Screening In Primary Care Research Articles

Participants' experience in using a point of Care Rapid Antigen Test (RAT) for SARS-CoV-2.

Learning objectives: On completion of this presentation, participant should be able to: Understand the feasibility of RAT for SARS-CoV-2 screening in primary care Understand the role of RAT for SARS-CoV-2 screening in prevention of COVID-19 transmission in community Context: The COVID-19 pandemic has paralyzed human interactions worldwide. At least half of COVID-19 transmissions could originate from asymptomatic individuals. Rapid Antigen Testing (RAT) with nasal sampling at the point of care is inexpensive, fast and less invasive than PCR testing. Objective: The overall study objective was to examine the feasibility of point-of-care RAT for detecting SARS-CoV-2 amongst an asymptomatic population living in congregate housing. Design: Cross-sectional survey. Setting: This study was conducted at the University of British Columbia (UBC). Approximately 1500 undergraduate student were at the study site during February-April 2021. Population: Students living in UBC housing and staff working in the UBC housing sites were eligible. People testing positive for COVID-19 in the prior 90 days were excluded from the study. Intervention: The BD Veritor testing kit was used to test bilateral nasal specimens. Results were ready by the small BD Veritor reader. Outcome measures: Experiences of surveyed participants completing RAT. The survey was conducted during the last three weeks the site was open. Results: A total of 223 participants consisting of 134 (60%) females and 89 (40%) males completed the survey for a 37% response rate. Participants were mainly of European descent (45%), though there were East Asians (18%), African/ Caribbean (5%) and Indigenous (3%) people who also completed the survey. Almost all (98%) reported that RAT was acceptable/very acceptable and 97% would take another test. Participants believed they would test negative given their careful observation of public health measures such as hand washing, mask wearing and restricting contacts to their small "bubble". Their expectation of testing negative was based on having no or minimal interactions with any person who had tested positive. More than two thirds of participants reported RAT provide them peace of mind and reduced anxiety levels. Participants found the RAT to be safe, easy, accessible and rapid. Conclusions: Rapid antigen testing for detecting COVID-19 is well accepted and could support the detection of infection at an early stage amongst asymptomatic individuals while easing their worries.

Screening for type 2 diabetes after a diagnosis of gestational diabetes by ethnicity: A retrospective cohort study

AimsTo estimate rates and identify determinants of post-partum glucose screening attendance in women with a history of gestational diabetes mellitus (GDM). MethodsRetrospective cohort study using the Clinical Practice Research Datalink linked to Hospital Episode Statistics, to identify women diagnosed with GDM between 01/01/2000 and 05/11/2018. Age adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using multivariable logistic regression models. ResultsIn 10,868 women with GDM, with an average follow-up of 5.38 years (95% CI 5.31,5.45), there was an average of 3.79 (95% CI 3.70,3.89) screening episodes per individual, with a mean time to first screening test of 1.22 (95% CI 1.18, 1.25) years. South Asian women had a significantly greater likelihood of being screened compared to White women within the first 5 years post-partum, aOR: 1.89 95% CI (1.20,2.98). A low proportion of women received at least one test per year of follow-up (23.87%). Older age at GDM diagnosis, polycystic ovary syndrome, prescribed medication for GDM, and living in England, were all associated with a greater likelihood of being screened. ConclusionWhile the majority of women with previous GDM receive at least one glucose screening test within the first 5 years post-partum, fewer than a quarter of them receive on average one test per year of follow-up. Developing strategies to motivate more women to attend screening in primary care is essential.

Suspected Dementia in Young Adults: Cognitive Screening Tools for Use in Primary Care.

