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The role of alcohol in the management of hypertension in patients in European primary health care practices – a survey in the largest European Union countries

The role of alcohol in the management of hypertension in patients in European primary health care... Background: Even though addressing lifestyle problems is a major recommendation in most guidelines for the treatment of hypertension (HTN), alcohol problems are not routinely addressed in the management of hypertension in primary health care. Methods: Internet based survey of 3081 primary care physicians, recruited via the mailing lists of associations for general practitioners (GPs) in France, Germany, Italy, Spain and the UK. Clinical practice, attitudes, knowledge, education and training were assessed. Logistic regression to predict screening, brief intervention and treatment for alcohol dependence in the management of hypertension were assessed. Results: Overall, about one third of the interviewed GPs reported sufficient screening in cases with HTN (34.0 %, 95 % confidence interval (CI):32.1–35.8 %). One out of five GPs screened and delivered brief interventions in HTN patients with hazardous consumption (22.2 %, 95 % CI: 20.6–23.8 %) and about one in 13 GPs provided treatment for HTN patients with alcohol dependence other than advice or brief intervention (7.8 %, 95 % CI: 6.8–8.9 %). Post-graduate training and belief in their effectiveness predicted interventions. There were marked differences between countries. Conclusions: While current interventions were overall low, marked differences between countries indicate that current practices could be improved. Education and post-graduate training seems to be key in improving clinical practice of including interventions for problematic alcohol consumption and alcohol dependence in primary health care. Keywords: Primary health care, Blood pressure, Hypertension, Hazardous drinking, Alcohol use disorders, Disease management, Screening Abbreviations: BASIS, Baseline Alcohol Screening and Intervention Survey; GP, General practitioner; HTN, Hypertension; UK, United Kingdom * Correspondence: [email protected]; [email protected] Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden, Germany Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rehm et al. BMC Family Practice (2016) 17:130 Page 2 of 7 Background was translated into French, German, Italian, and Spanish Hypertension (HTN) is the single most important risk and the national versions were again tested and finalized factor for mortality and burden of disease, globally and with the help of local experts. A brief summary of the especially for high income countries in Europe [1]. Its main survey and its subsections are given in Additional file 1. effect is on cardiovascular outcomes, and consequently, re- It contained 28 core items (in addition to a few country- duction of blood pressure is among the risk factor targets specific items) and was put online in all languages of the World Health Organisation ‘Global Action Plan for using SurveyMonkey (http://www.surveymonkey.com). Prevention and Control of Non-communicable Diseases’ TheEnglish version of thesurveycan be foundon- for the period 2013–2020 [2]. Primary health care has trad- line (Additional file 2). The theoretical basis was the itionally hadakeyroleinthe detectionand themanage- Information-Motivation-Behavioural Skills model [26, 27], ment of HTN [3]. Part of this management involves advice which stipulates that information and education is not suf- and interventions on lifestyle factors underlying HTN, ficient to adopt behaviours; in addition there needs to be and guidelines recommend lifestyle changes as important motivation and behavioural skills. This model had been means to reduce blood pressure, prevent and/or avoid adopted to care of non-communicable diseases [28]. medication for HTN [3–5]. Both epidemiology and ran- domized trials converge in demonstrating that alcohol Survey implementation consumption, in particular heavy drinking, is one of the In each of the five countries, regional or nationwide GP most important lifestyle based risk factors for HTN [6–9]. associations disseminated the web link to the survey to However, the mortality and disease burden attributable their members, mainly via electronic mail (for details see to HTN has increased globally since 1990 [1] and large Table 1). The median completion time was 8.8 min, with European surveys still show a large proportion of adults a span from under 2 min to over an hour). Four responses with uncontrolled HTN (http://apps.who.int/gho/data/ were removed from the data set due to suspicion of being ?theme=home), indicating the need for further action. Of duplicates. The entire survey was answered by 2468 re- all lifestyle factors, alcohol seems to