Pragmatic case finding as a strategy to improve addressing alcohol in general practice – a mixed methods pilot study
Background: Alcohol screening and brief interventions (SBI) in primary care are effective and may reach a large proportion of the population. SBI implies addressing alcohol with patients seeking health care for other reasons than alcohol and provide brief alcohol interventions (BAI) if hazardous or harmful alcohol consumption is identified. Most studies on SBI have focused on universal, widespread screening, whereas few studies have explored targeted or relevance-based strategies. General practitioners (GPs) accept responsibility for managing alcohol-related health problems but are not in favour of universal screening measures. SBI has had minimal impact on routine practice in primary care. Pragmatic case finding (PCF) is an identification strategy based on clinical relevance of alcohol in stead of universal screening, and developed in primary care with GPs.
Methods: We operationalised PCF using focus group interviews (N=25) and free text questionnaires (N=55) with GPs (process reported elsewhere). Theoretical Domains Framework (TDF) with capabilities, opportunities, and motivation (COM-B model) and Behaviour Change Wheel (BCW) provided a theroerical basis for exploring barriers and facilitators for PCF. We then planned a four-session teaching seminar on PCF and piloted this in four GP clinics. Examples of topics from the sessions were pragmatic case finding as an eye-opener, the significance of understanding the clinical effects of alcohol, and the driver’s license as a barrier. Potential effects of the seminar on addressing alcohol were explored in brief focus group interviews 1-3 months after completed intervention, and with a validated questionnaire based on TDF before and after the intervention.
Results: Four GP clinics in two cities in Norway (N=36 GPs) met the eligibility criteria and accepted participation. The pilot study was run during the Covid-19 pandemic, which caused frequent cansellations and long delays between sessions. We investigated potential effects of the intervention regarding capability, opportunity, and motivation for addressing alcohol. Focus group interviews revealed a shift in alcohol conversations towards shared decision making and focus on health impact and normalisation of alcohol conversations. The questionnaire revealed small but similarly positive effects.
Conclusion: This pilot study supports PCF as a viable strategy for addressing alcohol in general practice. After four decades of failed attempts to implement universal screening strategies, it is reasonable to focus on relevance-based clinical strategies adapted to regular clinical reasoning. Universal strategies may in theory reach more people but are seldom implemented. We have identified positive effects of PCF on the quality and character of alcohol conversations in primary care. Further research is needed to understand which patient groupss might benefit from PCF, and wether some patient groups are less likely to benefit.