Memory complaints are frequent among young adults presenting in general practice. Many of them will have reversable, functional cognitive impairment that can easily be mistaken for dementia. Its accurate and timely identification is warranted to prevent further escalation to overt dementia syndrome. To evaluate the recommended primary care screening cognitive tools for dementia for use in younger people. 2.5 years clinical data were collected during the course of ongoing patient care for all assessed face-to-face patients in a secondary care memory service for younger adults. Cognitive screening and assessment tests used in primary [General Practice Assessment of Cognition (GPCOG)] and secondary [Addenbrooke's Cognitive Examination-III (ACE-III), Rowland Universal Dementia Assessment Scale (RUDAS), Salzburg Dementia Test Prediction (SDTP)] care were analyzed for their accuracy to identify dementia and memory complaints. Area under the curve in receiver operating characteristic curves was used to measure predictive value of tests for a clinical diagnosis of dementia. 348 young adults were assessed for cognitive impairment. Following comprehensive Memory Clinic assessments, 241 (69.25%) were diagnosed with memory complaints in the absence of relevant neuropathology and 107 with dementia. GPCOG, especially the informant part, and RUDAS had low accuracy to identify dementia (AUC = 0.465 and AUC = 0.698, respectively). In contrast, ACE-III and SDTP demonstrated the highest accuracy (AUC = 0.799 and AUC = 0.809/0.817, respectively). Dementia screening in younger people will benefit from SDTP incorporated as part of the screening cognitive toolset. The national guidance on dementia screening tools, diagnostic pathways, and management should also refer to younger adults.

Feasibility of Food FARMacia: Mobile Food Pantry to Reduce Household Food Insecurity in Pediatric Primary Care.

Despite recommendations for systematic food insecurity screening in pediatric primary care, feasible interventions in clinical settings are lacking. The goal of this study was to examine reach, feasibility, and retention in Food FARMacia, a pilot clinically based food insecurity intervention among children aged <6 years. We examined electronic health record data to assess reach and performed a prospective, longitudinal study of families in Food FARMacia (May 2019 to January 2020) to examine attendance and retention. We used descriptive statistics and bivariate analyses to assess outcomes. Among 650 pediatric patients, 172 reported household food insecurity and 50 registered for Food FARMacia (child mean age 22 ± 18 months; 88% Hispanic/Latino). Demographic characteristics of Food FARMacia participants were similar to those of the target group. Median attendance rate was 75% (10 sessions) and retention in both the study and program was 68%. Older child age (retention: age 26.7 ± 18.7 months vs. attrition: age 12.1 ± 13.8 months, p = 0.01), Hispanic/Latino ethnicity (retention: 97% vs. attrition: 69%, p < 0.01), and larger household size (retention: 4.5 ± 1.1 vs. attrition: 3.7 ± 1.4, p = 0.04) correlated with retention. A clinically based mobile food pantry pilot program and study reached the target population and were feasible.

Cannabis use, comorbidities, and prescription medication use among older adults in a large healthcare system in Los Angeles, CA 2019-2020.

To describe the reported prevalence of cannabis use and co-use with prescription medications among older adult patients attending primary care (PC) clinics in Los Angeles, CA. We used electronic health record (EHR) data from sixty PC clinics part of a university-based, urban healthcare system. Patients' ≥50 years of age with an annual physical examination between July 2019 and May 2020 were eligible for inclusion (n=42,555). Cannabis use was assessed by clinic staff at the time of the visit and recorded in the EHR. We also used EHR data on clinical characteristics including current prescriptions and comorbidities. The median age was 63 years (range: 50-101) and 56% were female. Recent cannabis use was reported by 7.6%, which was higher than tobacco use (4.0%; p< 0.01). Prevalence of cannabis use was higher among patients prescribed psychotropic medications. For instance, 10.9% of patients prescribed benzodiazepines reported cannabis use as compared with 7.3% among patients without a prescription for benzodiazepines (p< 0.01). Patients with neurologic/musculoskeletal medications such as antiepileptics also had a higher prevalence of cannabis use when compared with those without these prescriptions (13.6% vs. 7.6% respectively; p< 0.01) as did those who were prescribed muscle relaxants (10.3% vs. 7.5% respectively; p< 0.01). After adjusting for age, sex, race/ethnicity, and comorbidities those prescribed medications for psychiatric (adjusted OR=1.5; 95% CI 1.4-1.7), respiratory (adjusted OR=1.2; 95% CI 1.1-1.3), or neurologic conditions (adjusted OR=1.4; 95% CI 1.2-1.5) had increased odds of cannabis use compared with those not prescribed these medications. The prevalence of cannabis use among older adults attending PC clinics in a university-based healthcare system was higher among those prescribed medications, which may interact with cannabis. These findings suggest that key groups of older patients who may benefit from routine PC screening for cannabis use and brief advice.