be the least inter- spondents (80.1 % of those who started: 3081) between vened in the management of HTN [10–13], which is no September 29 and December 1, 2015. surprise given the low screening and intervention rates for The survey included a number of free text items, includ- hazardous drinking and alcohol use disorder in primary ing descriptions how alcohol problems were managed. A health care [14, 15]. Interventions for hazardous drinking coding scheme based on free text responses given in are scarce [15–17]; and alcohol use disorders have the Germany and the UK was developed and subsequently all lowest treatment rate of all mental disorders [18–20], such responses were classified by two independent raters despiteevidence thatthere areeffectiveinterventions for each language. Kappa agreement coefficients were available for both hazardous drinking and for alcohol calculated and ranged from 0.31 to 1 in the variables use disorders [21, 22], which could be implemented analyzed. Non-concordant ratings were revisited and a at the primary care level [23, 24]. finaldecision wasmadebyJM. Thus, improving alcohol interventions in primary health care promises to yield substantial health benefits Statistical analyses [10–13, 25]. The main question to realize this potential Three different indicators for good practice alcohol is how to best implement such interventions [23], both management in patients with HTN were derived from for hazardous drinking and for alcohol use disorders, as responses given in the questionnaire: a) sufficient part of routine management of HTN. Together with pri- screening for alcohol use (at least 7 out of 10 HTN pa- mary care associations in the five largest countries in the tients); b) sufficient screening (as above) in addition to European Union (France, Germany, Italy, Spain, and the management of alcohol problems in hypertensive pa- United Kingdom (UK)), we developed a survey of gen- tients with hazardous drinking levels by the GP them- eral practitioners (GPs) to explore knowledge, attitudes selves or within the same practice usually with brief and clinical practice of lifestyle interventions in the man- interventions (for rationale see care [21, 29]; c) sufficient agement of HTN and to help a potential implementation screening and management of alcohol dependence in of alcohol interventions (Baseline Alcohol Screening and hypertensive patients by the GPs themselves or within Intervention Survey (BASIS)). the same practice. Indicator c was only met if GPs did not only offer brief advice or counselling as management Methods for alcohol dependence but also reported other interven- Design of the BASIS survey and pilot tions, such as psychotherapy, or pharmacotherapy. This All authors were involved in drafting and finalizing the operationalization was chosen, as current guidelines do survey, originally in English. After an empirical pilot not recommend brief advice only as a treatment inter- study in five countries (N = 41 respondents), the survey vention for dependence [30, 31]. Rehm et al. BMC Family Practice (2016) 17:130 Page 3 of 7 Table 1 Assessment details by country Country Region of drawn sample Local responsibles Incentives Response rate Number of complete responses France National sample SFMG None 8.5 % 512 Germany Mostly Bavaria BHÄV No personal incentives; 2.3 % 103 €15 paid to BHÄV suborganisation Hamburg CIAR €15 voucher 7.9 % 88 Italy National sample SIMG None 10.1 % 360 Spain National sample semFYC None 9.4 % 802 National sample semergen None 1.1 % 95 UK National sample MediConf £10 voucher 4.1 % 508 Total 5.7 % 2468 Note. SFMG Société Française de Médecine Générale, BHÄV Bayerischer Hausärzteverband, CIAR Centre for Interdisciplinary Addiction Research, SIMG Società Italiana di Medicina Generale, semFYC Sociedad Española de Medicina de Familia y Comunitaria. semergen = Sociedad Española de Médicos de Atención Primaria Refers to number of any response among all contacted individuals An advertisement in a nationwide newspaper was placed during the period of data collection with very little response. Out of 103 GPs, 98 were from Bavaria and the remaining five from Hesse (1), North Rhine-Westphalia (2) and Saxony (2). The response rate was calculated by omitting the 54,000 potential readers from the denominator Logistic regressions on each indicator were computed (questionnaire items 32–34) was also considered for inclu- with Stata 14.0 [32], using the following variables as co- sion in the models. However, it was decided against it as it variates (specifications in parentheses): age (categories as would have overly limited the generalizability of the find- dummy variables with ‘70 or older’ as reference cat- ings by reducing thesamplesizeby24%(from2468 to egory), sex, country (dummy coded with UK as reference 1885) because these items were not assessed among UK re- category), beliefs about success of different lifestyle in- spondents and responses were not required to complete terventions for hypertension (questionnaire items 3 and thesurveyin the remainingcountries. 