Modelling the costs and outcomes of changing rates of screening for alcohol misuse by GPs in the Australian context

Economic evaluations of alcohol prevention interventions: Is the evidence sufficient? A review of methodological challenges

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There are few economic evaluations of alcohol prevention interventions.

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Consideration of impacts beyond an individual’s health in evaluations is limited.

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No published studies using other priority-setting methods in the alcohol area.

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Consideration of wider societal perspectives and health inequalities is minimal.

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Including inter-sectoral costs and consequences in evaluations is challenging.

Public health interventions have unique characteristics compared to health technologies, which present additional challenges for economic evaluation (EE). High quality EEs that are able to address the particular methodological challenges are important for public health decision-makers. In England, they are even more pertinent given the transition of public health responsibilities in 2013 from the National Health Service to local government authorities where new agents are shaping policy decisions.

Addressing alcohol misuse is a globally prioritised public health issue. This article provides a systematic review of EE and priority-setting studies for interventions to prevent and reduce alcohol misuse published internationally over the past decade (2006–2016). This review appraises the EE and priority-setting evidence to establish whether it is sufficient to meet the informational needs of public health decision-makers.

619 studies were identified via database searches. 7 additional studies were identified via hand searching journals, grey literature and reference lists. 27 met inclusion criteria. Methods identified included cost-utility analysis (18), cost-effectiveness analysis (6), cost-benefit analysis (CBA) (1), cost-consequence analysis (CCA) (1) and return-on-investment (1). The review identified a lack of consideration of methodological challenges associated with evaluating public health interventions and limited use of methods such as CBA and CCA which have been recommended as potentially useful for EE in public health. No studies using other specific priority-setting tools were identified.

Training and tailored outreach support to improve alcohol screening and brief intervention in Aboriginal Community Controlled Health Services

INTRODUCTION AND AIMS

Aboriginal Community Controlled Health Services (ACCHSs) are often the primary point of contact for Indigenous Australians experiencing alcohol-related harms. Screening and brief intervention (SBI) is a cost-effective treatment for reducing these harms. Factors influencing evidence-based alcohol SBI delivery in ACCHSs have been identified. Evaluations of strategies targeting these factors are required. The aim of this paper is to quantify the effect of training and tailored outreach support on the delivery of alcohol SBI in four Aboriginal Community Controlled Health Services (ACCHSs).

DESIGN AND METHODS

A pre- post- assessment of alcohol information recorded in computerised patient information systems of four ACCHSs.

RESULTS

For ACCHSs combined there was a statistically significant increase in the proportion of eligible clients with an electronic record of any alcohol information (3.2% to 7.5%, P < 0.0001) and a valid alcohol screen (1.6% to 6.5%, P < 0.0001), and brief intervention (25.75% to 47.7%, P < 0.0001). All four ACCHSs achieved statistically significant increases in the proportion of clients with a complete alcohol screen (10.3%; 7.4%; 2%, P < 0.0001 and 1.3%, P < 0.05), and two in the proportion with a heavy drinking screen (7% and 3.1%, P < 0.0001).

DISCUSSION AND CONCLUSIONS

Implementing evidence-based alcohol SBI in ACCHSs is likely to require multiple strategies tailored to the characteristics of specific services. Outreach support provided by local drug and alcohol practitioners and a one item heavy drinking screen offer considerable promise for increasing routine alcohol SBI delivery in ACCHSs. Training and outreach support appear to be effective for achieving modest improvements in alcohol SBI delivery in ACCHSs.

How and when health-care practitioners in Aboriginal Community Controlled Health Services deliver alcohol screening and brief intervention, and why they don't: a qualitative study

INTRODUCTION

Indigenous Australians experience a disproportionately high burden of alcohol-related harm. Alcohol screening and brief intervention (SBI) offers the potential to reduce this harm if barriers to its delivery in Aboriginal Community Controlled Health Services (ACCHSs) can be optimally targeted.

AIMS

. Examine health-care practitioners' perceptions of, and practices in, alcohol SBI in ACCHSs.

METHODS

Semi-structured group interviews with 37 purposively selected health staff across five ACCHSs.

RESULTS

Alcohol screening independent of standard health assessments was generally selective. The provision of brief intervention was dependent upon factors related to the patient. Four key factors underlying health-care practitioners' perceptions of alcohol SBI were prominent: outcome expectancy; role congruence; utilisation of clinical systems and processes; and options for alcohol referral. Discussion. The influence of outcome expectancy and role congruence on health-care practitioners' alcohol SBI practices has been identified previously, as has to a lesser extent, their less than optimal use of clinical systems and processes. The influence of options for alcohol referral on health-care practitioners' willingness to deliver alcohol SBI primarily related to their misunderstanding of alcohol SBI and the lack of culturally appropriate alcohol referral options for their patients.