Targeted Electronic Patient Portal Messaging Increases Hepatitis C Virus Screening in Primary Care: a Randomized Study.

Electronic health record (EHR) tools such as direct-to-patient messaging and automated lab orders are effective at improving uptake of preventive health measures. It is unknown if patient engagement in primary care impacts efficacy of such messaging. To determine whether more engaged patients, defined as those who have an upcoming visit scheduled, are more likely to respond to a direct-to-patient message with an automated lab order for hepatitis C virus (HCV) screening. Randomized trial PARTICIPANTS: One thousand six hundred randomly selected Stanford Primary Care patients, 800 with an upcoming visit within 6 months and 800 without, born between 1945 and 1965 who were due for HCV screening. Each group was randomly divided into cohorts of 400 subjects each. Subjects were followed for 1 year. One 400 subject cohort in each group received a direct-to-patient message through the EHR portal with HCV antibody lab order. The EHR was queried on a monthly basis for 6 months after the intervention to monitor which subjects completed HCV screening. For any subjects screened positive for HCV, follow-up through the cascade of HCV care was monitored, and if needed, scheduled by the study team. Of 1600 subjects, 538 (34%) completed HCV screening. In the stratum without an upcoming appointment, 18% in the control group completed screening compared to 26% in intervention group (p<0.01). Similarly, in the stratum with an upcoming appointment, 34% in the control group completed screening compared to 58% in the intervention group (p<0.01). Direct-to-patient messaging coupled with automated lab orders improved HCV screening rates compared to standard of care, particularly in more engaged patients. Including this intervention in primary care can maximize screening with each visit, which is particularly valuable in times when physical throughput in the healthcare system may be low.

Why do people take part in atrial fibrillation screening? Qualitative interview study in English primary care

ObjectivesThere is insufficient evidence to support national screening programmes for atrial fibrillation (AF). Nevertheless, some practitioners, policy-makers and special interest groups have encouraged introduction of opportunistic screening in primary care...

Usual source of primary care and preventive care measures in the COVID-19 pandemic: a nationwide cross-sectional study in Japan

ObjectivesTo assess multiple preventive care measures and to examine their associations with having a usual source of primary care and primary care performance during the COVID-19 pandemic in Japan.DesignNationwide cross-sectional...

Diagnostic Accuracy of the Telephone Interview for Cognitive Status for the Detection of Dementia in Primary Care.

Cognitive diagnostic work-up in primary care is not always physically feasible, owing to chronic disabilities and/or travel restrictions. The identification of dementia might be facilitated with diagnostic instruments that are time efficient and easy to perform, as well as useful in the remote setting. We assessed whether the Telephone Interview for Cognitive Status (TICS) might be a simple and accurate alternative for remote diagnostic cognitive screening in primary care. We administered the TICS (range, 0-41) for 810 of 1,473 older people aged 84.5 (SD, 2.4) years. We scrutinized electronic health records for participants with TICS scores ≤30 and for a random sample of participants with TICS scores >30 for a dementia diagnosis using all data from the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial for 8-12 years of follow-up. We used multiple imputation to correct for verification bias. Of the 810 participants, 155 (19.1%) had a TICS score ≤30, and 655 (80.9%) had a TICS score >30. Electronic health records yielded 8.4% (13/154) dementia diagnoses for participants with TICS ≤30 vs none with TICS >30. Multiple imputation for TICS >30 yielded a median of 7/655 (1.1%; interquartile range, 5-8) estimated dementia cases. After multiple imputation, the optimal cutoff score was ≤29, with mean sensitivity 65.4%, specificity 87.8%, positive predictive value 11.9%, negative predictive value 99.0%, and area under the curve 77.4% (95% CI, 56.3%-90.0%). In the present older population, the TICS performed well as a diagnostic screening instrument for excluding dementia and might be particularly useful when face-to-face diagnostic screening is not feasible in family practice or research settings. The potential reach to large numbers of people at low cost could contribute to more efficient medical management in primary care.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care

