The provision of preventive care for modifiable health risk behaviours by clinicians within substance use treatment settings: A systematic review

Journal Pre-proof The provision of preventive care for modifiable health risk behaviours by clinicians within substance use treatment settings: A systematic review

Danika Tremain, Megan Freund, Luke Wolfenden, Jenny Bowman, Adrian Dunlop, Kate Bartlem, Jacqueline Bailey, Tameka McFadyen, Julia Dray, Paula Wye, Lucy Leigh, John Wiggers PII:

S0091-7435(19)30346-9

DOI:

https://doi.org/10.1016/j.ypmed.2019.105870

Reference:

YPMED 105870

To appear in:

Preventive Medicine

Received date:

8 May 2019

Revised date:

26 September 2019

Accepted date:

12 October 2019

Please cite this article as: D. Tremain, M. Freund, L. Wolfenden, et al., The provision of preventive care for modifiable health risk behaviours by clinicians within substance use treatment settings: A systematic review, Preventive Medicine(2019), https://doi.org/ 10.1016/j.ypmed.2019.105870

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© 2019 Published by Elsevier.

Journal Pre-proof The provision of preventive care for modifiable health risk behaviours by clinicians within substance use treatment settings: A systematic review Danika Tremain, BPsyc (Hons)1,2,3, Megan Freund, PhD2,3, Luke Wolfenden, PhD1,2,3, Jenny Bowman, PhD3,5, Adrian Dunlop, PhD2,4,6, Kate Bartlem PhD1,3,5, Jacqueline Bailey, BPsyc (Hons)3,5, Tameka McFadyen1,3, Julia Dray, PhD1,2,3,5, Paula Wye, PhD3,5, Lucy Leigh7, John Wiggers, PhD1,2,3 Authors' affiliations Population Health, Hunter New England Local Health District, Wallsend, Australia.

2.

Faculty of Health, The University of Newcastle, Callaghan, Australia.

3.

Hunter Medical Research Institute, New Lambton Heights, Australia.

4.

Drug and Alcohol Clinical Services, Hunter New England Local Health District,

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Newcastle, Australia.

Faculty of Science and Information Technology, The University of Newcastle, Callaghan,

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Australia.

Centre for Translational Neuroscience and Mental Health, Waratah, Australia.

7.

Clinical Research Design and Statistics, Hunter Medical Research Institute, New

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Lambton Heights, Australia.

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Corresponding author: Danika Tremain. Locked Bag 10, Wallsend NSW 2287, Australia. Tel: +61 2 4924 6477; Fax: +61 2 4924 6490. [email protected]

Word Count: 4438 Tables: 5 Figures: 3

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Journal Pre-proof Abstract People who use substances have a high prevalence of other modifiable health risk behaviours such as tobacco smoking which contribute to an increased mortality and morbidity. Preventive care can reduce the prevalence of such behaviours and is recommended by clinical practice guidelines. This review describes the prevalence of preventive care delivery by substance use treatment healthcare providers and examines differences by treatment setting. Five databases were searched for studies published between 2005-2017. Eligible studies reported levels of preventive care (assessment, brief advice and/or referral/follow-up) in substance use treatment services for tobacco smoking, nutrition or physical activity. Two

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reviewers independently conducted article screening, data extraction and methodological

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quality assessment. Sixteen studies were included and all except one investigated care provision for tobacco smoking only. Four studies reported care levels as a proportion and 12

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studies reported care as a score-based mean. Client-reported receipt of smoking cessation care ranged from: 79-90% for assessment; 15-79% for brief advice; 0-30% for

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referral/follow-up. Meta-regression analyses of 12 studies found clinician-reported

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preventative care for tobacco smoking was more frequently reported in studies assessing care occurring across multiple substance use treatment settings, compared to studies reporting

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provision in inpatient only. This review indicated that, compared to smoking cessation care, little is known about the level of preventive care for nutrition or physical activity. Overall, the delivery of smoking cessation care reported was sub-optimal. High levels of assessment

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relative to brief advice and low levels of referral to ongoing assistance were indicated.

Keywords: Substance use treatment centres; tobacco smoking; nutritional status; physical activity; preventive medicine

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Journal Pre-proof Highlights 

First study to synthesise the literature regarding the provision of preventive care in substance use treatment settings



All but one study focussed on smoking cessation care



Overall, delivery of preventive care was sub-optimal



High levels of assessment relative to brief advice, and low levels of referral, were indicated

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Acknowledgments

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The authors would like to thank Ms Debbie Booth, Senior Research Librarian, University

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Library, University of Newcastle, for her assistance in developing the review search strategy

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and Clinical Research Design and Statistics (CREDITTS), Hunter Medical Research Institute

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(HMRI) for their assistance with the statistical analysis.

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Funding source: Infrastructure support was provided by Hunter Medical Research Institute. Financial disclosures: No financial disclosures were reported by the authors of this paper.

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Conflict of interest: The authors report no conflict of interest.