CONCLUSION

An intervention combining interactive, supportive and reinforcing evidence-based dissemination strategies is most likely required to enhance health-care practitioners' knowledge and skills in alcohol SBI delivery, positively orientate them to their role in its delivery, and facilitate integration of evidence-based alcohol SBI into routine clinical processes and locally available systems

Evidence-based alcohol screening and brief intervention in Aboriginal Community Controlled Health Services: experiences of health-care providers

INTRODUCTION AND AIMS

Alcohol screening and brief intervention (SBI) is a cost-effective treatment for reducing alcohol misuse in non-Indigenous populations. To increase the likelihood of alcohol SBI proving cost-effective for Indigenous Australians in practice, strategies to increase its uptake in Aboriginal Community Controlled Health Services (ACCHSs) should be implemented. The aim of this study is to describe the experiences of health-care providers supported to implement evidence-based alcohol SBI in two ACCHSs.

DESIGN AND METHODS

Pre- and post-surveys were administered to health staff (n = 32) participating in training workshops, followed by group interviews with health-care providers delivering alcohol SBI. Patient group interviews were also conducted. Survey results were summarised using descriptive statistics and interviews were analysed using a phenomenological approach.

RESULTS

Thirty-two per cent (n = 10) of workshop participants were confident or very confident at baseline to deliver alcohol SBI, increasing significantly to 81% (n = 25) post-training (McNemar Test, P < 0.05). Fifty-seven per cent (n = 16) of health-care providers attending workshops reported delivering alcohol SBI in the following 6 months. Group interviews with health-care providers elicited five themes relating to their experiences of alcohol SBI delivery. Patients in group interviews expressed a preference to be screened for alcohol as part of health assessments.

DISCUSSION AND CONCLUSIONS

Training workshops appear to be an acceptable initial strategy for disseminating alcohol SBI to ACCHSs. Outreach support is required to assist health-care providers to tailor guidelines and resources, and optimally integrate their clinical skills with evidence-based practice. Patients' needs should inform the tailoring process. Tailored collaborative and supportive strategies are probably required to optimally disseminate alcohol SBI in ACCHSs.

Reducing alcohol related harm experienced by Indigenous Australians: identifying opportunities for Indigenous primary health care services

OBJECTIVE

Identify key issues and opportunities relating to the dissemination of cost-effective interventions for alcohol in Indigenous-specific settings.

METHODS

Update previous reviews of the Indigenous alcohol literature, particularly in relation to intervention and dissemination studies aimed at identifying and integrating into routine clinical care those strategies that are most cost-effective in reducing alcohol-related harm.

RESULTS

The harmful use of alcohol has been identified as a major public health issue, which has a disproportionately high negative impact on Indigenous Australians. While the disproportionately high burden of harm borne by Indigenous Australian communities is well documented in descriptive studies, attempts to redress this imbalance through well controlled intervention and dissemination studies appear to have been inadequate to date. There is compelling evidence from the non-Indigenous community that brief intervention is an effective treatment for harmful alcohol use, compared to the relatively lower levels of evidence for primary and tertiary level interventions. The effectiveness of brief intervention for alcohol in Indigenous Australian communities should, therefore, be examined.

CONCLUSIONS AND IMPLICATIONS

An opportunity exists to implement brief intervention into Indigenous primary health care settings, as an evidence-based strategy using established resources. There is the possibility that such Indigenous-specific health services research will lead the dissemination field in demonstrating how the implementation process can be successfully tailored to specific and defined clinical settings.

Disseminating best-evidence health-care to Indigenous health-care settings and programs in Australia: identifying the gaps

Indigenous Australians experience a disproportionately greater burden of harm from smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) than the general Australian population. A critical step in further improving efforts to reduce this harm is to review existing efforts aimed at increasing the uptake of evidence-based interventions in Indigenous-specific health-care settings and programs. This study systematically identifies and reviews published Indigenous-specific dissemination studies targeting SNAP interventions. An electronic search of eight databases and a manual search of reference lists of previous literature reviews were undertaken. Eleven dissemination studies were identified for review: six for nutrition and physical activity as a component of diabetes care, three for alcohol and two for smoking. The majority of studies employed continuing medical education (n = 9 studies), suggesting that improving health-care providers' knowledge and skills is a focus of current efforts to disseminate best-evidence SNAP interventions in Indigenous health-care settings. Only two studies evaluated reminder systems, despite their widespread use in Indigenous-specific health-care services, and only one study employed academic detailing, despite its cost-effectiveness at modifying health-care provider behavior. There is a clear need for more Indigenous-specific dissemination research targeting the uptake of secondary prevention and to establish reliable and valid measures of Indigenous-specific health-care delivery, in order to determine which dissemination strategies are most likely to be effective in Indigenous health-care settings and programs.

Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback

In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.