BACKGROUND AND AIMS: Screening and brief interventions (SBI) delivered in primary health care (PHC) are cost-effective in decreasing alcohol consumption; however, they are underused. This study aims to identify implementation strategies that focus on SBI uptake and measure impact on: 1) heavy drinking; and 2) delivery of SBI in PHC.
METHODS: Meta-analysis was conducted of controlled trials of SBI implementation strategies in PHC to reduce heavy drinking. Key outcomes included alcohol consumption, screening, brief interventions and costs in PHC. Predictor measures concerned single versus multiple strategies, type of strategy, duration and physician-only input versus that including mid-level professionals. Standardised mean differences (SMD) were calculated to indicate the impact of implementation strategies on key outcomes. Effect sizes were aggregated using meta-regression models.
RESULTS: The 29 included studies were of moderate methodological quality. Strategies had no overall impact on patients' reported alcohol consumption (SMD 0.07;95%-CI -0.02-0.16), despite improving screening (SMD 0.53;95%-CI 0.28-0.78) and brief intervention delivery (SMD 0.64;95%-CI 0.27-1.02). Multifaceted strategies, i.e. professional and/or organisational and/or patient oriented strategies, seemed to have strongest effects on patients' alcohol consumption (p<0.05, compared with professional oriented strategies alone). Regarding SBI delivery, combining professional with patient oriented implementation strategies had the highest impact (p<0.05). Involving other staff besides physicians was beneficial for screening (p<0.05).
CONCLUSIONS: To increase delivery of alcohol screening and brief interventions and decrease patients' alcohol consumption, implementation strategies should include a combination of patient, professional and organisational oriented approaches and involve mid-level health professionals as well as physicians. This article is protected by copyright. All rights reserved.
OBJECTIVES: A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.
METHODS: The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.
RESULTS: Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence.
CONCLUSION: Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.
BACKGROUND: Audit and feedback (A&F) has long been used to improve quality of care, albeit with variable results. This meta-analytic study tested whether Feedback Intervention Theory, a framework from industrial/organizational psychology, explains the observed variability in health care A&F research.
METHOD: None
DATA SOURCE: studies cited by Jamtvedt's 2006 Cochrane systematic review of A&F, followed by database searches using the Cochrane review's search strategy to identify more recent studies.
INCLUSION CRITERIA: Cochrane review criteria, plus: presence of a treatment group receiving only A & F; a control group receiving no intervention; a quantitatively measurable outcome; minimum n of 10 per arm; sufficient statistics for effect size calculations. Moderators: presence of discouragement and praise; correct solution, attainment level, velocity, frequency, and normative information; feedback format (verbal, textual, graphic, public, computerized, group vs. individual); goal setting activity.
PROCEDURE: meta-analytic procedures using the Hedges-Olkin method.
RESULTS: Of 519 studies initially identified, 19 met all inclusion criteria. Studies were most often excluded due to the lack of a feedback-only arm. A&F has a modest, though significant positive effect on quality outcomes (d = 0.40, 95% confidence interval = +/-0.20); providing specific suggestions for improvement, written, and more frequent feedback strengthened this effect, whereas graphical and verbal feedback attenuated this effect.
CONCLUSIONS: A&F effectiveness is improved when feedback is delivered with specific suggestions for improvement, in writing, and frequently. Other feedback characteristics could also potentially improve effectiveness; however, research with stricter experimental controls is needed to identify the specific feedback characteristics that maximize its effectiveness.
OBJECTIVES: To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit. DATA SOURCES: We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information. STUDY SELECTION: We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes. DATA EXTRACTION: Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes. DATA SYNTHESIS: One hundred studies met our inclusion criteria. The number and methodologic quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P = .02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P = .001). CONCLUSIONS: Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
A systematic review was undertaken of studies that test the effectiveness of different strategies used to increase general practitioners' rates of screening for and giving advice about hazardous and harmful alcohol consumption. Resources were MEDLINE, EMBASE, Cinahl and the Cochrane Library. Inclusion criteria were those of the Effective Practice and Organisation of Care Group of the Cochrane Collaboration. A meta-analysis was undertaken, using a random effects model, of 15 programs identified in 12 trials. Effect sizes, calculated using the logged odds ratio, were adjusted by inverse variance weights to control for the sample sizes of the studies. In the results, analysis of the intervention groups resulted in screening and advice-giving rates of 45% and analysis of the comparison groups resulted in rates of 32%. The weighted mean effect size was heterogeneous. It was concluded that although the small numbers of programs studied suggest caution be used in interpreting the results, it seems it is possible to increase the engagement of general practitioners in screening and giving advice for hazardous and harmful alcohol consumption. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Screening and brief interventions (SBI) delivered in primary health care (PHC) are cost-effective in decreasing alcohol consumption; however, they are underused. This study aims to identify implementation strategies that focus on SBI uptake and measure impact on: 1) heavy drinking; and 2) delivery of SBI in PHC.
METHODS:
Meta-analysis was conducted of controlled trials of SBI implementation strategies in PHC to reduce heavy drinking. Key outcomes included alcohol consumption, screening, brief interventions and costs in PHC. Predictor measures concerned single versus multiple strategies, type of strategy, duration and physician-only input versus that including mid-level professionals. Standardised mean differences (SMD) were calculated to indicate the impact of implementation strategies on key outcomes. Effect sizes were aggregated using meta-regression models.
RESULTS:
The 29 included studies were of moderate methodological quality. Strategies had no overall impact on patients' reported alcohol consumption (SMD 0.07;95%-CI -0.02-0.16), despite improving screening (SMD 0.53;95%-CI 0.28-0.78) and brief intervention delivery (SMD 0.64;95%-CI 0.27-1.02). Multifaceted strategies, i.e. professional and/or organisational and/or patient oriented strategies, seemed to have strongest effects on patients' alcohol consumption (p<0.05, compared with professional oriented strategies alone). Regarding SBI delivery, combining professional with patient oriented implementation strategies had the highest impact (p<0.05). Involving other staff besides physicians was beneficial for screening (p<0.05).
CONCLUSIONS:
To increase delivery of alcohol screening and brief interventions and decrease patients' alcohol consumption, implementation strategies should include a combination of patient, professional and organisational oriented approaches and involve mid-level health professionals as well as physicians. This article is protected by copyright. All rights reserved.