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Journal Pre-proof Background People with substance use problems experience a significantly lower life expectancy than the general population (Chang et al., 2011; Chesney et al., 2014; Lawrence et al., 2013; Nordentoft et al., 2013); up to 9-17 years less in the UK (Chang et al., 2011; Hayes et al., 2011), 30 years shorter in Europe (Nordentoft et al., 2013; Stenbacka et al., 2010) and 20-23 year shorter in Australia (Lawrence et al., 2013). There is a high prevalence of other modifiable health risk behaviours such as tobacco smoking, insufficient nutrition and insufficient physical activity (Baca and Yahne, 2009; Barbadoro et al., 2011; Kalman, 1998; Kelly et al., 2012; Prochaska et al., 2004) among people with substance use problems. Such

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risk factors contribute significantly to the overall burden of disease (Alba et al., 2004; Hurt et

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al., 1996; Islam et al., 2013; Lawrence et al., 2013; Stenbacka et al., 2010) and increased morbidity and mortality for this group (Hurt et al., 1996; Lawrence et al., 2013; Stenbacka et

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al., 2010), over and above that associated with their substance use.

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Cochrane systematic reviews (Hillsdon et al., 2005; Rees et al., 2013; Rice et al., 2013; Rigotti et al., 2007) demonstrate preventive care delivered by clinicians as part of routine

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treatment is effective in increasing tobacco smoking cessation (Rice et al., 2013; Rigotti et al., 2007), improving nutrition (Rees et al., 2013), and increasing physical activity (Hillsdon

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et al., 2005). Guidelines for the provision of preventive care recommend the 5As (ask, assess, advise, assist, arrange/refer) model (Fiore and Baker, 2008; RACGP, 2009; West et al.,

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2000). The 5As model was initially developed for smoking cessation (Fiore and Baker, 2008; Glasgow et al., 2004) with subsequent application to dietary risks and insufficient physical activity (Glasgow et al., 2004). However, the simplified 2As +R (assess, advise and refer) model (Fiore and Baker, 2008) has been recommended as an effective way to address modifiable health risk behaviours whilst also acknowledging competing clinical priorities and brevity of clinician contact (Fiore and Baker, 2008; Glasgow et al., 2004; Schroeder and Morris, 2010). Substance use treatment services are an opportune setting to provide preventive care. Treatment services are commonly delivered by skilled behaviour change professionals, across multiple patient contacts (Fiore and Baker, 2008; National Institute on Drug Abuse, 2012; New South Wales Health, 2007), and include a model of care consistent recommended preventive health care. Despite this opportunity, to our knowledge there has been no attempt to synthesise the literature describing the level of preventive care delivered in these settings.

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Journal Pre-proof Understanding the level of care in substance use treatment services is an important first step to identifying whether and how investment to improve care provision is warranted as a means of improving client health outcomes. To address this gap in knowledge, a systematic review was undertaken to describe the level of preventive care delivery by substance use treatment clinicians regarding three modifiable health risk behaviours: tobacco smoking, insufficient nutrition, and insufficient physical activity and examine the difference in care provision across treatment settings. The quality of such studies was also examined.

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Methods

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Identification of studies

A search of the Medline, Medline in process, Embase, CINAHL, PsycINFO, databases was

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undertaken using terms for ‘preventive care’, ‘chronic disease health risk behaviours’ and

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‘substance use treatment settings’ (see Supplementary Material for the Medline example search). All volumes from the past five years of three relevant journals were also hand

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searched. Drug and Alcohol Review, Journal of Substance Abuse Treatment, and Addictive Behaviours were chosen as the journal’s scope were inclusive of preventive medicine and

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provided an international context. Google Scholar was searched using similar terms and the first 200 articles were screened for eligibility. The reference lists of all included studies were

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searched for additional eligible studies.

All searches were limited to English language articles published in the previous 12 years (January 2005 to September 2017) to provide an understanding of current care levels. Eligibility criteria

Eligible studies were those that were: 

Published as original research in a peer reviewed journal (excluded case studies, commentaries, dissertations, conference abstracts, protocols, reviews, or editorial).

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Targeted adult substance use clients (≥18 years old), or the study reported data from those over 18 years separately to children.

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Observational studies, including cross-sectional and longitudinal study designs. Baseline measures of preventive care reported in intervention studies were also included.

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Journal Pre-proof 

Described the level of preventive care undertaken by routine substance use treatment clinicians in substance use treatment settings including inpatient, residential, community and hospital-based services.



Included an empirical description of the prevalence of at least one of three recommended

elements

of

preventive

care;

assessment,

brief

advice,

or

referral/follow-up for the following risks tobacco smoking, insufficient nutrition, insufficient physical activity. Score based measure of these outcomes were also included. 

Care was reported as client self-report receipt of care, clinician self-report of

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providing care or medical record audit. Studies that reported care provided by the

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service unit were excluded. Level of preventive care could be reported as a proportion or as a mean score.

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Study selection

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All titles and abstracts retrieved by the search were uploaded into Covidence (Veritas Health Innovation), and independently screened for initial eligibility by two authors (DT and JBa,

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TM, JD, KB). Studies clearly not meeting the inclusion criteria by review of their abstract were excluded. The full text of the remaining citations were retrieved and independently

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examined by two authors (DT and MF, JBa, PW, KB, JD). Disagreements regarding eligibility were resolved through discussion between two authors or if required consultation

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with a third reviewer (JBo).

