The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial) How can we recognize continuous quality improvement? Implementing guidelines to routinely prevent chronic vascular disease in primary care: the Preventive Evidence into Practice cluster randomised controlled trial Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial Physician and patient communication training in primary care: effects on participation and satisfaction. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial Delivery of Brief Interventions for Heavy Drinking in Primary Care: Outcomes of the ODHIN 5-Country Cluster Randomized Trial Randomized controlled trial of a computer strategy to increase general practitioner preventive care. A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study. Effect of Training on Primary Care Residents’ Performance in Brief Alcohol Intervention: A Randomized Controlled Trial Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. Training primary care clinicians in maintenance care for moderated alcohol use Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial. Integration and sustainability of alcohol screening, brief intervention, and pharmacotherapy in primary care settings. Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial. Health promotion in the general practice consultation: a minute makes a difference. Encouraging GPs to undertake screening and a brief intervention in order to reduce problem drinking: a randomized controlled trial. Cost-effectiveness of strategies to market and train primary health care physicians in brief intervention techniques for hazardous alcohol use. Increased Documented Brief Alcohol Interventions With a Performance Measure and Electronic Decision Support Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study. Addressing Alcohol Problems in Primary Care: A Cluster Randomized, Controlled Trial of a Systems Intervention: The Screening and Intervention in Primary Care (SIP) Study Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention. Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial. A Multisite Initiative to Increase the Use of Alcohol Screening and Brief Intervention Through Resident Training and Clinic Systems Changes The cost-effectiveness of tailored, postal feedback on general practitioners' prescribing of pharmacotherapies for alcohol dependence. The impact of behavioral and mental health risk assessments on goal setting in primary care
Background Lifestyle risk factors like smoking , nutrition , alcohol consumption , and physical inactivity ( SNAP ) are the main behavioural risk factors for chronic disease . Primary health care is an appropriate setting to address these risk factors in individuals . Generalist community health nurses ( GCHNs ) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time . The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practice s of GCHNs . Methods The trial used a quasi-experimental design involving four generalist community nursing services in NSW , Australia . The services were r and omly allocated to either an intervention group or control group . Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessment s and interventions . The control group provided usual care .  A sample of 129 GCHNs completed surveys at baseline , 6 and 12 months to examine changes in their practice s and levels of confidence related to the management of SNAP risk factors . Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice . Results Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers . Nurses in the intervention group reported assessing physical activity , weight and nutrition more frequently , as well as providing more brief interventions for physical activity , weight management and smoking cessation . There was little change in referral rates except for an improvement in weight management related referrals . Nurses ’ perception of the importance of ‘ client and system-related ’ barriers to risk factor management diminished over time . Conclusions This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practice s of GCHNs . Barriers to referral remained . The service model needs to be adapted to sustain these changes and enhance referral . Trial registration Background The risk factors for chronic disease , smoking , poor nutrition , hazardous alcohol consumption , physical inactivity and weight ( SNAPW ) are common in primary health care ( PHC ) affording opportunity for preventive interventions . Community nurses are an important component of PHC in Australia . However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice . This study aim ed to address this gap in our knowledge . Methods The study was a quasi-experimental trial involving four generalist community nursing ( CN ) services in New South Wales , Australia . Two services were r and omly allocated to an ‘ early intervention ’ and two to a ‘ late intervention ’ group . Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients . Those in the late intervention group provided usual care for the first 6 months and then received training .  Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected . Data on their SNAPW risk factors , readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline , 3 and 6 months . Analysis compared changes using univariate and multilevel regression techniques . Results 804 participants were recruited from 2361 ( 34.1 % ) eligible clients . The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group ( from 12.9 to 23.3 % and 12.3 to 19.1 % respectively ) as did the proportion who recalled being referred for dietary or physical activity interventions ( from 9.5 to 15.6 % and 5.8 to 21.0 % respectively ) . There was no change in the late intervention group . There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group . Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months . Conclusion The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity , this did not translate into significant changes in lifestyle behaviours or weight . This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses . Trial registration Objective Continuous quality improvement ( CQI ) methods are foundational approaches to improving healthcare delivery . Publications using the term CQI , however , are method ologically heterogeneous , and labels other than CQI are used to signify relevant approaches . St and ards for identifying the use of CQI based on its key method ological features could enable more effective learning across quality improvement ( QI ) efforts . The objective was to identify essential method ological features for recognizing CQI . Design Previous work with a 12-member international expert panel identified reliably abstract ed CQI method ological features . We tested which features met rigorous a priori st and ards as essential features of CQI using a three-phase online modified-Delphi process . Setting Primarily United States and Canada . Participants 119 QI experts r and omly assigned into four on-line panels . Intervention(s ) Participants rated  CQI features and discussed their answers using online , anonymous and asynchronous discussion boards . We analyzed ratings quantitatively and discussion threads qualitatively . Main outcome measure(s ) Panel consensus on definitional CQI features . Results Seventy-nine ( 66 % ) panelists completed the process . Thirty-three completers self-identified as QI research ers , 18 as QI practitioners and 28 as both equally . The features ‘ systematic data guided activities , ’ ‘ design ing with local conditions in mind ’ and ‘ iterative development and testing ’ met a priori st and ards as essential CQI features . Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI . Conclusions We found consensus among a broad group of CQI research ers and practitioners on three features as essential for identifying QI work more specifically as ‘ CQI . ’ All three features are needed as a minimum st and ard for recognizing CQI methods Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease . Setting 32 urban general practice s in 4 Australian states . R and omisation Stratified r and omisation of practice s. Participants 122 general practitioners ( GPs ) and practice nurses ( PNs ) were recruited at baseline and 97 continued to 12 months . 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease , stroke , diabetes , chronic renal disease , cognitive impairment or severe mental illness . Intervention The practice level intervention over 6 months included small group training of practice staff , feedback on audited performance , practice facilitation visits and provision of patient education and referral information . Outcome measures Primary : 1 . Change in proportion of  patients aged 40–69 years  with smoking status , alcohol intake , body mass index ( BMI ) , waist circumference ( WC ) , blood pressure ( BP ) recorded and for those aged 45–69 years with lipids , fasting blood glucose and cardiovascular risk in the medical record . 2 . Change in the level of risk for each factor . Secondary change in self-reported frequency and confidence of GPs and PNs in assessment . Results Risk recording improved in the intervention but not the control group for WC ( OR 2.52 ( 95 % CI 1.30 to 4.91 ) ) , alcohol consumption ( OR 2.19 ( CI 1.04 to 4.64 ) ) , smoking status ( OR 2.24 ( 1.17 to 4.29 ) ) and cardiovascular risk ( OR 1.50 ( 1.04 to 2.18 ) ) . There was no change in recording of BP , lipids , glucose or BMI and no significant change in the level of risk factors based on audit data . The confidence but not reported practice s of GPs and PNs in the intervention group improved in the assessment of some risk factors . Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit . Trial registration number Australian and New Zeal and Clinical Trials Register ( ANZCTR ) : ACTRN12612000578808 , results Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site OBJECTIVE To assess the effects of a communication skills training program for physicians and patients . DESIGN A r and omized experiment to improve physician communication skills was assessed 1 and 6 months after a training intervention ; patient training to be active participants was assessed after 1 month . Across three primary medical care setting s , 156 physicians treating 2,196 patients were r and omly assigned to control group or one of three conditions ( physician , patient , or both trained ) . MAIN OUTCOME MEASURES Patient satisfaction and perceptions of choice , decision-making , information , and lifestyle counseling ; physicians ' satisfaction and stress ; and global ratings of the communication process . RESULTS The following significant ( p < .05 ) effects emerged : physician training improved patients ' satisfaction with information and overall care ; increased willingness to recommend the physician ; increased physicians ' counseling ( as reported by patients ) about weight loss , exercise , and quitting smoking and alcohol ; increased physician satisfaction with physical exam detail ; increased independent ratings of physicians ' sensitive , connected communication with their patients , and decreased physician satisfaction with interpersonal aspects of professional life . Patient training improved physicians ' satisfaction with data collection ; if only physician or patient was trained , physician stress increased and physician satisfaction decreased . CONCLUSION Implication s for improving physician-patient relationship outcomes through communication skills training are discussed Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm . We also examined patient- , physician- , and system-level factors affecting screening rates and , among those who screened positive , rates of brief intervention and referral to treatment . Results Screening rates were highest in the NPP and MA arm ( 51 % ) ; followed by the PCP arm ( 9 % ) and the Control arm ( 3.5 % ) . Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm . The PCP arm had higher brief intervention and referral rates ( 44 % ) among patients screening positive than either the NPP and MA arm ( 3.4 % ) or the Control arm ( 2.7 % ) . Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm . Conclusion Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation . Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models . Trial registration : Clinical Trials PURPOSE We aim ed to test whether 3 strategies — training and support , financial reimbursement , and an option to direct screen-positive patients  to an Internet-based method of giving brief advice — have a longer-term effect on primary care clinicians ’ delivery of screening and advice to heavy drinkers operationalized with the Alcohol Use Disorders Identification Test – Consumption ( AUDIT-C ) tool . METHODS We undertook a cluster r and omized factorial trial with a 12-week implementation period in 120 primary health care units throughout Catalonia , Engl and , Netherl and s , Pol and , and Sweden . Units were r and omized to 8 groups : care as usual ( control ) ; training and support alone ; financial reimbursement alone ; electronic brief advice alone ; paired combinations of these conditions ; and all 3 combined . The primary outcome was the proportion of consulting adult patients ( aged 18 years and older ) receiving intervention — screening and , if screen-positive , advice — at 9 months . RESULTS Based on the factorial design , the ratio of the log of the proportion of patients given intervention at the 9-month follow-up was 1.39 ( 95 % CI , 1.03–1.88 ) in units that received training and support as compared with units that did not . Neither financial reimbursement nor directing screen-positive patients to electronic brief advice led to a higher proportion of patients receiving intervention . CONCLUSIONS Training and