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Barriers to implement screening for alcohol consumption in Spanish hypertensive patients

Barriers to implement screening for alcohol consumption in Spanish hypertensive patients Abstract Background Alcohol intake and hypertension (HT) are interrelated public health problems with cost-effective interventions at the primary care level that, to date, are poorly implemented. Objective This study aims to explore the barriers to implementing alcohol interventions for people with HT in primary care. Methods As part of the project BASIS (Baseline Alcohol Screening and Intervention Survey), an internet survey from five European countries was developed to determine the role of alcohol in the management of HT in primary care practice. The survey contained 28 core items and 7 country-specific items. We present answers from Spanish general practitioners (GPs), who were reached through the main professional and scientific societies via e-mail and asked to take the online survey. Results In total, 867 GPs answered the survey (65.1% women, 70.4% > 30 years old). As indicated by the Alcohol Use Disorders Identification Test-C scores, 12.4% of GPs who responded were risky drinkers (21.3% of men versus 7.1% of women). GPs reported considering alcohol relatively unimportant in HT treatment, as well as a difficult condition to deal with. The three main barriers to implement screening for alcohol consumption in HT patients were the lack of time (50.0%), considering alcohol unimportant for HT (28.4%) and stigma (16.5%). Conclusions GPs did not consider alcohol consumption a relevant factor for HT and, additionally, found it difficult to deal with alcohol problems. Some of the barriers for alcohol screening could be overcome through structural changes in the health system, such as empowering GPs to treat alcohol use disorders (rather than a single focus on implementing preventive strategies) by enhancing training in alcohol diagnosis and treatment. Alcohol, barriers, hypertension, primary care, screening, treatment Introduction Alcohol is a risk factor for more than 200 health conditions (1). One way in which alcohol affects health is by its impact on blood pressure and hypertension (HT) (2), which are themselves major risk factors for cardiovascular diseases, and therefore related to increased mortality (3). Globally, cardiovascular disease is the largest cause of death (4). In Europe, 30–40% of the European population suffers from HT (5) (defined as blood pressure ≥140/90 (6)), while 15% of European citizens are risky drinkers (7) (defined as a quantity or pattern of alcohol use that places individuals at risk for adverse health and social outcomes). For research and clinical purposes, risky drinking is defined considering quantity and frequency of drinking by using alcohol standard units per day (SDU) or the Alcohol Use Disorders Identification Test (AUDIT)-C which includes information on SDU. Alcohol use and HT are among eight factors (e.g. tobacco use, high body mass index, high cholesterol, hyperglycaemia, poor diet and physical inactivity) which account for 61% of healthy life years lost due to cardiovascular disease. As determinants, alcohol combined with HT represent 1369 years of life lost and 1478 disability-adjusted life years (8). Several risk factors are linked to HT, including older age, gender (young men and women >65 years old), family history of HT, race, overweight, poor diet, lack of physical activity, stress, tobacco and alcohol use (9). The relationship between alcohol consumption and blood pressure is well established. Regular alcohol use increases blood pressure in HT patients under treatment, and alcohol-related HT decreases with abstinence or reductions in alcohol consumption (10). A recent comprehensive meta-analysis has shown that the effect of reducing alcohol intake on improving HT is more significant at higher levels of drinking (11). Moreover, risky drinkers have a 1.5 times greater risk of presenting uncontrolled HT (12)—defined as persistent high blood pressure, despite lifestyle changes and taking diuretic and antihypertensive medications (13)). In Spain, despite the improvement of HT management in the last decade, <25% of hypertensive patients have controlled blood pressure levels (6). In rural areas, the prevalence of HT is high because the level of awareness of high blood pressure is low. Regarding gender, men have lower level of awareness about the risk of having high blood pressure than women, as in other countries (14). In addition, the risk perception of risky alcohol use is low in the Spanish general population, especially among risky drinkers, men in general and young people (15,16). Part of the reason for insufficient levels of blood pressure control is the difficulties in adhering to lifestyle advice (17). It is worth noting that the reduction of raised blood pressure is one of the nine strategic goals identified in the World Health Organization’s ‘Global Action Plan for Prevention and Control of Non-Communicable Diseases (NCDs) 2013–2020’. In Spanish primary care, 17.9% of the population older than 14 years has a diagnosis of HT (18.7% women). For the population older than 40 years, this figure increases to 32%, and for those older than 70 years, it is between 60% and 70% (18). Alcohol, consumed by 77.6% of the Spanish population (19), is a lifestyle factor that should be taken into account in the management of HT, since screening and brief intervention (BI) tools have demonstrated their effectiveness in tackling this problem (20). However, several barriers hamper the implementation of screening, brief intervention and referral to treatment (SBIRT) strategies in primary care—lack of time and resources, insufficient knowledge and skills and negative attitudes towards SBIRT (21). In Europe, research shows that training, support and financial incentives for SBIRT should lead to improved access to this cost-effective strategy (22). In other countries, such as the USA, SBIRT programmes with committed leadership and the use of specialists to deliver the service have been demonstrated to be useful (23). Reducing alcohol consumption in hypertensive patients would improve HT management and reduce pharmacological treatment. Unfortunately, screening and BI for risky drinking are underused in general, and also among hypertensive patients (24). There is a paucity of studies analysing the barriers to identification and treatment of risky drinkers among this specific patient population in routine practice. These patients are a target population for SBIRT because they attend primary care and suffer from an alcohol-related condition, clearly warranting BI. Studies to date which focus on SBIRT barriers have several limitations. They do not analyse in depth why these barriers appear in the first place. They generally do not assess the impact of GPs’ attitude, socio-demographic characteristics, GPs’ drinking patterns, or their training in alcohol management of those barriers. Furthermore, they do not analyse differences between those who regularly implement SBIRT and those who do not, and do not study a specific target population as hypertensive patients. We designed our study to correct these limitations. This study aims to (i) identify GPs’ attitudes and possible barriers in the identification and clinical management of alcohol use among HT patients; and (ii) explore whether any of the following GP’s characteristics were associated with these barriers: sex, age, GP training (graduate and postgraduate), number of patient visits per day and GP’s own pattern of alcohol consumption. These factors represent either commonly cited barriers of alcohol screening among GPs (e.g. lack of training, workload) (25) or personal characteristics (i.e. sex, age and pattern of alcohol consumption), which were hypothesized to impact on the GP’s perception of HT patients’ alcohol consumption. Here, we present data from the Spanish sample of the Baseline