Data extraction and study descriptors The following data was extracted: author(s) and year of publication, year(s) of study, country of study, study population, study setting (residential/inpatient or outpatient/community), results (including sample size, and level of preventive care), measurement tool, and information required for assessment of methodological quality. Two authors independently completed data extraction for each included study (DT and MF, KB, JBa, TM). Disagreements regarding data extraction were resolved through discussion between two authors. Critical appraisal of methodological quality Studies were appraised using the Joanna Briggs Institute Prevalence Critical Appraisal Tool, a tool designed for use in systematic reviews of prevalence (Munn et al., 2014). The tool 6

Journal Pre-proof assesses nine methodological criteria (see Table 1). Each paper was independently reviewed by two authors (DT and JBa, KB, TM, JD). Disagreements regarding coding were resolved through discussion or a third reviewer (MF). Preventive care practices Where possible, measures of care reported for each study were categorised based on the three recommended practices of the 2 As + R model of preventive care (Fiore and Baker, 2008): i) assessment of health risk behaviours, ii) provision of brief advice to modify health risk behaviours, and iii) referral/follow-up to further behaviour change support. For each element

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of care (assessment, brief advice and referral/follow-up) and for each health risk behaviour (tobacco smoking, insufficient nutrition, and insufficient physical activity) the proportion of

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patients receiving or clinicians providing preventive care were reported as a measure of

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prevalence. Where scores combining elements were reported, mean scores were reported for the specified scale.

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Data Synthesis

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We sought to pool data across studies in random-effects meta-analyses for each measure of care provision, and for each risk factor where studies were considered sufficiently

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homogenous. In instances where data could not be pooled, or where considerable study heterogeneity was identified, the findings of included studies were reported narratively. To

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examine differences in care provision across treatment settings, we sought to undertake a meta-regression including measure of care provision as the dependent variable and classifying treatment setting as either i) inpatient/residential, ii) outpatient/community, or iii) multiple (where results were reported overall and not reported separately by setting) treatment settings.

All statistical analyses were programmed using Stata v13.0 (StataCorp, 2013). Results Studies identified A total of 8293 records were identified in the search, 5247 from the database search and 3046 identified through the other sources (relevant journals, Google scholar and reference lists). After the removal of 1891 duplicate studies, 6402 abstracts were screened and 6172 were excluded based on tittle and abstract. Two hundred and thirty full-text articles were assessed

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Journal Pre-proof for eligibility and 214 were excluded (Figure 1). Sixteen studies met the inclusion criteria and were included in the review.. Description of studies Studies were undertaken from 2005 to 2015. Thirteen studies were conducted within the United States, two in Australia and one in the United Kingdom. Ten studies utilised clinician report, nine utilised client report, and one used medical record audits (four studies used both client and clinician report) to assess care provision. Sample sizes ranged from 42 to 2067, with 11 studies reporting a sample size over 200. Six studies were conducted in

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inpatient/residential settings, five studies in outpatient/community settings, eight in multiple

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settings and four in other settings (i.e. methadone, opioid substitution clinics). Fifteen of the 16 studies reported care provision for tobacco smoking only. One study,

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conducted by the current authors, reported care provision for multiple health risk behaviours (tobacco smoking, insufficient fruit and/or vegetable consumption, insufficient physical

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activity) (Tremain et al., 2016). Four studies reported the prevalence of preventive care

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provision as either the proportion of clients receiving preventive care through client selfreport, or the proportion of clinicians providing preventive care to clients through clinician

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self-report. Twelve studies reported care provision as a mean score.

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Journal Pre-proof Figure 1: PRISMA study flow diagram

Identification

Additional records identified through other sources (n = 3046) Records identified through database searching (n = 5247)

Hand-searching (n=2846) Google Schoolar (n=200)

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Screening

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Records after duplicates removed (n = 6402)

Records excluded (n = 6172)

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Full-text articles assessed for eligibility (n = 230)

Included

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Eligibility

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Records screened (n = 6402)

Studies included in narrative synthesis (n = 16)

Studies included in quantitative synthesis (meta-regression) (n = 12)

Full-text articles excluded (n = 214)

Non-English (n=5) Ineligible setting (n=60) Ineligible outcomes (n=115) Qualitative data (n=8) Data collected< 2005 (n=5) Duplicate (n=5) Child/adolescent participants (n=4) Commentary, conference abstract or letter to editor (n=12)

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Journal Pre-proof Critical appraisal of methodological quality No studies met all nine methodological criteria (see Table 1). Twelve of the 16 studies met five or more of the quality criteria; with the highest number of criteria was met by one study (8 criteria). Studies most frequently described the study participants and setting in detail (15/16), utilised an appropriate sample frame to address the target population (11/15), measured the condition in a standard, reliable way (11/15), and conducted appropriate statistical analysis (11/15). Studies least frequently recruited participants in an appropriate way (5/16), included an adequate sample size (5/16) and utilised valid methods for the

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identification of the condition (6/16).

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Journal Pre-proof Table 1: Critical appraisal of included studies

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Journal Pre-proof Provision of preventive care Estimates of prevalence across included studies were synthesised narratively due to the relatively small numbers of studies that reported measures or prevalence of recommended elements of preventive care, and heterogeneity in reported measures. A number of studies included score-based measures of preventive care and were considered suitably homogenous for meta-analysis as they used similar measurement tools. Given differences in the scales used to assess care provision, all tobacco smoking preventive care outcomes were first standardised (Hedges and Olkin, 1985).