support of primary health care units has a lasting , albeit small , impact on the proportion of adult patients given an alcohol intervention at 9 months BACKGROUND Previous interventions targeting primary care practitioners with the aim of increasing preventive care delivery have demonstrated limited effectiveness . The primary aim of this study was to assess the effectiveness of a computerized continuing medical education program to increase rates of three screening behaviors ( cholesterol , blood pressure , and cervical screening ) and to identify three risk behaviors ( smoking , alcohol consumption , benzodiazepine use ) in general practice . METHODS Nineteen general practitioners were r and omly allocated to intervention or control conditions . Those given the intervention received a computerized feedback system . The intervention was delivered using a touch-screen computer located in the surgery waiting area . The preventive behaviors of interest were patient smoking , alcohol use , benzodiazepine use , and blood pressure , cholesterol and cervical screening using the Papanicolou test . Differences in performance by group in each of the outcomes was measured at baseline and 3-month follow-up . Logistic regression analyses with generalized estimating equations were conducted as the main analyses . RESULT At 3-month follow-up , statistically significant differences were evident in the following outcome measures : accurate classification of benzodiazepine users ( z = 2.8540 , P < 0.05 ) ; accurate classification of non-benzodiazepine users ( z = 2.7339 , P < 0.05 ) ; accurate classification of hazardous or harmful alcohol drinkers ( z = 2.3079 , P < 0.02 ) ; blood pressure screening ( z = 3.4136 , P < 0.001 ) ; and cholesterol screening ( z = 6.6313 , P < 0.001 ) . CONCLUSION A computerized system of performance-specific feedback was effective at increasing some preventive care services in general practice OBJECTIVE This study examines the impact of marketing strategies on the dissemination of a brief alcohol intervention program to general practitioners ( GPs ) . The marketing strategy was tested to determine the most effective way to promote awareness about and consideration of a brief alcohol intervention program . The study also examines the impact of training and support strategies to promote the program 's implementation in routine primary care . METHOD A pragmatic trial was carried out in Australia , Belgium ( Fl and ers ) , Denmark , Engl and , New Zeal and and Spain ( Catalonia ) in which GPs were r and omly allocated into one of three marketing conditions ( direct mail , telemarketing and academic detailing [ personal visits ] ) . The GPs who requested a brief intervention program and agreed to use it were stratified by previous marketing condition and r and omly allocated into one of three implementation strategy groups : written guidance , outreach training and outreach training plus ongoing telephone support . RESULTS Acceptance of the brief intervention program was more effective with use of telemarketing ( 65 % ) and academic detailing ( 67 % ) than with direct mail ( 32 % ) for promoting awareness about and consideration of a brief alcohol intervention program . The median proportion of patients screened was higher for trained GPs ( 6 % ) and supported GPs ( 9 % ) than for control GPs ( 1 % ) , who received only written guidance on how to conduct brief intervention . Similarly , the median rate for giving advice to at-risk patients was higher for trained GPs ( 3 % ) and supported GPs ( 3 % ) than for control GPs ( 0 % ) . CONCLUSIONS The adoption of more direct approaches for disseminating evidence -based intervention programs to GPs is a necessary first step for changing practice behavior . However , outreach training was required to promote actual use of a new procedure in routine practice Background Brief alcohol interventions ( BAI ) reduce alcohol use and related problems in primary care patients with hazardous drinking behavior . The effectiveness of teaching BAI on the performance of primary care residents has not been fully evaluated . Methods A cluster r and omized controlled trial was conducted with 26 primary care residents who were r and omized to either an 8-hour , interactive BAI training workshop ( intervention ) or a lipid management workshop ( control ) . During the 6-month period after training ( i.e. , from October 1 , 2003 to March 30 , 2004 ) , 506 hazardous drinkers were identified in primary care , 260 of whom were included in the study . Patients were interviewed immediately and then 3 months after meeting with each resident to evaluate their perceptions of the BAI experience and to document drinking patterns . Results Patients reported that BAI  trained residents : conducted more components of BAI than did controls ( 2.4 vs 1.5 , p = .001 ) ; were more likely to explain safe drinking limits ( 27 % vs 10 % , p = .001 ) and provide feedback on patients ’ alcohol use ( 33 % vs 21 % , p = .03 ) ; and more often sought patient opinions on drinking limits ( 19 % vs 6 % , p = .02 ) . No between-group differences were observed in patient drinking patterns or in use of 9 of the 12 BAI components . Conclusions The  BAI-trained residents did not put a majority of BAI components into practice , thus it is difficult to evaluate the influence of BAI on the reduction of alcohol use among hazardous drinkers AIMS To assess the effect of a tailored multi-faceted improvement programme on  general practitioners ' ( GPs ' ) behaviour towards prevention of hazardous and harmful alcohol consumption . The improvement programme consisted of activities aim ed at the GP , organization and patient . Educational training sessions and visits by a facilitator were tailored to the GPs ' needs and attitudes . DESIGN Cluster r and omized controlled trial . SETTING General practice s in the Netherl and s. PARTICIPANTS Seventy-seven general practice s ; 119 GPs participated . Data from 6318 patients were available , of whom 765 ( 12.1 % ) were at risk . A total of 1502 patients ' electronic medical records were review ed . MEASUREMENTS The primary outcome was the number of eligible patients who received screening and advice .  