4: dummy variables, each scored 1 if rated (highly) suc- cessful, else 0), knowledge (questionnaire item 1: dummy Results variable, scored 1 if alcohol was selected as important Two thousand four hundred sixty eight health profes- risk factor for HTN, else 0), education (questionnaire sionals participated in the survey (for details see Table 1). items 24 and 27: dummy variables, each scored 1 for at With respect to the indicators of good practice alcohol least 4 out of 5 points on Likert scale regarding ad- management (= main dependent variables), Table 2 gives equacy of graduate education on alcohol/HTN, else 0; the prevalence by country. questionnaire items 25 and 28: dummy variables, each The overview of influencing variables for good practice scored 1 if post-graduate education on alcohol, HTN alcohol management are given in Table 3, where the was received, else 0), and workload (questionnaire item 7: reference country was always the UK. Clearly screening continuous variable containing number of daily patient for alcohol was best implemented in the UK and Spain, contacts, z-standardized for each country to achieve com- management of hazardous drinking levels was best im- parability). A measure of the respondents’ drinking patterns plemented in Spain (87 % of all identified GPs treated Table 2 Good practice alcohol management by country France Germany Italy Spain UK Total N = 512 N = 191 N = 360 N = 897 N = 508 N = 2468 Indicator A: Proportion of GPs screening at least 7 out of 5.9 (4.1–8.3) 26.7 (20.9–33.4) 36.1 (31.3–41.2) 45.8 (42.6–49.1) 42.5 (38.3–46.9) 34.0 (32.1–35.8) 10 hypertensive patients for alcohol % (CI) Indicator B: Proportion of GPs with sufficient screening (as A) 4.5 (3.0–6.7) 18.8 (13.9–25.0) 26.1 (21.8–30.9) 35.0 (32.0–38.2) 15.7 (12.8–19.2) 22.2 (20.6–23.8) and self-management of alcohol problems in patients with hazardous drinking levels % (CI) Indicator C: Proportion of GPs with sufficient screening (as A) 2.0 (1.0–3.6) 14.1 (9.9–19.8) 3.6 (2.1–6.1) 13.2 (11.1–15.5) 4.7 (3.2–7.0) 7.8 (6.8–8.9) and self-management of alcohol problems in patients with alcohol dependence %(CI) Notes. GP General Practitioner Treatment of alcohol problems only via brief intervention or advice did not qualify as indicator for sufficient alcohol management Rehm et al. BMC Family Practice (2016) 17:130 Page 4 of 7 Table 3 Prediction of good practice alcohol management a a a N = 2468 Model A Model B Model C Pseudo R .1208 .1164 .1113 Predictors: OR p OR p OR p Sex: 0 = male, 1 = female 0.80 (0.66–0.97) .026 1.15 (0.92–1.42) .221 1.22 (0.88–1.68) .232 Age: less than 30 years old 0.66 (0.21–2.10) 0.71 (0.20–2.54) 1.20 (0.14–10.57) Age: 30–39 years old 0.91 (0.31–2.67) 0.69 (0.21–2.28) 0.97 (0.12–7.81) Age: 40–49 years old 0.96 (0.33–2.83) 0.75 (0.23–2.78) 0.84 (0.10–6.77) Age: 50–59 years old 0.88 (0.30–2.58) 0.72 (0.22–2.34) 1.19 (0.15–9.42) Age: 60–69 years old 0.97 (0.33–2.87) 0.89 (0.27–2.94) 1.10 (0.13–8.88) Age: at least 70 years old (reference category ) 1 .734 1 .791 1 .714 Country: only France 0.08 (0.05–0.12) 0.20 (0.12–0.32) 0.32 (0.14–0.67) Country: only Germany 0.43 (0.29–0.63) 1.04 (0.66–1.65) 2.79 (1.51–5.18) Country: only Italy 0.68 (0.49–0.96) 1.48 (0.99–2.21) 0.50 (0.23–1.08) Country: only Spain 0.98 (0.76–1.27) 2.57 (1.88–3.51) 2.45 (1.48–4.06) Country: UK (reference category ) 1 <.001 1 <.001 1 <.001 Belief: Patients successfully reduced blood pressure due to lifestyle change 1.21 (0.96–1.52) .098 1.18 (0.92–1.51) .198 1.70 (1.19–2.42) .003 Belief: Lifestyle changes successful to avoid prescribed HTN medication 1.42 (1.17–1.73) <.001 1.44 (1.15–1.79) .001 1.48 (1.07–2.06) .019 Knowledge: alcohol rated as important risk factor for HTN 1.27 (1.01–1.60) .043 1.43 (1.10–1.86) .007 1.21 (0.82–1.79) .332 Education: university education on alcohol was sufficient 1.41 (1.05–1.90) .022 1.34 (0.97–1.86) .079 1.25 (0.78–2.02) .353 Education: received post-graduate education on alcohol 1.49 (1.23–1.80) <.001 1.93 (1.55–2.40) <.001 2.49 (1.75–3.54) <.001 Education: university education on HTN was sufficient 0.91 (0.75–1.09) .301 1.04 (0.84–1.29) .702 0.95 (0.67–1.31) .752 Education: received post-graduate education on HTN 1.32 (0.98–1.75) .052 1.32 (0.93–1.89) .123 1.05 (0.59–1.87) .865 Workload: country-standardized measure of daily patient contacts 1.02 (0.94–1.12) .597 1.02 (0.92–1.12) .718 1.02 (0.90–1.16) .752 Notes. HTN Hypertension Logistic regression models predicted alcohol management using different indicators: For Model A, sufficient screening, i.e. at least 7 out of 10 HTN patients was predicted. For Model B and C, composite indicators