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Studies reporting preventive care provision as a proportion

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Tobacco smoking

Four studies (Cookson et al., 2014; Nahvi et al., 2014; Skelton et al., 2017; Tremain et al.,

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2016) reported the prevalence of tobacco smoking cessation care as a proportion. Two of the

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four studies used client report and two used clinician report. The prevalence of client reported care ranged from 79.1-89.9% for assessment (Nahvi et al., 2014; Tremain et al., 2016), 15-

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79% for brief advice (Cookson et al., 2014; Tremain et al., 2016), and 0-30% for referral/follow-up (Tremain et al., 2016). Of the two studies, reporting clinician reported

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smoking cessation care, one study reported the proportion of clinicians who sometimes or always provided care across 11 items of preventive care provision (including assessment,

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brief advice and referral to further support) (Skelton et al., 2017), the other study reported the proportion of clinicians who provided care to 80% or more of their clients for six items of preventive care provision (including assessment, brief advice and referral to further support) (Tremain et al., 2016) (Table 2). Insufficient nutrition

One study reported care provision for insufficient nutrition, in the form of insufficient fruit and/or vegetable consumption and used both client and clinician report (Tremain et al., 2016). In this study, client reported provision of care was 22.5% for assessment, 24.8% for brief advice and 1.1-10.2% across elements of referral/follow-up. Clinician reported provision of care reported in the same study was 22.2% for assessment, 48.2% for brief advice and 3.713% for referral/follow-up.

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Journal Pre-proof Table 2: Included studies reporting proportion of preventive care provision for tobacco smoking Author

Setting

Sample Size

Care element

Percentage

Tremain et al. (2016)

Community

386

Assessment

89.9

Nahvi et al. (2014)

Opioid substitution

319

Documentation of smoking status

Client Assessment

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therapy

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Brief Advice

79.1

Tremain et al. (2016)

Community

386

Brief Advice

Nahvi et al. (2014)

Opioid substitution

319

Prescribed any smoking cessation

Cookson et al. (2014) Combination

163

Received 'support' to stop smoking in their current treatment episode

15

Cookson et al. (2014) Combination

163

Ever received support to stop smoking by 'clinicians'

44

therapy

Community

386

Tremain et al. (2016)

Community

386

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Referral/follow-up Tremain et al. (2016)

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79.4 15.5

Offer to arrange referral

8.7

Recommended other support

29.4

J

Clinician Assessment Tremain et al. (2016)

Community

54

Assessment (80-100% of clients)

87

Skelton et al. (2017)

Outpatient & Inpatient

362

Smoking status recorded on file for 76-100% of clients

62

Tremain et al. (2016)

Community

54

Brief Advice (80-100% of clients)

79.6

Skelton et al. (2017)

Outpatient & Inpatient

362

Verbal advice to quit: sometimes or always

79

Skelton et al. (2017)

Outpatient & Inpatient

362

Pamphlets of written information about quitting tobacco smoking:

61

Brief Advice

13

Journal Pre-proof Author

Setting

Sample Size

Care element

Percentage

sometimes or always Referral/follow-up Tremain et al. (2016)

Community

54

Spoke to clients about telephone service (80-100% of clients)

40.7

Tremain et al. (2016)

Community

54

Arrange telephone service to call client (80-100% of clients)

0

Skelton et al. (2017)

Outpatient & Inpatient

362

Referral to telephone quitline: sometimes or always

52

Tremain et al. (2016)

Community

54

Advise clients to talk to GP/AMS (80-100% of clients)

38.9

Skelton et al. (2017)

Outpatient & Inpatient

362

Referral to a GP or other doctor: sometimes or always

58

Tremain et al. (2016)

Community

54

Advise clients to use other types of support (80-100% of clients)

33.3

Skelton et al. (2017)

Outpatient & Inpatient

362

Referral to stop smoking cessation service: sometimes or always

33

Skelton et al. (2017)

Outpatient & Inpatient

362

Participation in an onsite quit group or program: sometimes or always

20

Skelton et al. (2017)

Outpatient & Inpatient

362

SCC offered to every client who smoked

44

Skelton et al. (2017)

Outpatient & Inpatient

362

Follow-up to check on quit smoking progress: sometimes or always

Skelton et al. (2017)

Outpatient & Inpatient

362

Skelton et al. (2017)

Outpatient & Inpatient

362

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Pharmacotherapy

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52

Offer of free or subsidised NRT: Sometimes or always

46

Prescription of smoking cessation medicine: sometimes or always

24

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Table 3: Included studies reporting means for tobacco smoking related care Author

Setting

Sample Size

Care element

Mean

SD

1.66

1.07

1.45

0.86

1.55

0.97

3.3

1.99

CLIENT Brief Advice Guydish et al. (2011b) Guydish et al. (2011b) Guydish et al. (2011b) Campbell et al. (2017) Campbell et al. (2017) Campbell et al. (2017)

250

Residential

250

Residential

250

Combination

683

Benefits/risks of quitting/smoking discussed

Combination

683

Given advice on quitting

3.3

1.98

Combination

683

Given educational material

2.9

2

1.19

0.55

Referral/follow-up Guydish et al. (2011b) Campbell et al. (2017)

In the past month, how frequently did your clinician at this program

Residential

Residential

In the past month, how frequently did your clinician at this program

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encourage you to use NRT

In the past month, how frequently did your clinician at this program

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encourage you to reduce smoking to five or fewer cigarettes per day

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encourage you to quit smoking completely

In the past month, how frequently did your clinician at this program arrange for a follow-up appointment to discuss quitting smoking

Combination

683

Given cessation referral

2.4

1.91

Outpatient

80

S-KAS: Clinician Services

2.3

1.23

Overall preventive care Guydish et al. (2012a)

15

Author Guydish et al.