Alcohol Screening and Intervention Survey (BASIS) study on alcohol management in hypertensive patients in primary care practices of five European countries (for the European results of BASIS see (24)). Method Data collection A 35-item survey was developed to explore GPs’ attitudes, opinions and perceived barriers towards alcohol management in HT patients attending their practices. A pilot study using an English version of the survey was conducted among 41 health professionals of five different countries. The final versions (translated into French, German, Italian and Spanish) were administered online using SurveyMonkey© (http://www.surveymonkey.com/). Further details about the procedure and assessment of the survey have previously been published (24). The Spanish version of the questionnaire is available in the supplementary material. The following data were obtained from all participating GPs: demographics, alcohol use (AUDIT-C questionnaire (26)) (contained in the survey as the last three questions), number of patient visits per day and number of patients with HT diagnosis per day (for more details, see Supplementary material). Outcome measures GPs were also asked about the three most relevant risk factors for HT and how easy they found it to deal with them (respondents could choose from overweight, salt intake, sleep apnoea, alcohol use, physical activity, smoking and stress). The survey also asked GPs about the perceived capacity of their HT patients to reduce their blood pressure and/or avoid medication through lifestyle changes; and about their own ability and training to deal with risky drinking and alcohol dependence. Those GPs who reported screening for alcohol consumption in <30% of their HT patients were asked about the reasons that deter them from screening. For more details, see the questionnaire in the Supplementary material. Participants Different organizations—Semfyc (Sociedad Española de Medicina de Familia y Comunitaria, https://www.semfyc.es/medicos/) and Semergen (Sociedad Española de Médicos de Atención Primaria, http://www.semergen.es/)—Spanish professional and scientific GP societies, disseminated the survey link to their members via e-mail (n = 20620). Just over 4% (867 GPs) completed the survey, 65.1% being women and 70.4% being older than 30 years. As the study was an anonymous survey, it was exempt from the research ethics committee approval. All respondents were given a brief description of the aims of the study before the actual survey started. Consent to participate was therefore a precondition for taking the survey. Statistical analyses A descriptive analysis of the sample was carried out. Continuous variables were described using means (SD), whereas categorical variables were described using counts and percentages (95% CI). GPs with low alcohol screening rates (<30%) were compared with those who had high alcohol screening rates using the Student’s t-test for continuous variables (number of patients per day, number of patients with HT per day), and the Pearson’s chi-square test or Fisher’s exact test for categorical variables (sex, age >30 years old, alcohol graduate training, alcohol postgraduate training). Those variables with a P value of <0.1 in the univariate analyses were introduced in the logistic regression analysis with GPs with low alcohol screening rate being the dependent variable. To analyse the variables related to each barrier (age, gender, risky drinking, graduate and postgraduate training, number of visits per day), comparisons between screening rate groups were performed using the Student’s t-test for continuous variables and the Pearson’s chi-square test or Fisher’s exact test for categorical variables for each barrier identified. Categorical variables were re-coded into two categories where necessary. Risky drinking was defined as an AUDIT-C score of >4, which has been shown to provide high specificity in both men and women (0.96/0.98)). A P value of <0.05 was required for significance. Bonferroni correction was done, with P = 0.05/6 = 0.0083. All analyses were carried out using the SPSS statistical package (SPSS Inc., version 23.0, Chicago, IL). Results In total, 20620 Spanish GPs were contacted. The response rate was 5.6%, 1146 started the survey and 867 completed it (75.7%). Of the total sample, 65.1% (95% CI: 64.8–66.1%) were women and 70.4% (95% CI: 69.8–71.0%) were >30 years of age. Risky drinking among GPs was estimated at 12.4% (95% CI: 10.2–14.6%): 21.3% (95% CI: 18.6–24.0%) for men and 7.1% (95% CI: 5.4–8.8%) for women, with differences between gender being statistically significant (χ21df = 32.564, P < 0.001). On average, GPs attended 36.8 patients (SD = 18.3), including 13 HT patients per day (SD = 7.9). GPs’ opinions on the relationship between alcohol and HT Of all presented lifestyle factors related to HT, GPs judged alcohol as the least relevant and the second least easy to deal with (stress was the only risk factor considered more difficult to handle than alcohol, see Table 1). Furthermore, GPs estimated that giving advice on lifestyle changes could lead to patients avoiding HT medication in about every fourth case (95% CI: 23.5–28.5%) of a patient with HT diagnosis. More specifically, GPs reported 16% (95% CI: 13.9–18.1%) of HT patients would follow advice to change alcohol intake to avoid HT medication. Table 1. General practitioners’ perception of risk factors’ relevance for HT and easiness to deal with them (n = 867). Data collected between 29 September and 1 December 2015 Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) CI, confidence interval. View Large Table 1. General practitioners’ perception of risk factors’ relevance for HT and easiness to deal with them (n = 867). Data collected between 29 September and 1 December 2015 Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) CI, confidence interval. View Large Over half of the GPs regarded their graduate training on alcohol management as insufficient (62.5%, 95% CI: 59.7–65.3%) and only 53% (95% CI: 50.1–55.9%) had received some specific postgraduate training on alcohol management. One in four of GPs judged their graduate training on HT as insufficient (76.7%, 95% CI 73.9–79.5%) and 54.9% (95% CI 51.6–58.2%) had received specific postgraduate training on HT. Only 21.9% (95% CI 19.5–24.3%) of Spanish GPs who responded felt capable of dealing with both alcohol dependence and risky drinking, and 61.4% (95% CI: 58.6–64.2%) perceived themselves as capable of dealing only with risky drinking and 14.2% (95% CI: 12.2–16.2%) did not feel competent dealing with either risky drinking or alcohol dependence. Very few of the respondents felt capable of dealing with alcohol dependence but not with risky drinking (2.5%, 95% CI 1.7–3.8%). In total, 83.3% (95% CI 80.6–85.7%) of GPs perceived themselves as capable of dealing with risky drinkers (with or without being able to manage alcohol dependence in patients); meanwhile, 24.4% (95% CI 21.6–27.5%) perceived themselves as capable of dealing with alcohol dependence (irrespective of their ability to manage risky drinking). The description of GPs’ characteristics and the differences between low-screening respondents and high-screening respondents are reported in Table 2. Those GPs seeing the highest number of patients with HT per day (OR = 0.97 95% CI 0.95–0.99), with higher levels of graduate training (OR = 0.65 95% CI 0.47–0.91) and postgraduate training in alcohol (OR = 0.54 95% CI 0.39–0.74), were less likely to be low screening respondents (Table 3). Table 2. GPs’ sample characteristics and differences between low-screening and high-screening general practitionersGPs. Data collected between 29 September and 1 December 2015 All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) HT, hypertensive. aGPs’ low screening: GPs who screen for alcohol ≤3 out of 10 hypertensive patients. View Large Table 2. GPs’ sample characteristics and differences between low-screening and high-screening general practitionersGPs. Data collected between 