FINDINGS Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme . Although GPs in both groups became more involved after enrolment , this improvement waned during the trial . The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning ( intervention group ) , compared to our control condition , result ing in average improvement rates of 5 % ( screening ) and 2 % ( advice-giving ) at 12-month follow-up ( not significant ) . CONCLUSIONS A tailored , multi-faceted programme aim ed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement . There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care BACKGROUND Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice . An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines . AIM To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention ( SBI ) by general practitioners ( GPs ) . METHOD Subjects were 128 GPs , one per practice , from the former Northern and Yorkshire Regional Health Authority , who agreed to use the ' Drink-Less ' SBI programme in an earlier dissemination trial . GPs were stratified by previous marketing conditions and r and omly allocated to three intensities of training and support : controls ( n = 43 ) received the programme with written guidelines only , trained GPs ( n = 43 ) received the programme plus practice -based training in programme usage , trained and supported GPs ( n = 42 ) received the programme plus practice -based training and a support telephone call every two weeks . GPs were requested to use the programme for three months . Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with . RESULTS Seventy-three ( 57 % ) GPs implemented the programme and screened 11,007 patients for risk drinking . Trained and supported GPs were significantly more likely to implement the programme ( 71 % ) than controls ( 44 % ) or trained GPs ( 56 % ) ; they also screened , and intervened with , significantly more patients . Costs per patient screened were : trained and supported GPs , 1.05 Pounds ; trained GPs , 1.08 Pounds ; and controls , 1.47 Pounds . Costs per patient intervened with were : trained and supported GPs , 5.43 Pounds ; trained GPs , 6.02 Pounds ; and controls , 8.19 Pounds . CONCLUSION Practice -based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs Abstract OBJECTIVE : To evaluate whether training  primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior . DESIGN : We r and omized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design . The 12 intervention clinicians received a total of 2 1/4 hours of training in the maintenance care of alcohol problems in remission , a booster session , study material s and chart-based prompts at eligible patients ’ visits . Six controls provided usual care . Screening forms in the waiting rooms identified eligible patients , defined as those who endorsed : 1 or more items on the CAGE question naire or that they had an alcohol problem in the past ; that they have ‘ made a change in their drinking and are trying to keep it that way ’ ; and that they drank < 15 ( men ) or < 10 ( women ) drinks per week in the past month . Exit interviews with patients evaluated the clinician ’s actions during the visit . RESULTS : Of the 164 patients , 62 % saw intervention clinicians . Compared with patients of control clinicians , intervention patients were more likely to report that their clinician asked about their alcohol history ( odds ratio , 2.8 ; 95 % confidence interval , 1.3 , 5.8 ) . Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment , assist through offers for prescriptions and treatment referral , and receive higher satisfaction ratings for the visit . CONCLUSIONS : Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians ’ inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry AIM To test if training and support , financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice ( eBI ) can increase primary health-care providers ' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers . DESIGN Cluster r and omized factorial trial with 12-week implementation and measurement period . SETTING Primary health-care units ( PHCU ) in different locations throughout Catalonia , Engl and , the Netherl and s , Pol and and Sweden . PARTICIPANTS A total of 120 PHCU , 24 in each of Catalonia , Engl and , the Netherl and s , Pol and and Sweden . INTERVENTIONS PHCUs were r and omized to one of eight groups : care as usual , training and support ( TS ) , financial reimbursement ( FR ) and eBI ; paired combinations of TS , FR and eBI , and all of FR , TS and eBI . MEASUREMENTS The primary outcome measure was the proportion of eligible adult ( age 18 + years ) patients screened during a 12-week implementation period . Secondary outcome measures were proportion of screen-positive patients advised ; and proportion of consulting adult patients given an intervention ( screening and advice to screen-positives ) during the same 12-week implementation period . FINDINGS During a 4-week baseline measurement period , the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU ( 95 % CI 0.034 to 0.084 ) . Based on the factorial design , the ratio of the logged proportion screened during the 12-week implementation period was 1.48 ( 95 % CI = 1.13 - 1.95 ) in PHCU that received TS versus PHCU that did not receive TS ; for FR , the ratio was 2.00 ( 95 % CI = 1.56 - 2.56 ) . The option of referral to eBI did not lead to a higher proportion of patients screened . The ratio for TS plus FR was 2.34 ( 95 % CI = 1.77 - 3.10 ) , and the ratio for TS plus FR plus eBI was1.68 ( 95 % CI = 1.11 - 2.53 ) . CONCLUSIONS Providing primary health-care units with training , support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption . Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption OBJECTIVE At-risk drinking and alcohol use disorders are common in primary care and may adversely affect the treatment of patients with diabetes and /or hypertension . The purpose of this article is to report the impact of dissemination of a practice -based quality improvement approach ( Practice Partner Research Network-Translating Research into Practice [ PPRNet-TRIP ] ) on alcohol screening , brief intervention for at-risk drinking and alcohol use disorders , and medications for alcohol use disorders in primary care practice s. METHOD Nineteen primary care practice s from 15 states representing 26,005 patients with diabetes and /or hypertension participated in a group-r and omized trial ( early intervention vs. delayed intervention ) . The 12-month intervention consisted of practice site visits for academic detailing and participatory planning and network meetings for " best practice " dissemination . RESULTS At the end of Phase 1 , eligible patients in early-intervention practice s were significantly more likely than patients in delayed-intervention practice s to have been screened ( odds ratio [ OR ] = 3.30 , 95 % CI [ 1.15 , 9.50 ] ) and more likely to have been provided a brief intervention ( OR = 6.58 , 95 % CI [ 1.69 , 25.7 ] . At the end of Phase 2 , patients in delayed-intervention practice s were more likely than at the end of Phase 1 to have been screened ( OR = 5.18 , 95 % CI [ 4.65 , 5.76 ] ) and provided a brief intervention ( OR = 1.80 , 95 % CI [ 1.31 , 2.47 ] ) . Early-intervention practice s maintained their screening and brief intervention performance during Phase 2 . Medication for alcohol use disorders was prescribed infrequently . CONCLUSIONS PPRNet-TRIP is effective in improving and maintaining improvement in alcohol screening and brief intervention for patients with diabetes and /or hypertension in primary care setting This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention ( SBI ) by nurses in primary care . R and omisation was at the level of the practice and the interventions were : written guidelines ( controls , n=76 ) ; outreach training ( n=68 ) ; and training plus telephone-based support ( n=68 ) . After 3 months , just 39 % of controls implemented the SBI programme compared to 74 % of nurses in trained practice s and 71 % in trained and supported practice s. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues . However , there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management . Thus cost-effectiveness ratios ( cost per patient appropriately treated ) were similar between the three strategies . Given the potential for anxiety due to misdirected advice about alcohol-related risk , the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care OBJECTIVE --To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations . DESIGN --Controlled trial of 10 minute appointments . Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate ( median six minutes per patient ) . SETTING --10 general practice s in Nottinghamshire . SUBJECTS--16 general practitioners were recruited . Entry criteria were a booking rate of eight or more patients an hour , a wish for longer consultations , and plans to increase appointment length . MAIN OUTCOME MEASURES -- Duration of consultations ; recording of blood pressure , weight , and cervical cytology in the medical record ; recording of advice about smoking , alcohol , diet , exercise , and immunisation in the medical record ; reporting of the above activities by patients . RESULTS --Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions . Recording of blood pressure , smoking , alcohol consumption , and advice about immunisation was significantly more frequent in the experimental sessions , and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6 % in these sessions . Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions . There was little change in discussion of exercise , diet , and weight or cervical cytology activity . CONCLUSIONS --Shortage of time is a major factor in general practitioners ' failure to realise their potential in health promotion . General practice should be organised so that doctors can run 10 minute appointment sessions BACKGROUND GPs are in a key position to screen the population for problem drinking . However , so far this has not been extensively undertaken in general practice . Thus , studies relating to encouraging the undertaking in general practice of screening and initiating a brief intervention for problem drinking are needed . OBJECTIVES We aim ed to compare three approaches direct mail , telephone contact and academic detailing to encourage GPs to undertake screening and a brief intervention ( SBI ) for problem drinking . METHODS A total of 143 GPs in Copenhagen County were r and omly assigned to the three approaches . The outcome measures were the proportion of GPs who requested the SBI package ( uptake rate ) and the fraction of GPs who started using the package ( utilization rate ) . The costs of each approach were calculated . RESULTS Compared with the direct mailing approach , uptake rates were significantly higher among GPs approached by telephone ( 30 versus 72 % ; P = 0.0001 ) and in the academic detailing approach ( 30 versus 67 % ; P = 0.0006 ) . There was no significant difference between telephone contact and academic detailing ( 72 versus 67 % ; P = 0.75 ) . There was a higher utilization rate in the academic detailing approach than in telephone contact ( 61 versus 31 % ; P = 0.023 ) . There was no significant difference between direct mail and telephone contact ( 57 versus 31 % ; P = 0.16 ) or between direct mail and academic detailing ( 57 versus 61 % ; P = 0.95 ) . The respective costs of the telephone and academic detailing approaches were 10 and 16 times that of the direct mailing approach . CONCLUSION Telephone contact and academic detailing are more effective than direct mail in encouraging GPs to request an SBI package , but GPs who were approached by academic detailing were more likely to have utilized the package than GPs who were approached by telephone . The relatively high uptake and utilization rates obtained in the academic detailing approach suggest that this approach is to be preferred in encouraging a rapid uptake of SBI among GPs . However , the high costs associated with this approach need to be taken into consideration The cost-effectiveness of strategies to market and train primary care physicians in brief intervention for hazardous alcohol consumption was examined . Physicians were r and omly assigned to one of three marketing strategies design ed to promote the " uptake " of a brief intervention package for hazardous and harmful alcohol consumption . The strategies were direct mail , tele-marketing , or academic detailing .  One hundred and twenty-seven of those physicians who requested the package during the marketing phase ( phase 1 ) and who also agreed to participate in the training and support phase of the project ( phase 2 ) were matched into one of three training and support conditions : training and no support , training and minimal support , training and maximal support . An additional 34 physicians were r and omly selected and assigned to a control condition . The ultimate aim of training and support was to maximise physician screening and counselling rates .  Tele-marketing was found to be more cost-effective than academic detailing and direct mail in promoting the uptake of the package . For the training and support phase costs and effects increased with the level of support , hence the issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome Background Alcohol screening and brief interventions ( BIs ) are ranked the third highest US prevention priority , but effective methods of implementing BI into routine care have not been described . Objectives This study evaluated the prevalence of documented BI among Veterans Affairs ( VA ) out patients with alcohol misuse before , during , and after implementation of a national performance measure ( PM )  linked to incentives and dissemination of an electronic clinical reminder ( CR ) for BI . Methods VA out patients were included in this study if they were r and omly sample d for national medical record review s and screened positive for alcohol misuse ( Alcohol Use Disorders Identification Test-Consumption score ≥5 ) between July 2006 and September 2008 ( N=6788 ) . Consistent with the PM , BI was defined as documented advice to reduce or abstain from drinking plus feedback linking drinking to health . The prevalence of BI was evaluated among out patients who screened positive for alcohol misuse during 4 successive phases of BI implementation : baseline year ( n=3504 ) , after announcement ( n=753 ) and implementation ( n=697 ) of the PM , and after CR dissemination ( n=1834 ) , unadjusted and adjusted for patient characteristics . Results Among patients with alcohol misuse , the adjusted prevalence of BI increased significantly over successive phases of BI implementation , from 5.5 % ( 95 % CI 4.1%-7.5 % ) , 7.6 % ( 5.6%-10.3 % ) , 19.1 % ( 15.4%-23.7 % ) , to 29.0 % ( 25.0%-33.4 % ) during the baseline year , after PM announcement , PM implementation , and CR dissemination , respectively ( test for trend P<0.001 ) . Conclusions A national PM supported by dissemination of an electronic CR for BI was associated with meaningful increases in the prevalence of documented brief alcohol interventions AIMS To determine if GPs ' attitudes towards working with drinkers moderated the impact that training and support had on screening and brief intervention activity in routine practice . METHODS Subjects were 340 GPs from four countries who were part of a World Health Organization r and omized controlled trial to evaluate the effectiveness of training and support in increasing screening and brief alcohol intervention . GPs ' self-reported attitudes towards working with drinkers were measured with the Shortened Alcohol and Alcohol Problems Perception Question naire . RESULTS Whereas training and support increased GPs ' screening and brief intervention rates , it did so only for practitioners who already felt secure and committed in working with drinkers . Training and support did not improve attitudes towards working with drinkers and , moreover , worsened the attitudes of those who were already insecure and uncommitted . CONCLUSIONS To enhance the involvement of GPs in the management of alcohol problems , interventions that increase both actual experience and address practitioners ' attitudes is required . Such support could take the form of on-site support agents and facilitators Context Brief interventions can reduce problem drinking , but physicians infrequently use them . Contribution This r and omized trial , from an academic primary care setting , tested whether prompting  physicians with positive alcohol screening results that are linked to specific management recommendations works . Prompted faculty , but not residents , tended to discuss alcohol problems and counsel patients more often than did their counterparts who were not prompted . At 6 months , however , only patients of prompted residents had reduced their drinking . Implication s Prompting physicians with positive alcohol screening results and recommendations for action may or may not be effective , depending on patient , physician , and setting characteristics . The Editors Alcohol use disorders are a leading cause of disability and are as common and costly as coronary artery disease and depression ( 1 - 6 ) . Primary care setting s are ideal for alcohol screening and intervention ( 7 ) . Valid , brief , practical screening tools exist , and brief interventions can reduce drinking and improve health when delivered to primary care patients with alcohol problems ( 8 - 11 ) . However , alcohol problems are often unrecognized and untreated in primary care setting s ( 12 - 16 ) . Barriers to screening and intervention include issues related specifically to addictions ( such as patient readiness and physician discomfort , frustration , lack of confidence or skills , or pessimism about efficacy of intervention ) and issues related to the delivery of preventive services in general ( such as cost , acceptability , priorities , and time ) ( 17 , 18 ) . Physician prompting can improve the likelihood of cancer screening , administration of immunizations , and smoking cessation interventions ( 19 - 21 ) . Screening and intervention for alcohol problems , however , involve more complex assessment and intervention . The effectiveness of providing physicians with screening results and a prompt without training is unknown . Such a systems intervention would be easier and less costly to implement than training all physicians about addressing alcohol problems . We tested the hypotheses that providing physicians with patients ' alcohol screening results and simple individualized recommendations would increase physician alcohol counseling and decrease patient drinking . Methods Study Description The study was a cluster r and omized trial at the physician level because r and omization at the patient level would have risked contamination . The institutional review board of the Boston University Medical Center in Boston , Massachusetts , approved the study . Patients gave informed consent and were told that the physician may be given the results of alcohol screening questions . We obtained a Certificate of Confidentiality from the federal government . Participants Physicians were recruited , enrolled , and r and omly assigned before patients were enrolled . All faculty and resident primary care physicians in an urban academic practice ( excluding the authors ) were eligible . Physicians who had seen fewer than 80 patients in the previous 3 years or who anticipated leaving the practice within 6 months were excluded . We informed physicians that we would conduct a health screening study . We used a self-administered question naire to screen and enroll patients who spoke English or Spanish ( staff were available to assist ) ( 22 ) . This was done before a visit with one of the enrolled physicians . Eligible patients were current hazardous drinkers [ 23 ] , which was defined as having consumed alcohol in the past month and either 1 ) answered yes to one or more of the CAGE ( 24 - 26 ) alcohol screening questions  ( modified to refer to the past year rather than lifetime ) [ 27 ] or 2 ) drank hazardous amounts in the past month ( 28 , 29 ) . Hazardous amounts for men and women , respectively , were defined as more than 4 st and ard drinks per occasion or 14 drinks per week and as more than 3 st and ard drinks per occasion or 7 drinks per week in the past 30 days ( 26 , 30 ) . Assessment s Before patients were enrolled , physicians completed a confidential written survey ( July 1997 ) . They were asked about their attitudes toward patients with addictions ; their professional satisfaction when caring for patients with alcohol problems ; whether they or someone they knew had an alcohol or drug problem ; and other issues related to alcohol and physicians , including the physician 's usual practice s ( 18 ) . A trained staff research er interviewed enrolled patients before and after their visits with a physician ( between February 1998 and August 1999 ) . All questions not available in Spanish ( 31 ) were translated , back-translated , and checked for accuracy . The assessment visit that occurred before the physician visit addressed demographic characteristics , previous counseling for alcohol problems , and readiness to change ( 32 , 33 ) . Patients were also asked about medication use , medical comorbidity ( 34 , 35 ) , psychiatric comorbidity ( 36 , 37 ) , and tobacco and other drug use . Immediately after the physician visit , patients were interviewed to determine whether counseling had occurred , drinking amounts ( 38 , 39 ) , the quality of communication with the physician ( 40 ) , alcohol dependence symptoms ( 41 ) , and alcohol problems ( Short Inventory of Problems [ SIP-2R ] ) ( 42 ) . Six months later , patients were interviewed by telephone to determine alcohol consumption in the past 30 days ; the vali date d Timeline Followback method was used ( 43 ) . Patients and staff research ers were not blinded to group assignment ( in addition , patients were not necessarily given this information ) ; at follow-up , interviews were done without knowledge of group assignment . R and omization and Intervention Physicians were stratified by level of training ( resident or faculty ) and were r and omly assigned to the intervention or control group at the start of the study . The computer-generated r and omization was done by off-site data management personnel who had no patient or physician contact . The staff research er attached the intervention , a sheet of paper , to the encounter record the physician routinely received immediately before each patient visit . One side of the paper provided the patient 's alcohol screening results , a preliminary assessment , and specific recommendations . The screening results included answers to each of the CAGE questions , reports of usual weekly and per occasion maximum drinking amounts , and the patient 's report of readiness to change on a 10-point scale ( 44 ) ( see Appendix Figure ) . For patients reporting hazardous drinking amounts but no affirmative CAGE question naire responses , the assessment was drinking hazardous amounts and the recommendation was consider advising safe drinking limits and consider providing patients with a pamphlet provided by the study titled How to Cut Down on Your Drinking ( 27 ) . For patients reporting any affirmative CAGE responses but no hazardous drinking amounts , the assessment was possible alcohol problems and recommendations were consider advising abstinence , provide the pamphlet , and referral to addiction treatment . For patients reporting affirmative CAGE question naire responses and hazardous drinking amounts , the assessment was both possible alcohol problems and drinking hazardous amounts and recommendations were consider advising abstinence and referral to addiction treatment . The other side of the paper provided the predictive value of CAGE based on the prevalence of alcohol abuse or dependence in the practice ( 26 , 31 ) , definitions of hazardous drinking , an approach for patients who are not ready to change , a list of abuse or dependence symptoms , and referral information . To increase counseling rates ( not for data collection ) , we attached a Post-it note to the encounter form asking physicians to indicate whether alcohol was discussed and , if not , why ( 45 ) . Physicians in the  control  group did not receive any information from the study . Statistical Analysis All analyses were performed by using SAS software , version 8.1 [ SAS Institute , Inc. , Cary , North Carolina ] . The primary prespecified outcomes of the study were the occurrence of physician discussion s regarding alcohol problems during the physicianpatient encounter and a decrease in patient drinking . Patients were asked whether they had 1 ) received alcohol counseling , defined as advice on safe drinking limits , advice to cut down or abstain , or referral to an alcohol specialist or treatment program ; 2 ) received any advice [ including counseling ] ; or 3 ) participated in any discussion about alcohol ( including advice ) . An example question was : Did the doctor give you any advice about your drinking habits ? Drinks per drinking day was the primary drinking outcome . We examined additional measures in secondary analyses : days drinking ( any day on which a drink was taken ) , days binge drinking ( any day on which per occasion amounts noted previously were exceeded ) , proportion drinking hazardous amounts , proportion binge drinking , and proportion abstinent . We compared sociodemographic characteristics , level of training , and mean number of patients enrolled for physicians in the intervention and control groups by using the two independent sample s t-test and the Fisher exact test , as applicable . We then compared patients who were seen by physicians in the intervention and control groups with respect to measured characteristics . We compared patients who were available and unavailable at the 6-month follow-up by r and omized group , physician level of training , and sociodemographic characteristics . Outcomes were compared between physicians in the intervention and control groups by using an intention-to-treat analysis ( physicians were analyzed in the groups to which they were r and omly assigned ) . Generalized estimating equations ( GEE ) were used to adjust for clustering of patients by physician ( PROC GENMOD , SAS software , version 8.1 ) ( 46 ) . For continuous outcomes , we specified the identity link function ; for dichotomous outcomes , we specified the logit link AIMS To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care . DESIGN Two-year r and omized , controlled trial . SETTING / PARTICIPANTS Twenty-one primary care practice s across the United States with a common electronic medical record . INTERVENTION To promote alcohol screening and brief counseling . Intervention practice s received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies . MEASUREMENTS Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking , alcohol abuse or alcohol dependence . Secondary outcomes included change in blood pressure among patients with these diagnoses . FINDINGS Hypertensive patients in intervention practice s were significantly more likely to have been screened after 2 years than hypertensive patients in control practice s [ 64.5 % versus 23.5 % ; adjusted odds ratio ( OR ) = 8.1 ; 95 % confidence interval ( CI ) 1.7 - 38.2 ; P < 0.0087 ] . Patients in intervention practice s diagnosed with high-risk drinking , alcohol abuse or alcohol dependence were more likely than those in control practice s to have had alcohol counseling documented ( 50.5 % versus 29.6 % ; adjusted OR = 5.5 , 95 % CI 1.3 - 23.3 ) . Systolic ( adjusted mean decline = 4.2 mmHg , P = 0.036 ) and diastolic ( adjusted mean decline = 3.3 mmHg , P = 0.006 ) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling . CONCLUSIONS Primary care practice s receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population . Implementation of alcohol counseling for high-risk drinking , alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures BACKGROUND Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care , it is provided suboptimally . PURPOSE To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks . DESIGN Two-group ( intervention versus control ) , non-r and omized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care . SETTING / PARTICIPANTS R and omly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to ( September 2009 - 2010 , n=876 ) and following intervention ( October 2011 - 2012 , n=1,113 ) . INTERVENTION The intervention involved local leadership and consensus processes , electronic medical record system modification , educational meetings and outreach , provision of practice change re sources and support , and performance monitoring and feedback . MAIN OUTCOME MEASURES The primary outcome was differential change in client-reported receipt of three elements of preventive care ( assessment , brief advice , referral/follow-up ) for each of four behavioral risks individually ( smoking , inadequate fruit and vegetable consumption , alcohol overconsumption , physical inactivity ) and combined . Logistic regression assessed intervention effectiveness . RESULTS Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption ( + 23.8 % vs -1.5 % ) ; physical activity ( + 11.1 % vs -0.3 % ) ; all four risks combined ( + 16.9 % vs -1.0 % ) and for brief advice for inadequate fruit and vegetable consumption ( + 19.3 % vs -2.0 % ) ; alcohol overconsumption ( + 14.5 % vs -8.9 % ) ; and all four risks combined ( + 14.3 % vs + 2.2 % ) . The intervention was ineffective in increasing the provision of the remaining forms of preventive care . CONCLUSIONS The intervention 's impact on the provision of preventive care varied by both care element and risk type . Further intervention is required to increase the consistent provision of preventive care , particularly referral/follow-up Purpose Screening and brief intervention ( SBI ) is a seldom-used evidence -based practice for reducing unhealthy alcohol use among primary care patients . This project assessed the effectiveness of a regional consortium ’s training efforts in increasing alcohol SBI . Method Investigators combined alcohol SBI residency training efforts with clinic SBI implementation processes and used chart review s to assess impact on SBI rates in four residency clinics . Data were derived from a r and om sample of patient charts collected before ( 2010 ; n = 662 ) and after ( 2011 ; n = 656 ) resident training/clinic implementation . Patient charts were examined for evidence that patients were asked about alcohol use by a vali date d screening instrument , the screening result ( positive or negative ) , evidence that patients received a brief intervention , prescriptions for medications to assist abstinence , and referrals to alcohol treatment . Chi-square analyses identified differences in pre- and posttraining implementation of SBI practice s. Results Following program implementation , screening with vali date d instruments increased from 151/662 ( 22.8 % ) at baseline to 543/656 ( 82.8 % , P < .01 ) , and identification of unhealthy alcohol use increased from 12/662 ( 1.8 % ) to 41/656 ( 6.3 % , P < .01 ) . Performance of brief interventions more than doubled ( 10/662 [ 1.5 % ] versus 24/656 [ 3.7 % ] , P < .01 ) . There were no increases in the use of medications or referrals to treatment . Conclusions Resident training combined with clinic implementation efforts can increase the delivery of evidence -based practice s such as alcohol SBI in residency clinics AIMS The aims of this study were to conduct a r and omised controlled trial to evaluate the cost-effectiveness of tailored , postal feedback on general practitioners ' ( GPs ) prescribing of acamprosate and naltrexone for alcohol dependence relative to current practice and its impact on alcohol dependence morbidity . METHODS Rural communities in New South Wales , Australia , were r and omised into experimental ( N=10 ) and control ( N=10 ) communities .  Tailored feedback on their prescribing of alcohol pharmacotherapies was mailed to GPs from the experimental communities ( N=115 ) .  Segmented regression analysis was used to examine within and between group changes in prescribing and alcohol dependence hospitalisation rates compared to the control communities . Incremental cost-effectiveness ratios ( ICERs ) were estimated per additional prescription of pharmacotherapies and per alcohol dependence hospitalisation(s ) averted . RESULTS Post-intervention changes , relative to the control communities , in GPs ' prescribing rate trends in the experimental communities significantly increased for acamprosate ( β=0.24 , 95 % CI : 0.13 - 0.35 , p<0.001 ) , and significantly decreased for naltrexone ( β = -0.12 , 95 % CI : -0.17 to -0.06 ) per quarter . Quarterly hospitalisation trend rates for alcohol dependence , as principal diagnosis , significantly decreased ( β=-0.07 , 95 % CI : -0.13 to -0.01 , p<0.05 ) , compared to control communities . The median ICER per quarterly hospitalisation(s ) averted due to intervention was dominant ( dominant--$12,750 ) . CONCLUSION Postal , tailored feedback to GPs on their prescribing of acamprosate and naltrexone for alcohol dependence was a cost-effective intervention , in rural communities of NSW , to increase the overall prescribing of pharmacotherapies with a plausible effect on incidence reduction of hospitalisations for alcohol dependence as principal diagnosis Patient-centered health risk assessment s ( HRAs ) that screen for unhealthy behaviors , prioritize concerns , and provide feedback may improve counseling , goal setting , and health . To evaluate the effectiveness of routinely administering a patient-centered HRA , My Own Health Report , for diet , exercise , smoking , alcohol , drug use , stress , depression , anxiety , and sleep , 18 primary care practice s were r and omized to ask patients to complete My Own Health Report ( MOHR ) before an office visit ( intervention ) or continue usual care ( control ) .  Intervention practice patients were more likely than  control practice patients to be asked about each of eight risks ( range of differences 5.3–15.8 % , p < 0.001 ) , set goals for six risks ( range of differences 3.8–16.6 % , p < 0.01 ) , and improve five risks ( range of differences 5.4–13.6 % , p < 0.01 ) . Compared to controls , intervention patients felt clinicians cared more for them and showed more interest in their concerns .  Patient-centered health risk assessment s improve screening and goal setting .Trial Registration Clinical trials.gov identifier :
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 design ed to enable services to detect barriers , then devise and implement changes , result ing in service improvements .
We investigate the extent to which the three essential elements of CQI are being used ( data -guided activities , considering local conditions ; iterative development ) .