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Sample

Setting

Size

Care element

Mean

SD

Residential

229

S-KAS: Clinician Services

2.7

1.05

Residential

100

S-KAS: Clinician Services

1.93

0.69

Pagano et al. (2016)

Residential

229

S-KAS: Clinician Services

2.7

1.23

Pagano et al. (2016)

Residential

238

S-KAS: Clinician Services

2.3

1.23

Pagano et al. (2016)

Residential

247

S-KAS: Clinician Services

2.29

0.97

Martinez et al. (2015)

Combination

485

S-KAS: Clinician Services

2.4

1.13

McClure et al. (2014)

Combination

106

S-KAS: Clinician Services

2.16

1.09

McClure et al. (2014)

Opioid substitution therapy

97

S-KAS: Clinician Services

2.3

0.96

Methadone Maintenance

100

S-KAS: Clinician Services

2.08

1.12

Pagano et al. (2016)

Methadone Maintenance

100

S-KAS: Clinician Services

2.08

1.12

Pagano et al. (2016)

Methadone Maintenance

103

S-KAS: Clinician Services

2.55

1.15

Pagano et al. (2016)

Methadone Maintenance

106

S-KAS: Clinician Services

2.19

1.08

104

Cessation-related intake procedures

3.57

0.99

(2012a) Guydish et al. (2012b)

Guydish et al. (2012a)

CLINICIAN Assessment

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J

l a

f o

Eby et al. (2013a)

Outpatient

Eby et al. (2013a)

Inpatient

113

Cessation-related intake procedures

2.92

1.06

Eby et al. (2013a)

Outpatient & Inpatient

104

Cessation-related intake procedures

3.28

1.16

Eby et al. (2013a)

Combination

362

Cessation-related intake procedures

3.27

0.8

Eby et al. (2013b)

Combination

659

Cessation-related intake procedures

3.2

1.12

Rothrauff et al.

Community

615

Ask new patients whether they are current tobacco users

3.82

1.39 16

Author

Setting

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Sample Size

Care element

Mean

SD

Ask new patients whether they are current tobacco users

3.82

1.12

3.5

1.86

3.09

1.55

3.1

1.55

2.61

1.94

3.39

1.16

(2011) Eby et al. (2013b)

Combination

659

Thinking about when you first meet a new client, how often do you: Knudsen et al. (2010)

Combination

2067

Make sure to ask whether they are a current smoker and/or current tobacco user?

Rothrauff et al.

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Community

615

Ask non-smokers if they have ever smoked

Eby et al. (2013b)

Combination

659

Ask non-smokers if they have ever smoked

Knudsen et al. (2010)

Combination

2067

Ask non-smokers if they have ever been a smoker/tobacco user?

Eby et al. (2013a)

Outpatient

104

Guideline recommended counselling

Eby et al. (2013a)

Inpatient

113

Guideline recommended counselling

2.63

1.19

Eby et al. (2013a)

Outpatient & Inpatient

104

Guideline recommended counselling

3.06

1.17

Eby et al. (2013a)

Combination

362

Guideline recommended counselling

3.01

0.9

Eby et al. (2013b)

Combination

659

Guideline recommended counselling

3.06

1.18

615

Advise current tobacco users that they should quit

3.16

1.38

659

Advise current tobacco users that they should quit

3.5

1.38

(2011)

Brief Advice

Rothrauff et al. (2011)

Community

r P

e

rn

u o

J

l a

o r p

Eby et al. (2013b)

Combination

Knudsen et al. (2010)

Combination

2067

Advise current smokers that they should quit

2.54

1.83

Eby et al. (2013b)

Combination

659

Assess current tobacco users for their willingness to quit

3.17

1.39

Knudsen et al. (2010)

Combination

2067

Assess current smokers for their willingness to quit

2.65

1.82

Community

615

Use brief motivational interventions to increase willingness to quit

2.78

1.34

Rothrauff et al. (2011)

17

Author

Setting

Eby et al. (2013b)

Combination

Knudsen et al. (2010)

Sample

Journal Pre-proof Care element

Mean

SD

659

Use brief motivational interventions to increase willingness to quit

2.78

1.35

Combination

2067

Use brief motivational interventions to increase willingness to quit

2.16

1.79

Community

615

3.61

1.34

Community

615

2.58

1.43

Eby et al. (2013b)

Combination

659

Develop “quit plan” for patients interested in quitting tobacco use

2.58

1.43

Eby et al. (2013b)

Combination

659

Provide self-help materials about tobacco smoking cessation

2.92

1.44

Eby et al. (2013b)

Combination

659

Overall availability of tobacco pharmacotherapy (0 No, to 1 Yes)

0.83

1.57

Outpatient

33

S-KAP: Practice

3.48

0.84

Outpatient

178

S-KAP: Practice

2.2

0.9

Rothrauff et al. (2011)

Size

Offer positive feedback as patients work toward tobacco cessation goals

Referral/follow-up Rothrauff et al. (2011)

f o

Develop a “quit plan” for patients interested in quitting their tobacco

Overall preventive care Guydish et al. (2012a) Miller-Thomas et al. (2014)

o r p

use

l a

r P

e

n r u

Residential

o J

S-KAP: Practice

3.23

1.01

Residential

66

S-KAP: Practice

2.05

0.81

Pagano et al. (2016)

Residential

152

S-KAP: Practice

3.24

1.02

Pagano et al. (2016)

Residential

148

S-KAP: Practice

2.93

0.9

Pagano et al. (2016)

Residential

124

S-KAP: Practice

3.42

1

Miller-Thomas et al.