consisting of sufficient screening (as Model A) in addition to self-management of alcohol problemsinhypertensive patients with either hazardous drinking levels (Model B) or alcohol dependence (Model C) was predicted. For Model C, treatment of alcohol problems only via brief intervention or advice did not qualify as indicator for sufficient alcohol management For age and country, the p-values refer to an omnibus test for the entire variable, i.e., testing the global hypotheses that the coefficient for any age category or country deviates from the null hypothesis of no difference above chance only via brief interventions/advice), and treatment of were marked differences between European countries alcohol dependence was best implemented in Spain and though, with most of the screening and interventions been Germany. As hypothesized, post-graduate education and given in Spain and the UK, and least in France. Compared the belief that lifestyle interventions were successful in to British GPs, only a fraction of the French colleagues avoiding HTN-related prescriptions seem to impact on reported sufficient alcohol screening (OR = 0.08), and only th all three indicators. For screening and management of every 50 French GP reported sufficient screening and al- hazardous drinking levels, the GPs’ knowledge about the cohol management in alcohol dependent patients on their importance of alcohol as a risk factor for HTN was also own. We can only speculate about the reasons for the positively related. French situation, but it may have to do with lack of guide- lines. The French guidelines for HTN treatment developed Discussion in 2005 had to be withdrawn in 2011 (http://www.has-san- In this large survey, we found that alcohol interventions te.fr/portail/jcms/c_272459/fr/prise-en-charge-des-patients- were relatively scarce in European primary health care. adultes-atteints-d-hypertension-arterielle-essentielle- Overall, about one third of the interviewed GPs reported actualisation-2005-cette-recommandation-est-suspendue) sufficient screening in cases with HTN. One out of five as the authors’ conflict of interest statements did not meet GPs screened and delivered brief interventions in HTN pa- later introduced rules (http://www.has-sante.fr/portail/up- tients with hazardous consumption and about one of 13 load/docs/application/pdf/2011-09/cp_recos_suspendues_ GPs provided treatment for HTN patients with alcohol de- 19092011_vdef.pdf). In general, the notion of the benefi- pendence other than advice or brief intervention. There cial effects of alcohol on cardiovascular outcomes is strong Rehm et al. BMC Family Practice (2016) 17:130 Page 5 of 7 (“French paradox”; see [33]; see also the official training Union [20], alcohol interventions need to be prioritized materials of the French cardiologists [34]). The lack of and this could be done by financial incentives. A recent knowledge and training in Italian GPs with respect to cluster randomized trial with 746 providers in 120 primary screening and brief interventions has been found in several health care centers from five European countries has other European studies (INEBRIA: AMPHORA: [35]; see shown that modest financial incentives increase screening also http://www.epicentro.iss.it/alcol/apd2013/presenta- and intervention rates. Interestingly, there is a synergistic zioni/9.Cuffari.pdf), and has seemingly not improved over effect when financial incentives, training and support are the past years. offered together [17]. We hope that the involvement of Before we discuss potential conclusions of the results, several GP associations in the current study will help over- we would like to highlight limitations. First, response come these barriers in the future. rates are relatively low. While it is hard to compare re- sponse rates across physicians’ surveys, as there are differ- Additional files ent sampling frames and several web-based surveys do not even give response rates [36, 37], and even though Additional file 1: Structure of the questionnaire. Includes a table of all sections of the questionnaire (DOCX 17 kb) web-based surveys have comparably lower response rates Additional file 2: Questionnaire. Includes the entire questionnaire [38], an overall response rate of 6 % must be considered implemented in the survey (DOCX 35 kb) low. As a consequence, while the national/regional sam- pling frames can be considered as representative, the low Acknowledgements response rates suggest that a convenience sample of GP’s The authors acknowledge all GP associations and all GPs who took the time being more motivated and interested in the topic has been to respond to the survey. drawn [39]. Thus the screening and intervention rates re- ported are likely to be overestimates (for intervention Funding rates in samples of GP’s with representative sampling and The study