29 September and 1 December 2015 All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) HT, hypertensive. aGPs’ low screening: GPs who screen for alcohol ≤3 out of 10 hypertensive patients. View Large Table 3. Binary logistic regression results OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 Factors are related to GPs having low rates of alcohol screening in patients with HT. Data collected between 29 September and 1 December 2015. aVersus insufficient alcohol graduate training; bVersus insufficient alcohol postgraduate training. View Large Table 3. Binary logistic regression results OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 Factors are related to GPs having low rates of alcohol screening in patients with HT. Data collected between 29 September and 1 December 2015. aVersus insufficient alcohol graduate training; bVersus insufficient alcohol postgraduate training. View Large Barriers to implementing screening among low-screening respondents Just under one-fifth of the GPs (19%, 95% CI: 16.7–21.3%) screened for alcohol in, at most, 30% of their HT patients. Half of them reported lack of time as a barrier to screening for alcohol use (50%, 95% CI: 43.4–56.6%), and 28.4% (95% CI: 22.4–34.4%) considered alcohol consumption non-relevant for HT. For importance of all other barriers, see Table 4. We did not find any relevant pattern when analysing how the three most reported barriers were ranked (data not shown). Table 4. Gs’ ranking barriers to screen for alcohol use referred by low-screening GP respondents (n = 218). Data collected between 29 September and 1 December 2015. Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) View Large Table 4. Gs’ ranking barriers to screen for alcohol use referred by low-screening GP respondents (n = 218). Data collected between 29 September and 1 December 2015. Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) View Large Associations between GPs’ characteristics (sex, age, own risky drinking, training and workload) and each barrier were examined. Age, sex and risky drinking status were not associated with any of the reported barriers (P > 0.064). Insufficient undergraduate training was linked to higher rates of questioning the appropriateness of asking about alcohol use (7.5% versus 1.3%; χ21df = 5.7, Fisher’s exact test, P = 0.028). Furthermore, GPs with a higher mean number of appointments per day found lack of time to be a barrier (38.2 patients per day versus 35.4 per day; t = 2.3, P = 0.022). However, the observed differences did not remain significant after Bonferroni correction. Discussion In our sample, most of the responding GPs do not view alcohol screening as a priority among their HT patients because of the following reasons:(i) they largely perceive alcohol use as non-relevant for HT and (ii) they consider patients’ risky drinking as a difficult situation to handle. On top of that, they report low rates of perceived success when advising patients to decrease their alcohol intake. GPs have an important role not only in managing but also in preventing HT. This is reflected in a high percentage of GPs recommending most preventive lifestyle measures to their patients (reducing salt intake, healthy diet, physical activity, quit smoking, etc.), in accordance with clinical guidelines for the treatment of high blood pressure (27). However, reducing alcohol intake is the least recommended (28), despite alcohol and high blood pressure having a dose–response relationship (29): the higher the alcohol intake, the higher the risk of HT. Furthermore, risky drinking doubles the risk of HT (2). Giving advice to reduce alcohol consumption can lead to a reduced risk of developing HT, while non-adherence to lifestyle advice is associated with apparent treatment resistance (17). Screening for alcohol consumption and BI have demonstrated effectiveness to reduce alcohol consumption in primary care, even though implementation rates are low (30). Although Spain is one of the European countries where screening for alcohol and intervention are more often delivered (24), in our study, Spanish GPs considered alcohol as the least relevant lifestyle risk factor for HT. These results are in accordance with the fact that less than half of GPs reported a sufficient level of alcohol screening practice in HT patients (24). There is a dramatic difference between the readiness to deal with risky drinkers (83.3%) and the perceived competence to treat alcohol dependence (24.4%), which is a stigmatized mental disorder (31). GPs with the lowest rates of alcohol screening reported that time constraints and considering alcohol unimportant for HT were the main barriers to alcohol screening their HT patients. Time constraints have been identified as a barrier for screening and implementing BI in many studies (21,32,33). Spanish GPs have a high caseload, which is also a problem in many other European countries (34). In Catalonia, GPs have only 10 min per patient for a routine visit, similarly to other European countries (e.g. UK or Germany), despite feeling that they need more time to offer high-quality care. Other barriers which may be stigma related were also reported (i.e. fear of annoying the patient or feeling that having previous knowledge of the patient habits precludes repeating the questions). To foster less stigmatizing and more normalizing attitudes to alcohol screening, it has been proposed to measure AUDs as a continuum as is done with blood pressure (35). AUD is just the extreme end of the continuum of alcohol use. Understanding and talking about alcohol consumption as a continuum could help people to see their consumption as part of this continuum, rather than in discrete polar categories (healthy use/health disorder) (36). In this sense, adopting a definition and discourse of heavy use over time, which is responsible for the neurobiological changes associated with AUD and the substance-attributable burden of disease including social costs, might avoid some of the problems that current conceptualizations have and can help to reduce stigmatization. Barriers to alcohol screening in HT patients, described by GPs with low-screening rates, could be overcome through structural changes in primary care practice and more adequate training. Structural changes including proper reimbursement, sufficient time per patient, electronic health record systems that facilitate administering screening tools and enhanced professional training on alcohol management (graduate and postgraduate) can improve the implementation of screening and BI (37). The importance of professional training is highlighted in our study, where GPs who have received postgraduate education are more likely to screen and manage alcohol use in HT patients (24). However, we should avoid excessive optimism with regard to new strategies to improve BI implementation, as not all of them have been successful. In the Optimizing Delivery of Healthcare Intervention (ODHIN) study, a five-country cluster randomized factorial trial in which the researchers assessed three strategies to improve implementation of BI; internet intervention after screening failed to improve BI delivery, but training and support, and financial reimbursement were found to be valid strategies (25,38). In Catalonia, the engagement of GPs on a web-based BI was modest (data not published). According to GPs’ perceptions, financial incentives should be included in their salaries instead of being temporarily introduced and subject to a specific screening project. The ODHIN GPs felt that training and support must improve knowledge, skills and prioritization, and must be accompanied by enough time to learn techniques and to tailor them to specific barriers, according to different GPs’ points of view (39). The preventive model established in Spain for alcohol consumption seems to fail. Thus, it is important to spread the message among primary care professionals that managing AUD is, in fact, treating an illness, falling within their remit because