Hospital-based

101

S-KAP: Practice

2.5

1

Guydish et al. (2012a) Guydish et al. (2012b)

152

18

Author

Setting

Sample Size

Journal Pre-proof Care element

Mean

SD

(2014) Miller-Thomas et al.

VHA

56

S-KAP: Practice

3.5

1

Methadone Maintenance

50

S-KAP: Practice

2.79

0.98

Pagano et al. (2016)

Methadone Maintenance

50

S-KAP: Practice

2.79

0.97

Pagano et al. (2016)

Methadone Maintenance

55

S-KAP: Practice

3.28

1.03

Pagano et al. (2016)

Methadone Maintenance

42

S-KAP: Practice

3.5

0.96

(2014) Guydish et al. (2012a)

l a

f o

o r p

r P

e

n r u

o J

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Journal Pre-proof Insufficient physical activity In the one study examining care provision for insufficient physical activity (Tremain et al., 2016), client reported provision of care was 50.8% for assessment, 48.8% for brief advice and 1.7-18.2% for elements of referral/follow-up. In the same study, clinician reported provision of care was 44.4% for assessment, 51.9% for brief advice and 1.8-20.4% for referral/followup. Studies reporting provision of preventive care as a mean score Of the 12 studies reporting provision of preventive care as a mean score, all reported on

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tobacco smoking cessation care only (Campbell et al., 2017; Eby and Laschober, 2013a, b;

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Guydish et al., 2011b; Guydish et al., 2012a; Guydish et al., 2012b; Knudsen and Studts, 2010; Martinez et al., 2015; McClure et al., 2014; Miller-Thomas et al., 2014; Pagano et al.,

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2016; Rothrauff and Eby, 2011). Eight studies utilised clinician report (Eby and Laschober, 2013a, b; Guydish et al., 2012a; Guydish et al., 2012b; Knudsen and Studts, 2010; Miller-

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Thomas et al., 2014; Pagano et al., 2016; Rothrauff and Eby, 2011) and seven studies used

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client report (Campbell et al., 2017; Guydish et al., 2011b; Guydish et al., 2012a; Guydish et al., 2012b; Martinez et al., 2015; McClure et al., 2014; Pagano et al., 2016). The 12 studies

Client report

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utilised various items to assess each care element (Table 3).

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All seven studies that utilised client report, used the Tobacco Smoking, Knowledge, Attitudes and Services (S-KAS) assessment tool (Guydish et al., 2011b) and reported care as an overall mean score. Five studies reported an overall score for provision of preventive care (Guydish et al., 2012a; Guydish et al., 2012b; Martinez et al., 2015; McClure et al., 2014; Pagano et al., 2016) and two studies reported care as individual items (Campbell et al., 2017; Guydish et al., 2011b). There are four subscales in the S-KAS, with one measuring receipt of clinician delivered preventive care, ‘clinician services’. Clinician services reports the overall mean of five statements regarding the frequency of client receipt of tobacco smoking preventive care (1=Never to 5=Always), and two statements regarding the perception of clinician ability to assist people to quit tobacco smoking (1=Strongly disagree to 5=Strongly agree). Within the five studies that reported the S-KAS, the mean clinician services score ranged from 1.9 to 2.7.

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Journal Pre-proof Two studies reported the mean score for individual items based on a 5-point Likert scale where 1=Never and 5=Always (Campbell et al., 2017; Guydish et al., 2011b). The mean score for ranged from 1.5 to 3.3 for brief advice and the mean score for client receipt of referral/follow-up support to clients was 1.2 to 2.4 (Guydish et al., 2011b). Clinician report Of the eight studies using clinician report, four (Guydish et al., 2012a; Guydish et al., 2012b; Miller-Thomas et al., 2014; Pagano et al., 2016) used the Staff Knowledge, Attitudes and Practices (S-KAP) assessment tool (Delucchi et al., 2009), two studies reported the mean

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score for individual items on a 5-point Likert scale (Knudsen and Studts, 2010; Rothrauff and Eby, 2011), one reported overall mean care (Eby and Laschober, 2013a), and one reported

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both overall mean care and mean scores for individual items (Eby and Laschober, 2013b). There are five subscales in the S-KAP, with one subscale assessing preventive care provision.

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The ‘practices’ subscale reports the overall mean of eight statements regarding the frequency

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in which the clinician provided tobacco smoking preventive care (1=Never to 5=Always), and one statement regarding whether tobacco smoking cessation counselling is an important

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part of their job (1= Strongly disagree to 5=Strongly agree). Within the four studies that

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reported the S-KAP, the mean practice score ranged from 2.1 to 3.5. Three studies reported the mean score based on a 5-point Likert for individual items scale (Eby and Laschober, 2013b; Knudsen and Studts, 2010; Rothrauff and Eby, 2011) where

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1=Never and 5=Always. The mean scores ranged from 2.6 to 3.8 for assessing client tobacco smoking, 2.2 to 3.6 for brief advice, and 2.6 to 2.9 for clinician provision of referral/followup.

Two studies (Eby and Laschober, 2013a, b) reported overall mean care in the form of clinician provision of tobacco cessation related intake procedures (5 items based on Knudsen and Studts (Knudsen and Studts, 2010)) and clinician provision of guideline recommended counselling (8 items based on Fiore et al. (Fiore et al., 2008)). Clinician mean provision of tobacco cessation care (1=Never to 5=Always) for intake procedures and guideline recommended counselling ranged from 2.9 to 3.6 and 3.0 to 3.4, respectively (Eby and Laschober, 2013a, b).