was financially supported by an investigator initiated grant to the first author and the GWT-TUD (Gesellschaft für Wissens- und Technologietransfer a considerably higher response rate [14, 40]). Second, all der TU Dresden mbH – company with limited liabilities for transferring answers were self-reports and social desirability bias may knowledge and technology of the Dresden University of Technology) by have shifted some of our key results upwards [41]. In Lundbeck. The study sponsor has no role in study design, collection, analysis, and interpretation of data. The study sponsor also had no role in writing of the other words, based on the two major limitations of this report; and the decision to submit the paper for publication. The corresponding study, the rates for screening and interventions among author confirms that the authors had full access to the data in the study at all hypertensive primary health care patients in Europe are times, and had final responsibility for the decision to submit for publication. The corresponding author hereby states that no author has been reimbursed for most likely lower than described in this study. However, writing this manuscript. given the low response rate, we cannot fully rule out that we have underestimated the GPs’ involvement, e.g., if en- Availability of data and materials gaged GPs were too busy to participate in our survey. The dataset supporting the conclusions of this article is available in the figshare repository (doi:10.6084/m9.figshare.3505844), under the following link: https://figshare.com/articles/BASIS_data_set/3505844 Conclusions While our findings are susceptible to sample distortion, Authors’ contributions they are sufficiently robust to demonstrate that the GPs’ JR conceptualized the study and served as PI. H-JA, CG, AG, LK, ES and JR drafted the first version of the survey and JM implemented the survey online. involvement in alcohol screening and management All authors worked on the finalization of the survey. All authors except H-JA, among patients with HTN is generally poor in the lar- JM, LK, ES and JR served as site PIs and organized contacts to general gest European countries. Thus, the situation for HTN practitioners in their region/country. JM combined and cleaned all collected data, and conducted the quantitative and qualitative analyses. JR wrote patients is likely not better than for other primary care a first draft of the paper, and all authors contributed to and approved patients with respect to detection of and interventions for of the final version. heavy drinking and alcohol use disorders [14, 15, 17, 40]. What can be done about this? First, medical education at Competing interests universities have to put more emphasis on alcohol as one AG: reports grants and personal fees from Lundbeck and D&A Pharma during the conduct of the study and grants from TEVA and personal fees of the main risk factors for many disease conditions GPs from Abbivie outside the submitted work. see in their daily practice [40]. The lack of education AR: reports no conflict of interest. seems a common problem in all five countries, and was BS: reports no conflict of interest. CG: reports grants, sponsorship to attend scientific meetings, speaker also highlighted in some of the qualitative answers. honoraria and consultancy fees from Lundbeck during the conduct of the Moreover, post-graduate training was shown to increase study. Consultancy fees and salaries received not related to this study screening and intervention rates [16, 42], and this is, received from the NHS, RCGP, Omnimedia, Pfizer, Turning Point, Locala CIC, and doctors.net.uk (all UK). where GP associations can contribute. Secondly, given DD: reports grants from Cerin, Haute Autorité de la Santé, Ligue contre le the high overall workload of GPs, and the overall health cancer, Medtronic, Lundbeck, MSD, Novartis, Novo-Nordisk, Pfizer, and SFMG. burden attributable to alcohol in countries in the European ES: reports sponsorship to attend scientific meetings from Lundbeck. Rehm et al. 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Friedmann PD, Rose J, Hayaki J, Ramsey S, Charuvastra A, Dubé C, et al. • We accept pre-submission inquiries Training primary care clinicians in maintenance care for moderated alcohol � Our selector tool helps you to find the most relevant journal use. J Gen Intern Med. 2006;21:1269–75. � We provide round the clock customer support � Convenient online submission � Thorough peer review � Inclusion in PubMed and all major indexing services � Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

The role of alcohol in the management of hypertension in patients in European primary health care practices – a survey in the largest European Union countries

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Copyright © 2016 by The Author(s).
