Delivery of Brief Interventions for Heavy Drinking in Primary Care: Outcomes of the ODHIN 5-Country Cluster Randomized Trial

We congratulate Professor Anderson and colleagues on their latest publication from this important study [1]. Saitz and Daaleman's editorial highlights the substantial treatment gap that persists across multiple substance use disorders in the USA [2], and in relation to excessive alcohol consumption at least, this is a global problem [3]. For health providers seeking to address this translational divide, the findings from the ODHIN trial provide valuable evidence of which implementation strategies are likely to be most effective in encouraging health professionals to screen their patients for heavy drinking over the longer term. The take-home message builds on a growing body of research underlining the need for adequate training provision to facilitate improved rates of alcohol prevention activity in primary healthcare.

At the same time, and as the authors themselves acknowledge, the absolute impact of training and support on rates of patients screened was small, despite the fact that the participating practices may have been somewhat more motivated to engage with alcohol prevention activities than the general primary care population. Again this echoes previous research showing that training initiatives implemented even at national level have resulted in relatively modest progress towards the aim of routine adoption of alcohol interventions [4]. Thus whilst improved training provision is undoubtedly part of the solution, a successful recipe for scale-up will require additional ingredients. We offer our thoughts below on what future research and policy initiatives in this area might consider.

Sustainable approaches to financing the treatment and prevention of heavy drinking in primary healthcare: The results from the ODHIN trial confirm the limitations of using short term financial incentives to stimulate long term behaviour change in healthcare: an issue not limited to alcohol prevention [5]. Yet inadequate financial support for the prevention of heavy drinking remains a prime barrier to implementation. As such there is a clear need to devise and evaluate alternative approaches to financing screening and brief interventions, such as enhanced core provision in public health budgets, or incentives linked to real patient outcomes rather than process measures.

Moving beyond provider-level implementation strategies: Focussing on providers - or even practices - alone is a further potential limitation of the ODHIN approach. Successful implementation of health interventions within complex health system demands we tackle the underlying structural and support systems that shape their delivery. Future programmes should draw on the lessons learned from Phase IV of the WHO study [6] and the US- based SAMHSA SBIRT initiative [7], and include measures to improve the wider social and political context alongside those focussed at individual health professionals. At the other end of the scale, there is also increasing awareness that the patient perspective on alcohol prevention in routine healthcare has been very much missing from the evidence base to date [8]. We would also urge that more attention is paid to their views on, and experiences of, screening and brief alcohol interventions in future research.

Embed evaluations in policy programmes from the outset: Finally, even where there have been more sustained - and arguably more successful - programmes of reimbursement to encourage alcohol intervention delivery, there is limited robust evaluative evidence to allow us to accurately assess impact [9]. Future policy makers should be encouraged to build in measures from the outset to help capture the cost- and clinical effectiveness of alcohol interventions delivered in real-world settings. Routine electronic health data could play an important role in facilitating this objective but systems, standards and outcome measures need to be harmonised.

References

1. Anderson, P., et al., Delivery of Brief Interventions for Heavy Drinking in Primary Care: Outcomes of the ODHIN 5-Country Cluster Randomized Trial. The Annals of Family Medicine, 2017. 15(4): p. 335-340.

2. Saitz, R. and T.P. Daaleman, Now is the Time to Address Substance Use Disorders in Primary Care. The Annals of Family Medicine, 2017. 15(4): p. 306-308.

3. Rehm, J., et al., People with Alcohol Use Disorders in Specialized Care in Eight Different European Countries. Alcohol and Alcoholism, 2015. 50(3): p. 310-318.

4. Fitzgerald, N., et al., Alcohol brief interventions practice following training for multidisciplinary health and social care teams: A qualitative interview study. Drug and Alcohol Review, 2015. 34: p. 185- 193.

5. Campbell, S.M., et al., Effects of Pay for Performance on the Quality of Primary Care in England. New England Journal of Medicine, 2009. 361(4): p. 368-378.

6. Heather, N., WHO Collaborative Project on Identification and Management of Alcohol-related Problems in Primary Health Care - Report to the World Health Organisation on Phase IV: Development of Country-wide Strategies for Implementing Early Identification and Brief Intervention in Primary Health Care. . 2006, World Health Organisation, Department of Mental Health and Substance Abuse: Geneva.

7. Babor, T.F., F. Del Boca, and J.W. Bray, Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice. Addiction, 2017. 112: p. 110-117.

8. Ducharme, L.J., R.K. Chandler, and A.H.S. Harris, Implementing Effective Substance Abuse Treatments in General Medical Settings: Mapping the Research Terrain. Journal of Substance Abuse Treatment, 2016. 60: p. 110-118.

9. Scholin, L., A. O'Donnell, and N. Fitzgerald, Financial incentives for Alcohol Brief Interventions in Primary Care in Scotland. 2017, University of Stirling & Newcastle University for Scottish Health Action on Alcohol Problems: Edinburgh, Scotland.

Competing interests: None declared