21

Journal Pre-proof Differences in care provision by setting Due to the limited studies identified and the differing measurement tool utilised, metaregression could only be undertaken for tobacco smoking cessation care, and for studies that reported preventive care levels using a score derived from a 5-point Likert scale. Metaregression was undertaken using data from included studies reporting score-based measures of tobacco care provision to identify any differences in care provision by treatment setting. Higher scores represented more frequent care provision. For studies reporting multiple tobacco smoking preventive care outcomes within each treatment setting, the multiple

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standardised outcomes were then pooled to produce a single measure of tobacco smoking cessation care for each study and setting. These results were then included in a meta-

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regression examining level of care by treatment setting. The analysis was performed

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separately for client reported care and clinician reported care. Client reported provision of care

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Seven studies (Campbell et al., 2017; Guydish et al., 2011b; Guydish et al., 2012a; Guydish et al.,

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2012b; Martinez et al., 2015; McClure et al., 2014; Pagano et al., 2016) were included in the meta-

regression. Figure 2 displays the pooled, standardised estimates (and standard errors) for each

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client study, within each setting, the number of items pooled, and the study sample size. Overall, there was no significant difference in the reported tobacco smoking preventive care

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outcomes between the treatment settings (Table 4).

22

Journal Pre-proof

Study ID

ES (95% CI)

Residential/Inpatient/Hospital 1.75 (1.65, 1.85)

Guydish 2008, Residential/Inpatient/Hospital

2.57 (2.30, 2.84)

Guydish 2006-08, Residential/Inpatient/Hospital

2.80 (2.36, 3.23)

Pagano 2008, Residential/Inpatient/Hospital

3.07 (2.84, 3.29)

Pagano 2009, Residential/Inpatient/Hospital

2.28 (2.11, 2.45)

Pagano 2013, Residential/Inpatient/Hospital

2.64 (2.45, 2.83)

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Guydish 2006-07, Residential/Inpatient/Hospital

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Outpatient/community

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Guydish 2008, Outpatient/community

Combination

re

Martinez 2008-09, Combination McClure 2011-12, Combination

2.12 (1.96, 2.28) 1.98 (1.65, 2.31) 1.33 (1.29, 1.36)

-3.29

0

3.29

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na

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Campbell 2015, Combination

1.87 (1.51, 2.23)

Figure 2. Forest plot of standardised effect estimates of client service studies by setting

Table 4: Meta-regression of pooled tobacco smoking cessation estimates (client) on treatment setting. Setting

Estimate (95% CI)

P-value

Inpatient/residential/hospital

Ref

-

Outpatient/community

-0.63 (-1.86, 0.60)

0.263

Combination

-0.70 (-1.47, 0.07)

0.068

23

Journal Pre-proof Clinician reported provision of care Eight studies (Eby and Laschober, 2013a, b; Guydish et al., 2012a; Guydish et al., 2012b; Knudsen and Studts, 2010; Miller-Thomas et al., 2014; Pagano et al., 2016; Rothrauff and Eby, 2011) were

included in the meta-regression. Figure 3 displays the pooled, standardised estimates (and standard errors) for each study and treatment setting, the number of items pooled, and the corresponding sample size. Overall, combination treatment settings had lower pooled standardised score than inpatient settings (p = 0.023) (Table 5).

Study ES (95% CI)

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ID

Outpatient/community

3.26 (2.92, 3.61)

Guydish 2008, Outpatient/community

4.14 (3.09, 5.20)

Miller-Thomas 2005-07, Outpatient/community

2.44 (2.15, 2.74)

Rothrauff 2008, Outpatient/community

2.27 (2.21, 2.33)

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ro

Eby 2008a, Outpatient/community

Residential/Inpatient/Hospital

2.48 (2.22, 2.75)

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Eby 2008a, Residential/Inpatient/Hospital Guydish 2008, Residential/Inpatient/Hospital

3.20 (2.81, 3.59)

Guydish 2006-08, Residential/Inpatient/Hospital

2.53 (2.04, 3.03)

Pagano 2009, Residential/Inpatient/Hospital Pagano 2013, Residential/Inpatient/Hospital

Combination Eby 2008b, Combination

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Knudsen 2006-08, Combination

2.50 (2.10, 2.90) 3.26 (2.85, 3.66) 3.42 (2.96, 3.88) 3.18 (2.79, 3.57)

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Pagano 2008, Residential/Inpatient/Hospital

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Miller-Thomas 2005-07, Residential/Inpatient/Hospital

-5.2

2.21 (2.16, 2.26) 1.46 (1.43, 1.48)

0

5.2

Figure 3. Forest plot of standardised effect estimates of clinician service studies by setting

Table 5: Meta-regression of pooled tobacco smoking cessation estimates (clinician) on treatment setting. Setting

Estimate (95% CI)

P-value

Inpatient/residential/hospital

Ref

-

Outpatient/community

-0.09 (-0.86, 0.69)

0.809

Combination

-1.10 (-2.02, -0.18)

0.023

24

Journal Pre-proof Discussion To the authors’ knowledge, this is the first review to synthesis the published literature regarding the level of preventive care provision for modifiable health risk behaviours within substance use treatment settings. The identified studies covered a range of substance use treatment services and utilised both client and clinician reported prevalence of care. Metaregression analyses found clinician reported preventative care for tobacco smoking was more frequently reported in studies assessing care occurring across multiple substance use treatment settings, compared to studies reporting care provision in inpatient only settings. No differences were found for client reported provision of preventive care between outpatient,

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inpatient or combination settings.

