2.22; P = .01), functional (adjusted mean difference, 1.34; 95% CI, 0.08 to 2.59; P = .04), and physical well-being (adjusted mean difference, 2.79; 95% CI, 0.49 to 5.1; P = .02). CONCLUSION ADAPt-C collaborative care is feasible and results in significant reduction in depressive symptoms, improvement in quality of life, and lower pain levels compared with EUC for patients with depressive disorders in a low-income, predominantly Hispanic population in public sector oncology clinics.
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Affiliation(s)
- Kathleen Ell
- School of Social Work and Keck School of Medicine, University of Southern California, Los Angeles, CA 90089-0411, USA.
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Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus 2008; 28:7-30. [PMID: 18077300 DOI: 10.1300/j465v28n03_03] [Citation(s) in RCA: 610] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.
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Finch SA, Lalama C, Spino C, Schwartz HC, Wasserman RC, McCormick MC, Bernstein HH. Practice-based research network solutions to methodological challenges encountered in a national, prospective cohort study of mothers and newborns. Paediatr Perinat Epidemiol 2008; 22:87-98. [PMID: 18173787 DOI: 10.1111/j.1365-3016.2007.00894.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The emergence of practice-based research networks (PBRN) has facilitated the execution of multifaceted community-based studies. As study complexity increases, so does the number of methodological barriers encountered. This paper's goal was to delineate methodological barriers and to evaluate the effectiveness of selected strategies and approaches developed and implemented in allowing a prospective, national PBRN cohort study to succeed in enrolling geographically dispersed mother/healthy term infant dyads (n = 4300) on the day of post-partum discharge. Specific methodological barriers included: (1) obtaining multiple Institutional Review Board (IRB) approvals; (2) gathering longitudinal data from multiple individuals; (3) soliciting multiple perspectives on discharge decision making; and (4) bolstering minority enrolment. The most effective strategies and approaches we employed to address these methodological challenges were: (1) preparing and distributing the 'IRB Packet'; (2) recruiting multiple practices covered by the same IRB; and (3) obtaining supplemental funding for increasing minority enrolment. We expect that other PBRN investigators can benefit from our experience and solutions in the successful conduct of this multifaceted community-based study.
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Affiliation(s)
- Stacia A Finch
- Pediatric Research in Office Settings (PROS), Department of Research, American Academy of Pediatrics, Elk Grove Village, IL, USA
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Brown RL, Dimond AR, Hulisz D, Saunders LA, Bobula JA. Pharmacoepidemiology of potential alcohol-prescription drug interactions among primary care patients with alcohol-use disorders. J Am Pharm Assoc (2003) 2007; 47:135-9. [PMID: 17509999 DOI: 10.1331/xwh7-r0x8-1817-8n2l] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report on the proportion of individuals with alcohol-use disorders who take prescription medications that could interact with alcohol and on the proportion who recall advice to avoid alcohol with their medications. DESIGN Secondary analysis of a randomized controlled trial of telephone counseling. SETTING 18 primary care practices in south-central and southeastern Wisconsin. PATIENTS 897 adults with alcohol-use disorders as identified by systematic survey. INTERVENTION Telephone and mail survey. MAIN OUTCOME MEASURES Patient-reported prescription medication use, potential for alcohol-drug interactions according to DrugDex, and patient-reported receipt of advice not to take alcohol with their medications. RESULTS Of the 869 patients who provided usable information on prescription medication use, 348 (40.0%) were taking medications with alcohol interactions or proscriptions; the most frequently reported were bupropion, selective serotonin reuptake inhibitors, and various acetaminophen-containing compounds. Slightly more than 20% of patients were taking medications with moderate to severe alcohol interactions; over one-third of these 184 patients did not recall advice to avoid alcohol. CONCLUSION Practitioners who prescribe or dispense medications may need to enhance their efforts to advise patients about alcohol-drug interactions. Prescribing and dispensing medications that interact with alcohol present opportunities to administer alcohol screens and interventions.
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Affiliation(s)
- Richard L Brown
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53719, USA.
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Miller PM, Stockdell R, Nemeth L, Feifer C, Jenkins RG, Nietert PJ, Wessell A, Liszka H, Ornstein S. Initial Steps Taken by Nine Primary Care Practices to Implement Alcohol Screening Guidelines with Hypertensive Patients. Subst Abus 2006; 27:61-70. [PMID: 17062546 DOI: 10.1300/j465v27n01_08] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Network's- Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.
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Affiliation(s)
- Peter M Miller
- Center for Drug and Alcohol Programs, Medical University of South Carolina, 67 President St, PO Box 250861, Charleston, SC 29425, USA.
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Agabio R, Nioi M, Serra C, Valle P, Gessa GL. Alcohol use disorders in primary care patients in Cagliari, Italy. Alcohol Alcohol 2006; 41:341-4. [PMID: 16490789 DOI: 10.1093/alcalc/agl010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS To evaluate the number of subjects with possible alcohol use disorders (SPAUD) among primary care patients in Cagliari, Sardinia, Italy, by means of the self-administration of Alcohol use disorder identification test (AUDIT) and CAGE questionnaires. METHODS 939 patients waiting in 10 surgeries of primary care physicians were asked to take part in the study. A sample of 309 women and 197 men (total 506), aged between 18 and 65 years, agreed to participate and completed both questionnaires. SPAUD were defined as those achieving cut-off scores of 5 for AUDIT and/or 1 for CAGE. RESULTS Seventy-nine (15.61%) patients were SPAUD, achieving a positive score in at least one questionnaire. Fifty-six (11.07%) and forty-six (9.09%) patients yielded positive results with AUDIT and CAGE, respectively. Twenty-three (4.55%) patients were positive at both AUDIT and CAGE. Significantly higher proportions of men than women were recorded among SPAUD. CONCLUSIONS The results of the present survey indicate a high number of SPAUD in a sample of primary care settings in Cagliari, closely similar to the occurrence of alcohol use disorders estimated in several other community-based primary care clinics in Western Countries.
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Affiliation(s)
- Roberta Agabio
- Bernard B. Brodie Department of Neuroscience, University of Cagliari, Viale Diaz, 182, I-09126 Cagliari, Italy.
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