SIPS in primary health care: extending the existing evidence base Professor Eileen Kaner

Aim of the PHC trial 1. To identify the most efficient and acceptable screening approach and tool to detect hazardous and harmful drinking in routine primary care 2. and also evaluate the clinical impact and cost effectiveness of different models of BI.

Objectives To conduct a pragmatic cRCT of SBI in primary care in three English regions To conduct a pragmatic cRCT of SBI in primary care in three English regions To identify the optimal method and tool for alcohol screening in routine primary care To identify the optimal method and tool for alcohol screening in routine primary care To compare the (cost)effectiveness of different models of brief intervention with a control condition To compare the (cost)effectiveness of different models of brief intervention with a control condition To assess the uptake and use (implementation) of different SBI approaches by PHC clinicians To assess the uptake and use (implementation) of different SBI approaches by PHC clinicians To identify practitioner and system factors that predict successful implementation of SBI. To identify practitioner and system factors that predict successful implementation of SBI.

Screening issues 1. Approaches Universal screening: all patientsUniversal screening: all patients Targeted screening: key contexts/conditionsTargeted screening: key contexts/conditions 2. Tools FAST alcohol screening test (FAST)FAST alcohol screening test (FAST) Single alcohol screening questionnaire (SASQ)Single alcohol screening questionnaire (SASQ)

Brief interventions Condition 1Control - Patient Information Leaflet (PIL) Condition 1Control - Patient Information Leaflet (PIL) Condition 2Structured advice Condition 2Structured advice (+ PIL) 5 mins Condition 3Behaviour change counseling (+PIL + Structured Advice) – 20 mins Condition 3Behaviour change counseling (+PIL + Structured Advice) – 20 mins

Design 2 x 2 x 3

How will we assess effectiveness? Patient outcome measures Patient outcome measures Alcohol consumption – extended AUDITAlcohol consumption – extended AUDIT Alcohol related problems –APQAlcohol related problems –APQ Health related quality of life – EQ5DHealth related quality of life – EQ5D Health & wider societal costs - SUQHealth & wider societal costs - SUQ Motivational state – Readiness rulerMotivational state – Readiness ruler

Flow chart

How will we assess implementation? Ease of recruitment – speed, help needed Ease of recruitment – speed, help needed Screen conversion rates Screen conversion rates Factors supporting implementation Factors supporting implementation Factors impeding implementation Factors impeding implementation Acceptability to practitioners Acceptability to practitioners

Quantitative & qualitative process measures? Before/after questionnaire covering attitudes (sAAPPQ) Before/after questionnaire covering attitudes (sAAPPQ) Qualitative interviews with staff once recruitment is closed Qualitative interviews with staff once recruitment is closed Trial conditionsTrial conditions High and low performersHigh and low performers

Findings Outcomes not currently available Outcomes not currently available Some pilot work on targeting Some pilot work on targeting Recruitment – implementation clues Recruitment – implementation clues Experiences in training Experiences in training Early attitudinal data Early attitudinal data Before = baseline – but after trainingBefore = baseline – but after training After = follow-up - post interventionAfter = follow-up - post intervention

Pilot work Literature unclear on the best way to target in PHC Literature unclear on the best way to target in PHC We developed a short questionnaire to ask practitioners’ views We developed a short questionnaire to ask practitioners’ views Distributed to all 24 recruited practicesDistributed to all 24 recruited practices 190 questionnaires sent out190 questionnaires sent out 111 completed – 58%111 completed – 58% GPs (70%), nurses (17%), other (13%)GPs (70%), nurses (17%), other (13%)

Findings on targeting approach How is screening best achieved? How is screening best achieved? Universal 19%Universal 19% Targeted 68%Targeted 68% How should targeting occur? How should targeting occur? Key conditions 55%Key conditions 55% Key contexts 30%Key contexts 30% Both 15%Both 15%