This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT). SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars. The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist. The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Sustainability of healthcare professionals\u2019 adherence to clinical practice guidelines in primary care

BackgroundSustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting.AimTo explore the sustainability of primary care providers’ adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes.MethodsCochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers’ (PCPs’) adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted.ResultsEleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies.ConclusionCurrent guideline implementation strategies may potentially improve the sustainability of PCPs’ adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue.Trial registrationThe study protocol has been registered at PROSPERO (No. CRD42021259748).

Budget impact analysis of a machine learning algorithm to predict high risk of atrial fibrillation among primary care patients.

We investigated whether the use of an atrial fibrillation (AF) risk prediction algorithm could improve AF detection compared with opportunistic screening in primary care and assessed the associated budget impact. Eligible patients were registered with a general practice in UK, aged 65 years or older in 2018/19, and had complete data for weight, height, body mass index, and systolic and diastolic blood pressure recorded within 1 year. Three screening scenarios were assessed: (i) opportunistic screening and diagnosis (standard care); (ii) standard care replaced by the use of the algorithm; and (iii) combined use of standard care and the algorithm. The analysis considered a 3-year time horizon, and the budget impact for the National Health Service (NHS) costs alone or with personal social services (PSS) costs. Scenario 1 would identify 79 410 new AF cases (detection gap reduced by 22%). Scenario 2 would identify 70 916 (gap reduced by 19%) and Scenario 3 would identify 99 267 new cases (gap reduction 27%). These rates translate into 2639 strokes being prevented in Scenario 1, 2357 in Scenario 2, and 3299 in Scenario 3. The 3-year NHS budget impact of Scenario 1 would be £45.3 million, £3.6 million (difference ‒92.0%) with Scenario 2, and £46.3 million (difference 2.2%) in Scenario 3, but for NHS plus PSS would be ‒£48.8 million, ‒£80.4 million (64.8%), and ‒£71.3 million (46.1%), respectively. Implementation of an AF risk prediction algorithm alongside standard opportunistic screening could close the AF detection gap and prevent strokes while substantially reducing NHS and PSS combined care costs.

Patient and provider perspectives on self-administered electronic substance use and mental health screening in HIV primary care

BackgroundSubstance use disorders, depression and anxiety disproportionately affect people with HIV (PWH) and lead to increased morbidity and mortality. Routine screening can help address these problems but is underutilized. This study sought to describe patient and provider perspectives on the acceptability and usefulness of systematic electronic, self-administered screening for tobacco, alcohol, other substance use, and mental health symptoms among patients in HIV primary care.MethodsScreening used validated instruments delivered pre-appointment by both secure messaging and clinic-based tablets, with results integrated into the electronic health record (EHR). Qualitative analysis of semi-structured interviews with 9 HIV primary care providers and 12 patients in the 3 largest HIV primary care clinics in the Kaiser Permanente Northern California health system who participated in a clinical trial evaluating computerized screening and behavioral interventions was conducted. Interviews were audio-recorded and transcribed. A thematic approach was utilized for coding and analysis of interview data using a combination of deductive and inductive methods.ResultsFour key themes were identified: (1) perceived clinical benefit of systematic, electronic screening and EHR integration for providers and patients; (2) usefulness of having multiple methods of questionnaire completion; (3) importance of the patient–provider relationship to facilitate completion and accurate reporting; and (4) barriers, include privacy and confidentiality concerns about reporting sensitive information, particularly about substance use, and potential burden from repeated screenings.ConclusionsFindings suggest that electronic, self-administered substance use and mental health screening is acceptable to patients and may have clinical utility to providers. While offering different methods of screening completion can capture a wider range of patients, a strong patient–provider relationship is a key factor in overcoming barriers and ensuring accurate patient responses. Further investigation into facilitators, barriers, and utility of electronic screening for PWH and other high-priority patient populations is indicated.Trial registration ClinicalTrials.gov, NCT03217058. Registered 13 July 2017, https://clinicaltrials.gov/ct2/show/NCT03217058

Factors Associated with Screening Positive for Depression among Women Caregivers of Primary Palliative Care Patients in Kerala, India.