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Even though addressing lifestyle problems is a major recommendation in most guidelines for the treatment of hypertension (HTN), alcohol problems are not routinely addressed in the management of hypertension in primary health care. Methods: Internet based survey of 3081 primary care physicians, recruited via the mailing lists of associations for general practitioners (GPs) in France, Germany, Italy, Spain and the UK. Clinical practice, attitudes, knowledge, education and training were assessed. Logistic regression to predict screening, brief intervention and treatment for alcohol dependence in the management of hypertension were assessed. Results: Overall, about one third of the interviewed GPs reported sufficient screening in cases with HTN (34.0 %, 95 % confidence interval (CI):32.1–35.8 %). One out of five GPs screened and delivered brief interventions in HTN patients with hazardous consumption (22.2 %, 95 % CI: 20.6–23.8 %) and about one in 13 GPs provided treatment for HTN patients with alcohol dependence other than advice or brief intervention (7.8 %, 95 % CI: 6.8–8.9 %). Post-graduate training and belief in their effectiveness predicted interventions. There were marked differences between countries. Conclusions: While current interventions were overall low, marked differences between countries indicate that current practices could be improved. Education and post-graduate training seems to be key in improving clinical practice of including interventions for problematic alcohol consumption and alcohol dependence in primary health care. Keywords: Primary health care, Blood pressure, Hypertension, Hazardous drinking, Alcohol use disorders, Disease management, Screening Abbreviations: BASIS, Baseline Alcohol Screening and Intervention Survey; GP, General practitioner; HTN, Hypertension; UK, United Kingdom * Correspondence: [email protected]; [email protected] Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden, Germany Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rehm et al. BMC Family Practice (2016) 17:130 Page 2 of 7 Background was translated into French, German, Italian, and Spanish Hypertension (HTN) is the single most important risk and the national versions were again tested and finalized factor for mortality and burden of disease, globally and with the help of local experts. A brief summary of the especially for high income countries in Europe [1]. Its main survey and its subsections are given in Additional file 1. effect is on cardiovascular outcomes, and consequently, re- It contained 28 core items (in addition to a few country- duction of blood pressure is among the risk factor targets specific items) and was put online in all languages of the World Health Organisation ‘Global Action Plan for using SurveyMonkey (http://www.surveymonkey.com). Prevention and Control of Non-communicable Diseases’ TheEnglish version of thesurveycan be foundon- for the period 2013–2020 [2]. Primary health care has trad- line (Additional file 2). The theoretical basis was the itionally hadakeyroleinthe detectionand themanage- Information-Motivation-Behavioural Skills model [26, 27], ment of HTN [3]. Part of this management involves advice which stipulates that information and education is not suf- and interventions on lifestyle factors underlying HTN, ficient to adopt behaviours; in addition there needs to be and guidelines recommend lifestyle changes as important motivation and behavioural skills. This model had been means to reduce blood pressure, prevent and/or avoid adopted to care of non-communicable diseases [28]. medication for HTN [3–5]. Both epidemiology and ran- domized trials converge in demonstrating that alcohol Survey implementation consumption, in particular heavy drinking, is one of the In each of the five countries, regional or nationwide GP most important lifestyle based risk factors for HTN [6–9]. associations disseminated the web link to the survey to However, the mortality and disease burden attributable their members, mainly via electronic mail (for details see to HTN has increased globally since 1990 [1] and large Table 1). The median completion