they are trained to do so, in the same way they do with high blood pressure or hyperhcolesteromia (40). Alcohol consumption in Spain is slightly above the WHO European region per capita average (12.3 versus 11.9 l of pure alcohol per year), while the prevalence of AUD is lower (1.3% versus 7.5%), and the prevalence of alcohol use in the last 12 months is 73.4% (1). All these figures are typical of a viticulture society, in which there is a normative perception of high levels of consumption. We found that 12.4% of GPs who answered the survey were themselves classified as risky drinkers. Similar prevalences of risky drinking have been found among Italian resident physicians, US medical students, German hospital doctors and Belgian specialists (41–45), while the prevalence is low compared to Finnish medical students (24–49%) (46). We know that there is a misperception of alcohol use among risky drinkers, the so called ‘normative fallacy’, in which peers’ alcohol consumption is estimated to be at least as high as risky drinker’s intake (16). We expected that risky drinking GPs would be less aware of risky alcohol use among their patients, but our results did not support this hypothesis. However, we think that alcohol consumption patterns of GPs should continue to be considered in those studies that aim to explore barriers for BI, precisely because a lack of evidence is not evidence for a lack of effect or association. In Spain, a relationship exists between the patients’ awareness of their HT and living in rural areas. However, there are only a few studies that focus on alcohol consumption and living in rural areas (where, e.g., alcohol is perceived as a part of daily diet (47), and there is higher prevalence of adolescent alcohol consumption) (48), and no studies focusing on the relationship between HT awareness, alcohol consumption and rural areas. This approach is important because we already know that access to lifestyle counselling is lower in rural areas (49). Unfortunately, this point was also beyond the scope of our study. Furthermore, our study illustrates that the improved understanding of barriers can be directly translated into measures to improve the management of alcohol and HT at the primary care level. A reduction in workload could be brought about by introducing structural changes. Furthermore, promoting collaborative team-based policies between GPs, mental health care professionals, nurses and pharmacists or introducing financial incentives (37) could enhance alcohol and HT management. In addition, widespread (post-) graduate training to increase awareness of alcohol-related conditions and its management among primary care professionals, and facilitating skills to promote healthy lifestyle changes should be considered as key measures to improve knowledge and reduce the perceived stigma related to risky drinking or alcohol dependence. According to the Agency for Healthcare Research and Quality (US Department of Health and Human Services), ‘Integrated Behavioral Health Care’ is defined as ‘the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population’(50). In our opinion, BIs for risky drinkers should be interpreted in this context. This study has some limitations. Although the original sample to whom the survey was sent was representative of Spanish GPs, the response rate was low (5.6%), which should be taken into account when generalizing the results. This response rate was similar to other countries in the same study (between 4.1 and 8.5%), but lower than in other similar studies. Web-based behaviour change intervention studies, using personalized e-mails, were found to have better response rates than studies using generic e-mails. Hence, future studies in this field should bear this approach in mind. Moreover, limitations inherent to self-reported answers (e.g. memory effects reducing reliability) also apply to this study, while the social desirability bias can be assumed to be minimal, as survey responses were given anonymously. The main strength of the study, however, is that it covers a large territory. In conclusion, as long as GPs do not consider alcohol consumption a relevant factor to deal with when treating hypertensive patients, they will not intervene. Changing this perception must be a priority, because it is well known that alcohol plays an important role in resistant HT, on top of the high burden of disease due to both alcohol and HT. Barriers described might be overcome through structural changes that could include training and support, financial incentives, conceptualizing AUD and alcohol consumption as parameters on a continuum and treating AUD as an illness in its own right, instead of regarding it as a factor in a preventive model. These strategies all show promise for reducing HT and its associated burden. Supplementary material Supplementary material is available at Family Practice online. Declaration Funding: The study was financially supported by an investigator-initiated grant to Jürgen Rehm and the GWT-TUD (Gesellschaft für Wissens - und Technologietransfer der TU Dresden mbH—company with limited liabilities for transferring knowledge and technology of the Dresden University of Technology) by Lundbeck. The study sponsor has had no role in study design, collection, analysis and interpretation of data. The study sponsor has also had no role in writing this account or the decision to submit this paper for publication. The corresponding author confirms that all authors had full access to the data in the study at all times and had final responsibility for the decision to submit for publication. This work was supported by RD12/0028/0016 project, Plan Nacional de I+D+I and financed jointly with ISCII-Subdirección General de Evaluación y Fondo Europeo de Desarrollo Regional (FEDER). The study also received the support of ‘Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya’ (2014SGR649). Conflict of interest: LM has received honoraria from Lundbeck, outside the work for this project. HLP has received training funds from Lundbeck, Janssen, Pfizer, Lilly, Rovi and Esteve, and has also received fees from Lundbeck, Teva and Janssen. JÁA has acted as an advisor and received funding for research, publication and training from the following companies: Almirall, AstraZeneca, Glaxo-Smith-Kline, Lilly, Lundbeck, Merck, Pfizer, Servier, Esteve. JZ has acted as an advisor and has received funding for consultancy, research, publications and carrying out training activities from Lundbeck and Lilly and fees from F Glead. JR has received educational grants, travel support and honoraria from Lundbeck outside and unrelated to the work on this manuscript. 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Barriers to implement screening for alcohol consumption in Spanish hypertensive patients

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© The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
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Abstract