Background: The study encompasses findings from a prospective quantitative screening of women family caregivers for depression as part of a larger mixed methods study designed to develop and validate a caregiver burden inventory for the home-based palliative care programme in Kerala, India. Aim: We assessed the proportion of women caregivers screening positive for depression and explored the associated factors. Methods: The Primary care Screening Questionnaire for Depression (PSQ4D) was used to screen participants for depression. Other variables analysed were caregiver and patient related factors, stresses, strains, support received, caregiver burden and quality of life domain variables as per the EuroQol EQ-5D-5L instrument. Results: Forty women (20.0%, 95% Confidence Intervals [CI] 14.46% - 25.54%) screened positive for depression on the PSQ4D. This was more likely if the care recipient was the spouse, if the care recipient had cancer, if the caregiver perceived a moderate or high physical/psychological burden, or a high financial burden. Pain/ discomfort when included had an adjusted odds ratio (AOR) of 8.2 (95% CI 2.6-26.0) and tended to decrease the AOR of all other significantly associated variables, except cancer diagnosis in the care recipient. Conclusion: Depression levels among women caregivers in primary palliative care settings in Kerala seem comparable to prevalence levels among women in the general population. Those caregivers reporting pain/ discomfort should be screened for depression using simple locally validated measures. Depression is associated with higher caregiver burden and poorer quality of life. Screening and treatment of depression may help mitigate these situations.

Lessons Learned From a New Reverse-Integration Model to Improve Primary Care Screening in Community Mental Health Settings

The authors sought to describe a reverse-integration intervention aimed at improving preventive health screening in a community mental health clinic. The intervention, CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness), integrated primary care services into a large urban community mental health setting. It was implemented in 2015 and included a patient-centered team, population-based care, emphasis on screening, and evidence-based treatment. CRANIUM's strengths included provider acceptability, a patient-centered approach, sustained patient engagement, and economic feasibility. Challenges included underutilized staff, registry maintenance, and unanticipated screening barriers. The CRANIUM reverse-integration model can be feasibly implemented and was acceptable to providers.

Mental health screening in pediatric primary care for children with autism.

Children with autism experience high rates of co-occurring mental health conditions like challenging behaviors and anxiety. However, these co-occurring mental health needs are often not identified when they first become problematic. Pediatricians and their care staff are in a good position to identify mental health needs early and support families to connect to needed services. This study describes a project focused on mental health screening for children with autism in pediatric primary care clinics. Over half of eligible patients were screened using the Pediatric Symptom Checklist-17. Many children with autism had clinically elevated scores, suggesting the need for mental health assessment or services. In particular, children with positive screens had clinical elevations on the challenging behavior and attention subscales of the Pediatric Symptom Checklist-17. This finding is consistent with typical trends in co-occurring challenging behavior presentations in children with autism. Mental health screening in primary care is feasible and offers a promising opportunity to identify co-occurring mental health needs for children with autism early. Screening rates varied between clinics, suggesting tailored to improve routine screening in pediatric primary care for children with autism.

Atrial fibrillation (AF) pilot screening programme in primary care in Ireland: an implementation study protocol

IntroductionAtrial fibrillation (AF) is a major risk factor for stroke. There is a fivefold increase in stroke risk in the presence of AF. The irregular beating of the heart enables...

Letter to the Editor: Dietitian Perspectives: Are We Ready for Nutrition Risk Screening in Community and Primary Care?

Letter to the Editor: Dietitian Perspectives: Are We Ready for Nutrition Risk Screening in Community and Primary Care?

Improving Depression Screening in Primary Care: A Quality Improvement Initiative.

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial.

Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery. Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial. PHCPs in Portugal. Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58. PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial. The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider). The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices. A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.