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Of the 16 studies identified, 15 described the provision of preventive care for tobacco

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smoking only. The focus on tobacco smoking by the current literature may be due to the high prevalence of tobacco smoking within people with substance use problems (Guydish et al.,

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2016; Guydish et al., 2011a). In addition, smoking cessation guidelines often highlight people with substance as a focus population for smoking cessation care (Fiore et al., 2008; NSW

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Ministry of Health, 2002), whereas guidelines for insufficient fruit and/or vegetable consumption and insufficient physical activity make no such recommendations (Department

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of Health, 2014; UK Department of Health, 2011). It was difficult to summarise the level of tobacco smoking preventive across all 16 studies

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that reported this outcome given the range of measures used. However, for the four studies (Cookson et al., 2014; Nahvi et al., 2014; Skelton et al., 2017; Tremain et al., 2016) that reported care provision as a proportion, a trend in levels of care delivery was indicated across care elements. Care was most frequently provided for assessment of tobacco smoking, followed by brief advice and then for referral to further tobacco smoking cessation support. This trend is consistent with systematic reviews investigating the provision of smoking cessation care in other settings (Freund et al., 2008) and preventive care more generally (Bailey, 2018; McElwaine, 2015). Assessment of smoking risk was provided at relatively high levels (62-90%) and this may in part reflect that clients of healthcare services are routinely asked about their smoking status as a part of routine intake or admission procedures. Conversely, referral to ongoing cessation support was most often provided at particularly low levels (0-30%). Barriers to referral for smoking cessation care have been reported in general health settings and include time to complete the referral, lack of

25

Journal Pre-proof knowledge regarding referral options, perceptions regarding client interest in an offer of referral and perceived effectiveness of referral options (Cantrell and Shelley, 2009; Holtrop et al., 2008; Martin et al., 2017). Additionally, provision of referral may be low as some treatment settings may provide smoking cessation counselling and medication within the clients’ appointment (Baca and Yahne, 2009; Thurgood et al., 2016). Referral is a crucial element of preventive care as it allows the ongoing behaviour change support to be provided to the client (Fiore et al., 2008; Glasgow et al., 2004). As such, understanding the barriers to referral that may be specific to substance use settings, and the provision of smoking cessation counselling and medication with such settings, is likely to be an important step to inform

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future initiatives to increase care delivery.

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Thirteen studies reported smoking cessation care provision as a mean score. The majority of these studies reported provision as an overall care score rather than for single elements of

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care (i.e. assess, advice, refer). Of the studies reporting an overall mean score, client reported

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care ranged from 1.93 to 2.7 and clinician reported provision of care ranged from 2.05 to 3.5. Based on the Likert scale used (where 3=Occasionally), these outcomes suggest that, similar

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to studies reporting cessation care as a proportion, such care was not routinely provided. For studies reporting score-based measures of care provision little difference between settings

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for client reported provision of care was suggested. A minimal, but statistically significant, difference was observed between combination treatment settings and inpatient settings for

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clinician reported provision of care. No difference in care levels was found between outpatient and inpatient settings. The limited association of tobacco smoking related preventive care with treatment settings may indicate that care is being provided similarly across all settings. As such, all settings require implementation support to improve the provision of tobacco smoking cessation related preventive care. However, the results should be interpreted with caution as the scores were standardised to give an overall care provision due to the range of measures used and the limited number of studies in some setting groups. The one study that examined preventive care levels for insufficient fruit and vegetable consumption and insufficient physical activity, used both clinician and client surveys and reported care as a proportion. A similar trend to tobacco smoking cessation care was observed. . Care was most frequently provided for assessment (23-90%), followed by brief advice (25-80%), with minimal offers of referral to further support (0-30%) reported. Within

26

Journal Pre-proof risk factors, care was most frequently provided for tobacco smoking, followed by insufficient physical activity and insufficient nutrition. The review highlighted the range of methods used to measure and report the provision of preventive care within substance use settings which hindered comparison of care levels across studies. Within the 12 studies utilising mean scores to report care provision, there were variations in the items used to assess each care element across some studies. Score based measures can also be difficult to interpret when they are reported in aggregate form. Comparison of measures of client and clinician reported care levels was not able to be

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undertaken as clients reported from their own singular experience whereas clinicians reported care levels for multiple clients. Despite this, using two or more data collection methods

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within a single study does have merit as it allows triangulation of data and an examination of

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trends across data collection methods (Olsen et al., 2005).

The findings of this review should be interpreted in light of some potential limitations. First,

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no studies met all nine methodological criteria. Second, the review only included studies published in English. In addition, the search terms used may have missed relevant studies if

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they are used differently in other countries. Third, standardisation of results to create an overall estimate of care provision was required to conduct meta- regression analyses and

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inhibited the comparison of individual elements of care. Fourth, most studies were based in the United States, which may limit the generalisability of the results. Finally, only one study

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was identified that examined care provision for insufficient nutrition and insufficient physical activity, and so conclusions regarding the prevalence of preventive care for these risk factors is extremely limited. Conclusion

The majority of studies reporting the level of preventive care provided in substance use settings examined smoking cessation care only. Only one study was identified that investigated the provision of preventive care for insufficient nutrition or insufficient physical activity. Studies used a range of measurement tools and methodologies making synthesis and comparison across studies difficult. However, overall, suboptimal levels of preventive care were indicated, particularly for referral to ongoing assistance.

27

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