Abstract Background Alcohol intake and hypertension (HT) are interrelated public health problems with cost-effective interventions at the primary care level that, to date, are poorly implemented. Objective This study aims to explore the barriers to implementing alcohol interventions for people with HT in primary care. Methods As part of the project BASIS (Baseline Alcohol Screening and Intervention Survey), an internet survey from five European countries was developed to determine the role of alcohol in the management of HT in primary care practice. The survey contained 28 core items and 7 country-specific items. We present answers from Spanish general practitioners (GPs), who were reached through the main professional and scientific societies via e-mail and asked to take the online survey. Results In total, 867 GPs answered the survey (65.1% women, 70.4% > 30 years old). As indicated by the Alcohol Use Disorders Identification Test-C scores, 12.4% of GPs who responded were risky drinkers (21.3% of men versus 7.1% of women). GPs reported considering alcohol relatively unimportant in HT treatment, as well as a difficult condition to deal with. The three main barriers to implement screening for alcohol consumption in HT patients were the lack of time (50.0%), considering alcohol unimportant for HT (28.4%) and stigma (16.5%). Conclusions GPs did not consider alcohol consumption a relevant factor for HT and, additionally, found it difficult to deal with alcohol problems. Some of the barriers for alcohol screening could be overcome through structural changes in the health system, such as empowering GPs to treat alcohol use disorders (rather than a single focus on implementing preventive strategies) by enhancing training in alcohol diagnosis and treatment. Alcohol, barriers, hypertension, primary care, screening, treatment Introduction Alcohol is a risk factor for more than 200 health conditions (1). One way in which alcohol affects health is by its impact on blood pressure and hypertension (HT) (2), which are themselves major risk factors for cardiovascular diseases, and therefore related to increased mortality (3). Globally, cardiovascular disease is the largest cause of death (4). In Europe, 30–40% of the European population suffers from HT (5) (defined as blood pressure ≥140/90 (6)), while 15% of European citizens are risky drinkers (7) (defined as a quantity or pattern of alcohol use that places individuals at risk for adverse health and social outcomes). For research and clinical purposes, risky drinking is defined considering quantity and frequency of drinking by using alcohol standard units per day (SDU) or the Alcohol Use Disorders Identification Test (AUDIT)-C which includes information on SDU. Alcohol use and HT are among eight factors (e.g. tobacco use, high body mass index, high cholesterol, hyperglycaemia, poor diet and physical inactivity) which account for 61% of healthy life years lost due to cardiovascular disease. As determinants, alcohol combined with HT represent 1369 years of life lost and 1478 disability-adjusted life years (8). Several risk factors are linked to HT, including older age, gender (young men and women >65 years old), family history of HT, race, overweight, poor diet, lack of physical activity, stress, tobacco and alcohol use (9). The relationship between alcohol consumption and blood pressure is well established. Regular alcohol use increases blood pressure in HT patients under treatment, and alcohol-related HT decreases with abstinence or reductions in alcohol consumption (10). A recent comprehensive meta-analysis has shown that the effect of reducing alcohol intake on improving HT is more significant at higher levels of drinking (11). Moreover, risky drinkers have a 1.5 times greater risk of presenting uncontrolled HT (12)—defined as persistent high blood pressure, despite lifestyle changes and taking diuretic and antihypertensive medications (13)). In Spain, despite the improvement of HT management in the last decade, <25% of hypertensive patients have controlled blood pressure levels (6). In rural areas, the prevalence of HT is high because the level of awareness of high blood pressure is low. Regarding gender, men have lower level of awareness about the risk of having high blood pressure than women, as in other countries (14). In addition, the risk perception of risky alcohol use is low in the Spanish general population, especially among risky drinkers, men in general and young people (15,16). Part of the reason for insufficient levels of blood pressure control is the difficulties in adhering to lifestyle advice (17). It is worth noting that the reduction of raised blood pressure is one of the nine strategic goals identified in the World Health Organization’s ‘Global Action Plan for Prevention and Control of Non-Communicable Diseases (NCDs) 2013–2020’. In Spanish primary care, 17.9% of the population older than 14 years has a diagnosis of HT (18.7% women). For the population older than 40 years, this figure increases to 32%, and for those older than 70 years, it is between 60% and 70% (18). Alcohol, consumed by 77.6% of the Spanish population (19), is a lifestyle factor that should be taken into account in the management of HT, since screening and brief intervention (BI) tools have demonstrated their effectiveness in tackling this problem (20). However, several barriers hamper the implementation of screening, brief intervention and referral to treatment (SBIRT) strategies in primary care—lack of time and resources, insufficient knowledge and skills and negative attitudes towards SBIRT (21). In Europe, research shows that training, support and financial incentives for SBIRT should lead to improved access to this cost-effective strategy (22). In other countries, such as the USA, SBIRT programmes with committed leadership and the use of specialists to deliver the service have been demonstrated to be useful (23). Reducing alcohol consumption in hypertensive patients would improve HT management and reduce pharmacological treatment. Unfortunately, screening and BI for risky drinking are underused in general, and also among hypertensive patients (24). There is a paucity of studies analysing the barriers to identification and treatment of risky drinkers among this specific patient population in routine practice. These patients are a target population for SBIRT because they attend primary care and suffer from an alcohol-related condition, clearly warranting BI. Studies to date which focus on SBIRT barriers have several limitations. They do not analyse in depth why these barriers appear in the first place. They generally do not assess the impact of GPs’ attitude, socio-demographic characteristics, GPs’ drinking patterns, or their training in alcohol management of those barriers. Furthermore, they do not analyse differences between those who regularly implement SBIRT and those who do not, and do not study a specific target population as hypertensive patients. We designed our study to correct these limitations. This study aims to (i) identify GPs’ attitudes and possible barriers in the identification and clinical management of alcohol use among HT patients; and (ii) explore whether any of the following GP’s characteristics were associated with these barriers: sex, age, GP training (graduate and postgraduate), number of patient visits per day and GP’s own pattern of alcohol consumption. These factors represent either commonly cited barriers of alcohol screening among GPs (e.g. lack of training, workload) (25) or personal characteristics (i.e. sex, age and pattern of alcohol consumption), which were hypothesized to impact on the GP’s perception of HT patients’ alcohol consumption. Here, we present data from the Spanish sample of the Baseline Alcohol Screening and Intervention Survey (BASIS) study on alcohol management in hypertensive patients in primary care practices of five European countries (for the European results of BASIS see (24)). Method Data collection A 35-item survey was developed to explore GPs’ attitudes, opinions and perceived barriers towards alcohol management in HT patients attending their practices. A pilot study using an English version of the survey was conducted among 41 health professionals of five different countries. The final versions (translated into French, German, Italian and Spanish) were administered online using SurveyMonkey© (http://www.surveymonkey.com/). Further details about the procedure and assessment of the survey have previously been published (24). The Spanish version of the questionnaire is available in the supplementary material. The following data were obtained from all participating GPs: demographics, alcohol use (AUDIT-C questionnaire (26)) (contained in the survey as the last three questions), number of patient visits per day and number of patients with HT diagnosis per day (for more details, see Supplementary material). Outcome measures GPs were also asked about the three most relevant risk factors for HT and how easy they found