GPs' role security and therapeutic commitment in managing alcohol problems: a randomised controlled trial of a tailored improvement programme.

BACKGROUND: General practitioners with more positive role security and therapeutic commitment towards patients with hazardous or harmful alcohol consumption are more involved and manage more alcohol-related problems than others. In this study we evaluated the effects of our tailored multi-faceted improvement implementation programme on GPs' role security and therapeutic commitment and, in addition, which professional related factors influenced the impact of the implementation programme. METHODS: In a cluster randomised controlled trial, 124 GPs from 82 Dutch general practices were randomised to either the intervention or control group. The tailored, multi-faceted programme included combined physician, organisation, and patient directed alcohol-specific implementation strategies to increase role security and therapeutic commitment in GPs. The control group was mailed the national guideline and patients received feedback letters. Questionnaires were completed before and 12 months after start of the programme. We performed linear multilevel regression analysis to evaluate effects of the implementation programme. RESULTS: Participating GPs were predominantly male (63%) and had received very low levels of alcohol related education before start of the study (0.4 h). The programme increased therapeutic commitment (p = 0.005; 95%-CI 0.13 - 0.73) but not role security (p = 0.58; 95%-CI -0.31 - 0.54). How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs' reported proportion of patients asked about alcohol consumption at baseline, contributed to the effect of the programme on therapeutic commitment. CONCLUSIONS: A tailored, multi-faceted programme aimed at improving GP management of patients with hazardous and harmful alcohol consumption improved GPs' therapeutic commitment towards patients with alcohol-related problems, but failed to improve GPs' role security. How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs' reported proportion of patients asked about alcohol consumption at baseline, both increased the impact of the programme on therapeutic commitment. It might be worthwhile to monitor proceeding of role security and therapeutic commitment throughout the year after the implementation programme, to see whether the programme is effective on short term but faded out on the longer term. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00298220.

A randomized controlled trial of a tailored primary care program to reverse excessive alcohol consumption.

OBJECTIVES: To assess the effects of a tailored, multifaceted intervention in primary care on the level of patients' alcohol consumption and to investigate which patient and organizational factors determine a reduction in alcohol consumption. METHODS: This was a cluster randomized, controlled trial conducted among primary care practices in The Netherlands. Data from 6318 patients were available, of whom 712 patients from 70 practices were hazardous or harmful alcohol users. The improvement (intervention) program combined professional, organizational, and patient-directed activities. The emphasis was on educational training for general practitioners and support visits by a trained facilitator, tailored to the participants' needs and attitudes. The primary outcome was the proportion of patients with hazardous or harmful alcohol consumption, as measured with the Alcohol Use Disorders Identification Test, who reduced their levels of alcohol consumption to low-risk levels after 2 years. RESULTS: Of the hazardous and harmful alcohol users, a substantial proportion (41.6%) reduced their alcohol consumption to a low-risk level. The trial revealed a significant difference in favor of the control group: 35.5% of the patients with hazardous and harmful alcohol consumption in general practitioners' practices in the intervention group and 47.0% of this patient group in general practitioners' practices in the control group reduced their alcohol consumption to a low-risk level (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.43-0.90). Older age (OR, 1.02; 95% CI, 1.01-1.03), female sex (OR, 2.00; 95% CI, 1.26-3.19), and attitudes toward alcohol use seemed to be the most important predictors for the reduction of alcohol use to a low-risk level. Patients who considered it important to reduce alcohol consumption and patients who believed that less alcohol complicates relaxation were less likely to reduce their alcohol use to a low-risk level (OR, 0.39; 95% CI, 0.19-0.80 and OR, 0.58; 95% CI, 0.37-0.90, respectively). Characteristics of the general practices, however, were not associated with reduced alcohol use. CONCLUSIONS: Our results suggest that the intervention has been counterproductive because the proportion of patients reducing their levels of alcohol consumption to low-risk levels was lower in the intervention group compared with the control group. Furthermore, our study demonstrated that patients' attitudes toward alcohol use are an important determinant of the success of the program. Therefore, future research should focus on the effectiveness of methods to change patients' attitudes.

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme.

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 aimed at the GP, organization and patient. Educational training sessions and visits by a facilitator were tailored to the GPs' needs and attitudes. DESIGN: Cluster randomized controlled trial. SETTING: General practices in the Netherlands. PARTICIPANTS: Seventy-seven general practices; 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 reviewed. 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, resulting in average improvement rates of 5% (screening) and 2% (advice-giving) at 12-month follow-up (not significant). CONCLUSIONS: A tailored, multi-faceted programme aimed 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.