Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders
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This entry is our analysis of a study added to the Effectiveness Bank. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders.

Ruf D., Berner M., Kriston L. et al.
Alcohol and Alcoholism: 2010, 45(1), p. 70–78.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Ruf at

No matter which dissemination strategy was tried, just 4 in 10 GPs in Germany logged in to a government funded online alcohol intervention education and support system. Even among the few practices who joined the study, training was poorly attended.

Summary Funded by the German Ministry for Education and Research, the Outpatient Quality Management of Alcohol-Related Disorders in Primary Care project first developed a comprehensive quality management system for alcohol-related disorders in primary care. The next step was to create an online version accessible over the internet. The system includes practice guidelines and screening and documentation materials, offering GPs the chance to learn guideline-based information on diagnostic assessment and treatment of alcohol-related disorders through an e-learning tool and by documenting the progress of their own patients.

The featured report concerns the next phase of the project which trialled three ways of encouraging GPs to use the system. The most basic dissemination strategy was simply to tell GPs about the system. A step up was also to offer a four-hour training session for GPs covering alcohol-related disorders and the online system, including exercises at the computer to test the system and a discussion of its transfer in to practice. A further step up was to do this but also at the same time to train nurses from the same practices in parallel with their GPs and then to bring them together to discuss transfer of the system in to practice – an option expected to maximise the system's uptake.

All 2647 GPs in 12 districts in Germany were invited to participate in the study and were eligible to join it as long as they had broadband internet access, a practice nurse, and were prepared to recruit patients in to the trial. 2160 practices did not reply and many others refused to join the study, leaving 112 practices which both met the study's criteria and agreed to participate. They were randomly allocated to one of the three dissemination strategies.

Main findings

Among the 43 practices allocated to GP training, 28 GPs actually attended the session. Of the 42 allocated to GP plus practice nurse training, 10 fully participated in the training and another eight sent GPs but not practice nurses. Regardless of the dissemination strategy to which they had been allocated, roughly the same proportions (42–44%) logged in to the online system at least once. However, there was difference in subsequent usage. Among those who logged in at all, just 8% of those offered no training logged in again at least another five times. When nurse and doctor had been offered training this proportion rose to a third; when only the GP had been offered training, it rose still further to 56%, statistically significant differences. Both groups offered training were considerably more accurate in their diagnoses of alcohol-related disorders according to standard criteria (around 70% accuracy) than were GPs in practices not offered any training. However, there were no statistically significant differences between dissemination groups in the total time they spent logged in, whether they used the system to complete a continuing medical education module, the degree to which they used it to follow-up their patients' progress, whether they followed guidelines in referring patients for further treatment, and the progress made by their patients in reducing the severity of their drink-related problems. These findings were broadly replicated when the analysis was confined to practices which had attended the training as per their allocation, and when the analysis was based on the type of training they actually received (none; GP only; GP plus nurse) regardless of the option to which they had been allocated.

The authors' conclusions

For the authors one key issue was why none of the dissemination strategies was able to attract more than about 4 in 10 GPs to log in More may have used the web site to the degree that this was possible without logging in. The system was designed to enable users to access as many parts as possible without a log in, since the need for passwords had been identified as a major barrier. to the system even once. Lack of familiarity with using the internet seemed one major obstacle to usage. Another blockage seemed to be the time it took to use the system and the demands it made on the user, since the more complex and time-consuming elements which required registration and log in were barely used. Fast and easy access seemed to be very important.

Another issue was why so few practices sent both GPs and nurses to the training. Possible explanations include the lack of incentives for nurses to attend and unwillingness of doctors to integrate their practice teams in to alcohol treatment.

Training did appear to improve the diagnostic assessments of the GPs, but these results are based on a small and possibly atypical sample of GPs, and were achieved only on the basis of offering relatively expensive training options which were poorly attended; whether this represents a cost-effective result requires further investigation.

The fact that it was possible to motivate at least 44% of GPs to use the system merely by telling them about it and its internet address, and that offering training did not improve this figure, suggests that further efforts to increase use of such systems should focus on advertising the system, providing easy access, and solving barriers to its use. This might be achieved by integrating it in to main practice software systems and other information sources for doctors. Also the very low incentive to use online continuing medical education is an important barrier to widespread use; offering such systems may need to be backed by incentives such as more educational credits for using them.

Findings logo commentary A trial in Britain of ways to disseminate an alcohol screening and brief intervention package to GPs found that telemarketing led 72% of GPs to order the package. Offering training plus ongoing support then led 71% of these to start using it. But despite this support, typically just 11% of patients were screened and just 4% of all patients thought to be at risk were given the recommended advice. The featured study's contention that offering support and training will be relatively ineffective without strong incentives to make use of these offers and implement alcohol-related work is supported by international evidence that when practitioners are mandated to screen for alcohol problems, and completion of screening is a recorded performance measure, then near 100% screening can be achieved. When there is no great incentive or requirement to use alcohol intervention resources, simply sending them to practitioners risks being largely a waste of time.

Last revised 14 September 2011

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