it to deal with them (respondents could choose from overweight, salt intake, sleep apnoea, alcohol use, physical activity, smoking and stress). The survey also asked GPs about the perceived capacity of their HT patients to reduce their blood pressure and/or avoid medication through lifestyle changes; and about their own ability and training to deal with risky drinking and alcohol dependence. Those GPs who reported screening for alcohol consumption in <30% of their HT patients were asked about the reasons that deter them from screening. For more details, see the questionnaire in the Supplementary material. Participants Different organizations—Semfyc (Sociedad Española de Medicina de Familia y Comunitaria, https://www.semfyc.es/medicos/) and Semergen (Sociedad Española de Médicos de Atención Primaria, http://www.semergen.es/)—Spanish professional and scientific GP societies, disseminated the survey link to their members via e-mail (n = 20620). Just over 4% (867 GPs) completed the survey, 65.1% being women and 70.4% being older than 30 years. As the study was an anonymous survey, it was exempt from the research ethics committee approval. All respondents were given a brief description of the aims of the study before the actual survey started. Consent to participate was therefore a precondition for taking the survey. Statistical analyses A descriptive analysis of the sample was carried out. Continuous variables were described using means (SD), whereas categorical variables were described using counts and percentages (95% CI). GPs with low alcohol screening rates (<30%) were compared with those who had high alcohol screening rates using the Student’s t-test for continuous variables (number of patients per day, number of patients with HT per day), and the Pearson’s chi-square test or Fisher’s exact test for categorical variables (sex, age >30 years old, alcohol graduate training, alcohol postgraduate training). Those variables with a P value of <0.1 in the univariate analyses were introduced in the logistic regression analysis with GPs with low alcohol screening rate being the dependent variable. To analyse the variables related to each barrier (age, gender, risky drinking, graduate and postgraduate training, number of visits per day), comparisons between screening rate groups were performed using the Student’s t-test for continuous variables and the Pearson’s chi-square test or Fisher’s exact test for categorical variables for each barrier identified. Categorical variables were re-coded into two categories where necessary. Risky drinking was defined as an AUDIT-C score of >4, which has been shown to provide high specificity in both men and women (0.96/0.98)). A P value of <0.05 was required for significance. Bonferroni correction was done, with P = 0.05/6 = 0.0083. All analyses were carried out using the SPSS statistical package (SPSS Inc., version 23.0, Chicago, IL). Results In total, 20620 Spanish GPs were contacted. The response rate was 5.6%, 1146 started the survey and 867 completed it (75.7%). Of the total sample, 65.1% (95% CI: 64.8–66.1%) were women and 70.4% (95% CI: 69.8–71.0%) were >30 years of age. Risky drinking among GPs was estimated at 12.4% (95% CI: 10.2–14.6%): 21.3% (95% CI: 18.6–24.0%) for men and 7.1% (95% CI: 5.4–8.8%) for women, with differences between gender being statistically significant (χ21df = 32.564, P < 0.001). On average, GPs attended 36.8 patients (SD = 18.3), including 13 HT patients per day (SD = 7.9). GPs’ opinions on the relationship between alcohol and HT Of all presented lifestyle factors related to HT, GPs judged alcohol as the least relevant and the second least easy to deal with (stress was the only risk factor considered more difficult to handle than alcohol, see Table 1). Furthermore, GPs estimated that giving advice on lifestyle changes could lead to patients avoiding HT medication in about every fourth case (95% CI: 23.5–28.5%) of a patient with HT diagnosis. More specifically, GPs reported 16% (95% CI: 13.9–18.1%) of HT patients would follow advice to change alcohol intake to avoid HT medication. Table 1. General practitioners’ perception of risk factors’ relevance for HT and easiness to deal with them (n = 867). Data collected between 29 September and 1 December 2015 Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) CI, confidence interval. View Large Table 1. General practitioners’ perception of risk factors’ relevance for HT and easiness to deal with them (n = 867). Data collected between 29 September and 1 December 2015 Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) Relevance (%, 95% CI) Easiness to deal with (%, 95% CI) Overweight/obesity 91.3 (89.4–93.2) 30.1 (27.1–33.2) High salt intake 53.9 (50.6–57.2) 74.5 (71.6–77.4) Smoking 51.4 (48.1–54.7) 20.8 (18.1–23.5) Lack of physical activity 49.8 (46.5–53.1) 46.7 (43.4–50.0) Stress 20.8 (18.1–23.5) 6.1 (4.51–7.69) Sleep apnoea 20.2 (17.5–22.9) 13.1 (10.9–15.4) Alcohol use 12.6 (10.4–14.8) 8.7 (6.8–10.6) CI, confidence interval. View Large Over half of the GPs regarded their graduate training on alcohol management as insufficient (62.5%, 95% CI: 59.7–65.3%) and only 53% (95% CI: 50.1–55.9%) had received some specific postgraduate training on alcohol management. One in four of GPs judged their graduate training on HT as insufficient (76.7%, 95% CI 73.9–79.5%) and 54.9% (95% CI 51.6–58.2%) had received specific postgraduate training on HT. Only 21.9% (95% CI 19.5–24.3%) of Spanish GPs who responded felt capable of dealing with both alcohol dependence and risky drinking, and 61.4% (95% CI: 58.6–64.2%) perceived themselves as capable of dealing only with risky drinking and 14.2% (95% CI: 12.2–16.2%) did not feel competent dealing with either risky drinking or alcohol dependence. Very few of the respondents felt capable of dealing with alcohol dependence but not with risky drinking (2.5%, 95% CI 1.7–3.8%). In total, 83.3% (95% CI 80.6–85.7%) of GPs perceived themselves as capable of dealing with risky drinkers (with or without being able to manage alcohol dependence in patients); meanwhile, 24.4% (95% CI 21.6–27.5%) perceived themselves as capable of dealing with alcohol dependence (irrespective of their ability to manage risky drinking). The description of GPs’ characteristics and the differences between low-screening respondents and high-screening respondents are reported in Table 2. Those GPs seeing the highest number of patients with HT per day (OR = 0.97 95% CI 0.95–0.99), with higher levels of graduate training (OR = 0.65 95% CI 0.47–0.91) and postgraduate training in alcohol (OR = 0.54 95% CI 0.39–0.74), were less likely to be low screening respondents (Table 3). Table 2. GPs’ sample characteristics and differences between low-screening and high-screening general practitionersGPs. Data collected between 29 September and 1 December 2015 All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) HT, hypertensive. aGPs’ low screening: GPs who screen for alcohol ≤3 out of 10 hypertensive patients. View Large Table 2. GPs’ sample characteristics and differences between low-screening and high-screening general practitionersGPs. Data collected between 29 September and 1 December 2015 All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) All (n = 867), n (%) GPs’ low screeninga ( n = 218), n (%) GPs’ high screening (n = 649), n (%) χ2/Student’s t-test (P value) Gender (women) 564 (65.1) 140 (64.2) 424 (65.3) 0.089 (0.766) Age >30 years 610 (70.4) 149 (68.3) 461 (71.0) 0.564 (0.453) Risky drinking 94 (12.4) 22 (11.8) 72 (12.6) 0.075 (0.785) Appointments per day, mean (SD) 36.8 (18.3) 36.8 (9.1) 36.7 (20.5) –0.049 (0.901) Number of HT patients per day, mean (SD) 13.0 (7.9) 12.1 (6.6) 13.3 (8.3) 1.920 (0.055) Sufficient alcohol graduate training 323 (37.5) 66 (30.4) 257 (39.8) 6.163 (0.013) Sufficient alcohol postgraduate training 457 (53.0) 93 (42.9) 364 (56.4) 12.016 (0.001) HT, hypertensive. aGPs’ low screening: GPs who screen for alcohol ≤3 out of 10 hypertensive patients. View Large Table 