time was 8.8 min, with European surveys still show a large proportion of adults a span from under 2 min to over an hour). Four responses with uncontrolled HTN (http://apps.who.int/gho/data/ were removed from the data set due to suspicion of being ?theme=home), indicating the need for further action. Of duplicates. The entire survey was answered by 2468 re- all lifestyle factors, alcohol seems to be the least inter- spondents (80.1 % of those who started: 3081) between vened in the management of HTN [10–13], which is no September 29 and December 1, 2015. surprise given the low screening and intervention rates for The survey included a number of free text items, includ- hazardous drinking and alcohol use disorder in primary ing descriptions how alcohol problems were managed. A health care [14, 15]. Interventions for hazardous drinking coding scheme based on free text responses given in are scarce [15–17]; and alcohol use disorders have the Germany and the UK was developed and subsequently all lowest treatment rate of all mental disorders [18–20], such responses were classified by two independent raters despiteevidence thatthere areeffectiveinterventions for each language. Kappa agreement coefficients were available for both hazardous drinking and for alcohol calculated and ranged from 0.31 to 1 in the variables use disorders [21, 22], which could be implemented analyzed. Non-concordant ratings were revisited and a at the primary care level [23, 24]. finaldecision wasmadebyJM. Thus, improving alcohol interventions in primary health care promises to yield substantial health benefits Statistical analyses [10–13, 25]. The main question to realize this potential Three different indicators for good practice alcohol is how to best implement such interventions [23], both management in patients with HTN were derived from for hazardous drinking and for alcohol use disorders, as responses given in the questionnaire: a) sufficient part of routine management of HTN. Together with pri- screening for alcohol use (at least 7 out of 10 HTN pa- mary care associations in the five largest countries in the tients); b) sufficient screening (as above) in addition to European Union (France, Germany, Italy, Spain, and the management of alcohol problems in hypertensive pa- United Kingdom (UK)), we developed a survey of gen- tients with hazardous drinking levels by the GP them- eral practitioners (GPs) to explore knowledge, attitudes selves or within the same practice usually with brief and clinical practice of lifestyle interventions in the man- interventions (for rationale see care [21, 29]; c) sufficient agement of HTN and to help a potential implementation screening and management of alcohol dependence in of alcohol interventions (Baseline Alcohol Screening and hypertensive patients by the GPs themselves or within Intervention Survey (BASIS)). the same practice. Indicator c was only met if GPs did not only offer brief advice or counselling as management Methods for alcohol dependence but also reported other interven- Design of the BASIS survey and pilot tions, such as psychotherapy, or pharmacotherapy. This All authors were involved in drafting and finalizing the operationalization was chosen, as current guidelines do survey, originally in English. After an empirical pilot not recommend brief advice only as a treatment inter- study in five countries (N = 41 respondents), the survey vention for dependence [30, 31]. Rehm et al. BMC Family Practice (2016) 17:130 Page 3 of 7 Table 1 Assessment details by country Country Region of drawn sample Local responsibles Incentives Response rate Number of complete responses France National sample SFMG None 8.5 % 512 Germany Mostly Bavaria BHÄV No personal incentives; 2.3 % 103 €15 paid to BHÄV suborganisation Hamburg CIAR €15 voucher 7.9 % 88 Italy National sample SIMG None 10.1 % 360 Spain National sample semFYC None 9.4 % 802 National sample semergen None 1.1 % 95 UK National sample MediConf £10 voucher 4.1 % 508 Total 5.7 % 2468 Note. SFMG Société Française de Médecine Générale, BHÄV Bayerischer Hausärzteverband, CIAR Centre for Interdisciplinary Addiction Research, SIMG Società Italiana di Medicina