Targeting – extremely &/or important Key conditions Key conditions Mental health 87% Mental health 87% Gastrointestinal 77% Gastrointestinal 77% Hypertension 72% Hypertension 72% Accidents/trauma 63% Accidents/trauma 63% Other 32% Other 32% DiabetesDiabetes Abnormal bloodsAbnormal bloods Substance useSubstance use Sexual healthSexual health Key contexts Key contexts New patients 83% New patients 83% Chronic diseases 68% Chronic diseases 68% Minor injuries 61% Minor injuries 61% Smoking clinics 57% Smoking clinics 57% Sexual health 55% Sexual health 55% Other 11% Other 11% A&E referral Social problems Well person clinic Sickness certification

Targeting strategy Hypertension Hypertension Mental health problems Mental health problems Gastrointestinal problems Gastrointestinal problems Injuries/minor trauma Injuries/minor trauma And new patient registrations And new patient registrations But in universal arm we record presenting condition so we will have data to inform future targeting if this is the best screening strategy But in universal arm we record presenting condition so we will have data to inform future targeting if this is the best screening strategy

Overall PHC recruitment No. approached = 3562 No. eligible = 2991 (84%) No. screen positive = 900 (30%) No. consented to trial = 755 (84%)

Recruitment to conditions USASQ1 61 USASQ1 61 USASQ2 62 USASQ2 62 USASQ3 63 USASQ3 63 UFAST1 62 UFAST1 62 UFAST2 64 UFAST2 64 UFAST3 63 UFAST3 63 TSASQ1 64 TSASQ1 64 TSASQ2 63 TSASQ2 63 TSASQ3 61 TSASQ3 61 TFAST1 65 TFAST1 65 TFAST2 62 TFAST2 62 TFAST3 65 TFAST3 65 Total number of patients recruited = 755

Differential recruitment? No differences between conditions (of those approached): Condition 1:18% consented Condition 1:18% consented Condition 2: 22% consented Condition 2: 22% consented Condition 3: 24% consented Condition 3: 24% consented Difference in screening strategy Universal: 18% consented Universal: 18% consented Targeting: 25% consented Targeting: 25% consented

About a third of practices needed help to complete recruitment

Attitudes of staff (5-point scale, 5 = very useful/appropriate) How useful to offer screening: How useful to offer screening: Mean score: 4.3 (before) 4.4 (after) Mean score: 4.3 (before) 4.4 (after) How useful to offer BI How useful to offer BI Mean score: 4.2 (before) 4.2 (after) Mean score: 4.2 (before) 4.2 (after) How appropriate to manage AUD How appropriate to manage AUD Mean score: 4.0 (before) 4.9 (after) Mean score: 4.0 (before) 4.9 (after)

Barriers similar across the 3 questions and at both time points Limited time in consultations Limited time in consultations Lack of skills/expertise & confidence Lack of skills/expertise & confidence Patient honesty (screening) Patient honesty (screening) Patients unwilling to engage (BI) Patients unwilling to engage (BI) Lack of local resources – referral Lack of local resources – referral

How can SBI be made more appealing Increased advertising of SBI Increased advertising of SBI Explain positive outcomes & advantages Explain positive outcomes & advantages Easy accessible leaflets Easy accessible leaflets Make it routine – normalise approach Make it routine – normalise approach Universal screening – reduce stigma Universal screening – reduce stigma Reward practices Reward practices Special clinic time - appointment Special clinic time - appointment Dedicated health care worker – with time Dedicated health care worker – with time Continuity of care – AHW & GP in PHC Continuity of care – AHW & GP in PHC Offer continuing support Offer continuing support

Conclusions Practitioners prefer targeted screening Practitioners prefer targeted screening Recruitment successful Recruitment successful But 1/3 practices needed AHW input But 1/3 practices needed AHW input Mostly positive attitudes to SBI Mostly positive attitudes to SBI Trial participants are self-selected Trial participants are self-selected Trial outcome data due May 2010 (6 months) Trial outcome data due May 2010 (6 months) Screening outcomes due sooner Screening outcomes due sooner

Questions on the PHC trial