3. Binary logistic regression results OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 Factors are related to GPs having low rates of alcohol screening in patients with HT. Data collected between 29 September and 1 December 2015. aVersus insufficient alcohol graduate training; bVersus insufficient alcohol postgraduate training. View Large Table 3. Binary logistic regression results OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 OR 95% CI Number of HT patients per day 0.97 0.95–0.99 Sufficient alcohol graduate traininga 0.65 0.47–0.91 Sufficient alcohol postgraduate trainingb 0.54 0.39–0.74 Factors are related to GPs having low rates of alcohol screening in patients with HT. Data collected between 29 September and 1 December 2015. aVersus insufficient alcohol graduate training; bVersus insufficient alcohol postgraduate training. View Large Barriers to implementing screening among low-screening respondents Just under one-fifth of the GPs (19%, 95% CI: 16.7–21.3%) screened for alcohol in, at most, 30% of their HT patients. Half of them reported lack of time as a barrier to screening for alcohol use (50%, 95% CI: 43.4–56.6%), and 28.4% (95% CI: 22.4–34.4%) considered alcohol consumption non-relevant for HT. For importance of all other barriers, see Table 4. We did not find any relevant pattern when analysing how the three most reported barriers were ranked (data not shown). Table 4. Gs’ ranking barriers to screen for alcohol use referred by low-screening GP respondents (n = 218). Data collected between 29 September and 1 December 2015. Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) View Large Table 4. Gs’ ranking barriers to screen for alcohol use referred by low-screening GP respondents (n = 218). Data collected between 29 September and 1 December 2015. Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) Barrier % (95% CI) Lack of time 50.0 (16.7–21.3) Alcohol considered unimportant 28.4(22.4–34.4) Stigma 16.5 (11.6–21.4) Patient’s alcohol use previously known 4.1 (1.5–6.7) Considering asking as inappropriate 3.2 (0.9–5.5) Too much effort 2.8 (0.6–5.0) Screening methods unknown 2.3 (0.3–4.3) Lack of training 0.9 (0.4–2.2) Reported other barriers 10.6 (6.5–14.7) Reported no barrier 1.8 (0–3.6) View Large Associations between GPs’ characteristics (sex, age, own risky drinking, training and workload) and each barrier were examined. Age, sex and risky drinking status were not associated with any of the reported barriers (P > 0.064). Insufficient undergraduate training was linked to higher rates of questioning the appropriateness of asking about alcohol use (7.5% versus 1.3%; χ21df = 5.7, Fisher’s exact test, P = 0.028). Furthermore, GPs with a higher mean number of appointments per day found lack of time to be a barrier (38.2 patients per day versus 35.4 per day; t = 2.3, P = 0.022). However, the observed differences did not remain significant after Bonferroni correction. Discussion In our sample, most of the responding GPs do not view alcohol screening as a priority among their HT patients because of the following reasons:(i) they largely perceive alcohol use as non-relevant for HT and (ii) they consider patients’ risky drinking as a difficult situation to handle. On top of that, they report low rates of perceived success when advising patients to decrease their alcohol intake. GPs have an important role not only in managing but also in preventing HT. This is reflected in a high percentage of GPs recommending most preventive lifestyle measures to their patients (reducing salt intake, healthy diet, physical activity, quit smoking, etc.), in accordance with clinical guidelines for the treatment of high blood pressure (27). However, reducing alcohol intake is the least recommended (28), despite alcohol and high blood pressure having a dose–response relationship (29): the higher the alcohol intake, the higher the risk of HT. Furthermore, risky drinking doubles the risk of HT (2). Giving advice to reduce alcohol consumption can lead to a reduced risk of developing HT, while non-adherence to lifestyle advice is associated with apparent treatment resistance (17). Screening for alcohol consumption and BI have demonstrated effectiveness to reduce alcohol consumption in primary care, even though implementation rates are low (30). Although Spain is one of the European countries where screening for alcohol and intervention are more often delivered (24), in our study, Spanish GPs considered alcohol as the least relevant lifestyle risk factor for HT. These results are in accordance with the fact that less than half of GPs reported a sufficient level of alcohol screening practice in HT patients (24). There is a dramatic difference between the readiness to deal with risky drinkers (83.3%) and the perceived competence to treat alcohol dependence (24.4%), which is a stigmatized mental disorder (31). GPs with the lowest rates of alcohol screening reported that time constraints and considering alcohol unimportant for HT were the main barriers to alcohol screening their HT patients. Time constraints have been identified as a barrier for screening and implementing BI in many studies (21,32,33). Spanish GPs have a high caseload, which is also a problem in many other European countries (34). In Catalonia, GPs have only 10 min per patient for a routine visit, similarly to other European countries (e.g. UK or Germany), despite feeling that they need more time to offer high-quality care. Other barriers which may be stigma related were also reported (i.e. fear of annoying the patient or feeling that having previous knowledge of the patient habits precludes repeating the questions). To foster less stigmatizing and more normalizing attitudes to alcohol screening, it has been proposed to measure AUDs as a continuum as is done with blood pressure (35). AUD is just the extreme end of the continuum of alcohol use. Understanding and talking about alcohol consumption as a continuum could help people to see their consumption as part of this continuum, rather than in discrete polar categories (healthy use/health disorder) (36). In this sense, adopting a definition and discourse of heavy use over time, which is responsible for the neurobiological changes associated with AUD and the substance-attributable burden of disease including social costs, might avoid some of the problems that current conceptualizations have and can help to reduce stigmatization. Barriers to alcohol screening in HT patients, described by GPs with low-screening rates, could be overcome through structural changes in primary care practice and more adequate training. Structural changes including proper reimbursement, sufficient time per patient, electronic health record systems that facilitate administering screening tools and enhanced professional training on alcohol management (graduate and postgraduate) can improve the implementation of screening and BI (37). The importance of professional training is highlighted in our study, where GPs who have received postgraduate education are more likely to screen and manage alcohol use in HT patients (24). However, we should avoid excessive optimism with regard to new strategies to improve BI implementation, as not all of them have been successful. In the Optimizing Delivery of Healthcare Intervention (ODHIN) study, a five-country cluster randomized factorial trial in which the researchers assessed three strategies to improve implementation of BI; internet intervention after screening failed to improve BI delivery, but training and support, and financial reimbursement were found to be valid strategies (25,38). In Catalonia, the engagement of GPs on a web-based BI was modest (data not published). According to GPs’ perceptions, financial incentives should be included in their salaries instead of being temporarily introduced and subject to a specific screening project. The ODHIN GPs felt that training and support must improve knowledge, skills and prioritization, and must be accompanied by enough time to