Clinical trial NCT03108144: Personalized Alerts and Care Pathways to Prompt Prevention Interventions for Alcohol and Tobacco Users in Primary Care
Official title: Personalized Patient Alerts and Care Pathways to Prompt Prevention Interventions for Combined Alcohol and Tobacco Users in Primary Care
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Cancer
Keywords: smoking cessation
alcohol
primary care
screening
brief intervention
referral to treatment
cancer risk
Lead sponsor: Centre for Addiction and Mental Health
Sponsor class: OTHER
Collaborators: name: Canadian Cancer Society (CCS)
First posted: 2017-04-11
Enrollment: 15222
Sex: ALL
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Organizations will be randomly allocated in a 1:1 allocation ratio to Group A (Test) or Group B (Control) accounting for rurality, organization type, practice size and academic affiliation.
Primary purpose: PREVENTION

Brief summary: Tobacco and alcohol use present multiplicative risk for aerodigestive cancers. Reducing alcohol consumption improves smoking cessation outcomes and reduces cancer risk. Risky alcohol consumption and smoking are often treated separately despite concurrent treatment potentially leading to better outcomes for each. However, no rapidly scalable program exists for combined interventions in primary care clinics spread across wide geographic areas. This cluster randomized trial aims to report on the effects of a novel clinical decision support system (CDSS) on intervention rates by primary care practitioners addressing risky alcohol use in a smoking cessation program.

The investigators will be implementing a clinical decision support system (CDSS) in 221 primary care sites participating in the Smoking Treatment for Ontario Patients (STOP) program across Ontario, Canada. Sites will be blindly allocated to one of two clinical decision support systems guiding practitioners to provide a risky alcohol use intervention to smokers attempting to quit using nicotine replacement therapy (NRT). Risky alcohol use is defined as drinking above the Canadian Cancer Society's low-risk drinking guidelines. Primary analysis will measure the proportion of risky drinkers offered an alcohol intervention in each CDSS arm at baseline. Patients will be contacted by phone or email to track smoking cessation and alcohol consumption rates at 6- and 12-month follow up.

Upon completion of the trial, the effect of different clinical decision support systems on practitioner behavior, and on client tobacco and alcohol use, will be discussed. If the CDSS successfully promotes SBIRT for risky alcohol use in a primary care setting and/or improves patient-level outcomes, including smoking cessation rates and alcohol use reduction, this tool can be used as a model for other web-based behavior change interventions integrated into primary care practice.

Detailed description: Background: Primary care providers work in busy settings responding to a variety of acute and chronic problems. Implementing even brief evidence-based interventions for cancer risk behaviors, such as tobacco smoking and excess alcohol consumption, is sub-optimal due to time and knowledge constraints. These behaviors cluster in the same person and confer a multiplicative, positively associated risk for aero-digestive cancers but are often addressed separately, if at all, despite alcohol consumption undermining smoking cessation. Processes that reduce time and effort and yet increase practitioner effectiveness show promise to increase adoption of such practices. Computerized clinical decision support systems (CDSS) within practices allow for prompt procedural knowledge for practitioners, simplifies the decision-making process, and provides recommendations for patient care.

The initiation of the STOP Program (Smoking Treatment for Ontario Patients - an Ontario-wide initiative providing smoking cessation to eligible smokers who wish to quit), has demonstrated that such a system allows for rapid adoption of smoking cessation interventions in primary care with 189 sites (80% of eligible sites) in Ontario treating 40,000 smokers in 2 years. Approximately 36% consume alcohol above Canadian Cancer Society (CCS) guidelines (less than one drink per day for women; less then two drinks per day for men; no engagement in binge drinking) and those that do have a lower quit rate.

A combined alcohol and tobacco intervention delivered systematically using such a platform has never been studied before, which constitutes a missed opportunity to simultaneously address two closely related risk factors for cancer. Thus, implementation of a CDSS within the daily clinical workflow is a novel concept for cancer prevention with high potential to address the lack of brief interventions by health care providers.

Objective: Assess the effectiveness of a CDSS to increase the rates of brief alcohol intervention by healthcare providers and to reduce alcohol consumption in adult smokers making a quit attempt.

Methodology: Organizations from the STOP Program will be randomly allocated (1:1) to Group A or Group B.

Patient Population: Adult consenting smokers of the STOP Program identified as drinking above the sex-specific cut off at baseline will be eligible for the intervention.

Intervention: Half the sites will have a computer prompt built into STOP's data collection system, which will appear for any participant identified as drinking above the sex-specific cut off at baseline (Group A). The reminder will provide the practitioners with a five minute script advising their patient to reduce alcohol consumption to increase their chances of quitting smoking, and will be prompted to provide a self-help booklet to reduce alcohol intake. Sites without the prompt (Group B) will not receive reminders but will have access to the same resources.

Eligibility criteria: Inclusion Criteria:

* Participating clinics must be Family Health Team, Community Health Centre, or Nurse Practitioner-Led Clinic (primary care clinics) participating in the Smoking Treatment for Ontario Patients (STOP) program
* Clinic must use online portal to complete STOP questionnaires, in English, in real-time with patient

Exclusion Criteria:

* Non-primary care clinics participating in STOP program
* Clinics who conduct STOP questionnaires exclusively on paper, or in French, or not in real-time with patient

Primary outcomes:
measure: Intervention offer by practitioner
timeFrame: Approximately 10 minutes during 1-hour appointment between practitioner and patient
Secondary outcomes:
measure: Intervention delivery by practitioner
timeFrame: Approximately 10 minutes during 1-hour appointment between practitioner and patient
measure: Smoking cessation and non-risky drinking
timeFrame: 6-month follow-up
Other outcomes:
Locations:
city: Toronto
country: Canada
facility: Centre for Addiction and Mental Health
state: Ontario
Study officials:
affiliation: Centre for Addiction and Mental Health
name: Peter Selby, MBBS CCFP FCFP MHSc DipABAM
role: PRINCIPAL_INVESTIGATOR
References:
citation: Minian N, Noormohamed A, Lingam M, Zawertailo L, Le Foll B, Rehm J, Giesbrecht N, Samokhvalov AV, Baliunas D, Selby P. Integrating a brief alcohol intervention with tobacco addiction treatment in primary care: qualitative study of health care practitioner perceptions. Addict Sci Clin Pract. 2021 Mar 16;16(1):17. doi: 10.1186/s13722-021-00225-x.
citation: Minian N, Baliunas D, Noormohamed A, Zawertailo L, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov AV, Selby PL. The effect of a clinical decision support system on prompting an intervention for risky alcohol use in a primary care smoking cessation program: a cluster randomized trial. Implement Sci. 2019 Aug 23;14(1):85. doi: 10.1186/s13012-019-0935-x.
citation: Minian N, Noormohamed A, Zawertailo L, Baliunas D, Giesbrecht N, Le Foll B, Rehm J, Samokhvalov A, Selby PL. A method for co-creation of an evidence-based patient workbook to address alcohol use when quitting smoking in primary care: a case study. Res Involv Engagem. 2018 Feb 5;4:4. doi: 10.1186/s40900-018-0086-2. eCollection 2018.
citation: Minian N, Baliunas D, Zawertailo L, Noormohamed A, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov A, Selby PL. Combining alcohol interventions with tobacco addictions treatment in primary care-the COMBAT study: a pragmatic cluster randomized trial. Implement Sci. 2017 May 18;12(1):65. doi: 10.1186/s13012-017-0595-7.