learn techniques and to tailor them to specific barriers, according to different GPs’ points of view (39). The preventive model established in Spain for alcohol consumption seems to fail. Thus, it is important to spread the message among primary care professionals that managing AUD is, in fact, treating an illness, falling within their remit because they are trained to do so, in the same way they do with high blood pressure or hyperhcolesteromia (40). Alcohol consumption in Spain is slightly above the WHO European region per capita average (12.3 versus 11.9 l of pure alcohol per year), while the prevalence of AUD is lower (1.3% versus 7.5%), and the prevalence of alcohol use in the last 12 months is 73.4% (1). All these figures are typical of a viticulture society, in which there is a normative perception of high levels of consumption. We found that 12.4% of GPs who answered the survey were themselves classified as risky drinkers. Similar prevalences of risky drinking have been found among Italian resident physicians, US medical students, German hospital doctors and Belgian specialists (41–45), while the prevalence is low compared to Finnish medical students (24–49%) (46). We know that there is a misperception of alcohol use among risky drinkers, the so called ‘normative fallacy’, in which peers’ alcohol consumption is estimated to be at least as high as risky drinker’s intake (16). We expected that risky drinking GPs would be less aware of risky alcohol use among their patients, but our results did not support this hypothesis. However, we think that alcohol consumption patterns of GPs should continue to be considered in those studies that aim to explore barriers for BI, precisely because a lack of evidence is not evidence for a lack of effect or association. In Spain, a relationship exists between the patients’ awareness of their HT and living in rural areas. However, there are only a few studies that focus on alcohol consumption and living in rural areas (where, e.g., alcohol is perceived as a part of daily diet (47), and there is higher prevalence of adolescent alcohol consumption) (48), and no studies focusing on the relationship between HT awareness, alcohol consumption and rural areas. This approach is important because we already know that access to lifestyle counselling is lower in rural areas (49). Unfortunately, this point was also beyond the scope of our study. Furthermore, our study illustrates that the improved understanding of barriers can be directly translated into measures to improve the management of alcohol and HT at the primary care level. A reduction in workload could be brought about by introducing structural changes. Furthermore, promoting collaborative team-based policies between GPs, mental health care professionals, nurses and pharmacists or introducing financial incentives (37) could enhance alcohol and HT management. In addition, widespread (post-) graduate training to increase awareness of alcohol-related conditions and its management among primary care professionals, and facilitating skills to promote healthy lifestyle changes should be considered as key measures to improve knowledge and reduce the perceived stigma related to risky drinking or alcohol dependence. According to the Agency for Healthcare Research and Quality (US Department of Health and Human Services), ‘Integrated Behavioral Health Care’ is defined as ‘the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population’(50). In our opinion, BIs for risky drinkers should be interpreted in this context. This study has some limitations. Although the original sample to whom the survey was sent was representative of Spanish GPs, the response rate was low (5.6%), which should be taken into account when generalizing the results. This response rate was similar to other countries in the same study (between 4.1 and 8.5%), but lower than in other similar studies. Web-based behaviour change intervention studies, using personalized e-mails, were found to have better response rates than studies using generic e-mails. Hence, future studies in this field should bear this approach in mind. Moreover, limitations inherent to self-reported answers (e.g. memory effects reducing reliability) also apply to this study, while the social desirability bias can be assumed to be minimal, as survey responses were given anonymously. The main strength of the study, however, is that it covers a large territory. In conclusion, as long as GPs do not consider alcohol consumption a relevant factor to deal with when treating hypertensive patients, they will not intervene. Changing this perception must be a priority, because it is well known that alcohol plays an important role in resistant HT, on top of the high burden of disease due to both alcohol and HT. Barriers described might be overcome through structural changes that could include training and support, financial incentives, conceptualizing AUD and alcohol consumption as parameters on a continuum and treating AUD as an illness in its own right, instead of regarding it as a factor in a preventive model. These strategies all show promise for reducing HT and its associated burden. Supplementary material Supplementary material is available at Family Practice online. Declaration Funding: The study was financially supported by an investigator-initiated grant to Jürgen Rehm and the GWT-TUD (Gesellschaft für Wissens - und Technologietransfer der TU Dresden mbH—company with limited liabilities for transferring knowledge and technology of the Dresden University of Technology) by Lundbeck. The study sponsor has had no role in study design, collection, analysis and interpretation of data. The study sponsor has also had no role in writing this account or the decision to submit this paper for publication. The corresponding author confirms that all authors had full access to the data in the study at all times and had final responsibility for the decision to submit for publication. This work was supported by RD12/0028/0016 project, Plan Nacional de I+D+I and financed jointly with ISCII-Subdirección General de Evaluación y Fondo Europeo de Desarrollo Regional (FEDER). The study also received the support of ‘Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya’ (2014SGR649). Conflict of interest: LM has received honoraria from Lundbeck, outside the work for this project. HLP has received training funds from Lundbeck, Janssen, Pfizer, Lilly, Rovi and Esteve, and has also received fees from Lundbeck, Teva and Janssen. JÁA has acted as an advisor and received funding for research, publication and training from the following companies: Almirall, AstraZeneca, Glaxo-Smith-Kline, Lilly, Lundbeck, Merck, Pfizer, Servier, Esteve. JZ has acted as an advisor and has received funding for consultancy, research, publications and carrying out training activities from Lundbeck and Lilly and fees from F Glead. JR has received educational grants, travel support and honoraria from Lundbeck outside and unrelated to the work on this manuscript. AG has received financial support from Lundbeck, DyA Pharma and TEVA and has received fees by Lundbeck, DyA Pharma and Abbivie, which were unconnected to the research of this study. JM has received personal fees from Lundbeck. All other authors have no potential conflict of interest to declare. Acknowledgements The authors acknowledge all the GP associations and all GPs who participated in the survey. References 1. World Health Organization . Global Status Report on Alcohol and Health . http://apps.who.int/iris/ bitstream/10665/112736/1/9789240692763_eng. pdf?ua=1 (accessed on 12 January 2015). 2. Taylor B , Irving HM , Baliunas D et al. Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis . Addiction 2009 ; 104 : 1981 – 90 . Google Scholar CrossRef Search ADS PubMed 3. Rehm J , Gmel G , Serra C , Gual A . 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Family Practice – Oxford University Press

Published: Nov 2, 2017

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