Generale, semFYC Sociedad Española de Medicina de Familia y Comunitaria. semergen = Sociedad Española de Médicos de Atención Primaria Refers to number of any response among all contacted individuals An advertisement in a nationwide newspaper was placed during the period of data collection with very little response. Out of 103 GPs, 98 were from Bavaria and the remaining five from Hesse (1), North Rhine-Westphalia (2) and Saxony (2). The response rate was calculated by omitting the 54,000 potential readers from the denominator Logistic regressions on each indicator were computed (questionnaire items 32–34) was also considered for inclu- with Stata 14.0 [32], using the following variables as co- sion in the models. However, it was decided against it as it variates (specifications in parentheses): age (categories as would have overly limited the generalizability of the find- dummy variables with ‘70 or older’ as reference cat- ings by reducing thesamplesizeby24%(from2468 to egory), sex, country (dummy coded with UK as reference 1885) because these items were not assessed among UK re- category), beliefs about success of different lifestyle in- spondents and responses were not required to complete terventions for hypertension (questionnaire items 3 and thesurveyin the remainingcountries. 4: dummy variables, each scored 1 if rated (highly) suc- cessful, else 0), knowledge (questionnaire item 1: dummy Results variable, scored 1 if alcohol was selected as important Two thousand four hundred sixty eight health profes- risk factor for HTN, else 0), education (questionnaire sionals participated in the survey (for details see Table 1). items 24 and 27: dummy variables, each scored 1 for at With respect to the indicators of good practice alcohol least 4 out of 5 points on Likert scale regarding ad- management (= main dependent variables), Table 2 gives equacy of graduate education on alcohol/HTN, else 0; the prevalence by country. questionnaire items 25 and 28: dummy variables, each The overview of influencing variables for good practice scored 1 if post-graduate education on alcohol, HTN alcohol management are given in Table 3, where the was received, else 0), and workload (questionnaire item 7: reference country was always the UK. Clearly screening continuous variable containing number of daily patient for alcohol was best implemented in the UK and Spain, contacts, z-standardized for each country to achieve com- management of hazardous drinking levels was best im- parability). A measure of the respondents’ drinking patterns plemented in Spain (87 % of all identified GPs treated Table 2 Good practice alcohol management by country France Germany Italy Spain UK Total N = 512 N = 191 N = 360 N = 897 N = 508 N = 2468 Indicator A: Proportion of GPs screening at least 7 out of 5.9 (4.1–8.3) 26.7 (20.9–33.4) 36.1 (31.3–41.2) 45.8 (42.6–49.1) 42.5 (38.3–46.9) 34.0 (32.1–35.8) 10 hypertensive patients for alcohol % (CI) Indicator B: Proportion of GPs with sufficient screening (as A) 4.5 (3.0–6.7) 18.8 (13.9–25.0) 26.1 (21.8–30.9) 35.0 (32.0–38.2) 15.7 (12.8–19.2) 22.2 (20.6–23.8) and self-management of alcohol problems in patients with hazardous drinking levels % (CI) Indicator C: Proportion of GPs with sufficient screening (as A) 2.0 (1.0–3.6) 14.1 (9.9–19.8) 3.6 (2.1–6.1) 13.2 (11.1–15.5) 4.7 (3.2–7.0) 7.8 (6.8–8.9) and self-management of alcohol problems in patients with alcohol dependence %(CI) Notes. GP General Practitioner Treatment of alcohol problems only via brief intervention or advice did not qualify as indicator for sufficient alcohol management Rehm et al. BMC Family Practice (2016) 17:130 Page 4 of 7 Table 3 Prediction of good practice alcohol management a a a N = 2468 Model A Model B Model C Pseudo R .1208 .1164 .1113 Predictors: OR p OR p OR p Sex: 0 = male, 1 = female 0.80 (0.66–0.97) .026 1.15 (0.92–1.42) .221 1.22 (0.88–1.68) .232 Age: less than 30 years old 0.66 (0.21–2.10) 0.71 (0.20–2.54) 1.20 (0.14–10.57) Age: 30–39 years old 0.91 (0.31–2.67) 0.69 (0.21–2.28) 0.97 (0.12–7.81) Age: 40–49 years old 0.96 (0.33–2.83) 0.75 (0.23–2.78) 0.84 (0.10–6.77) Age: 50–59 years old 0.88 (0.30–2.58) 0.72 (0.22–2.34) 1.19 (0.15–9.42) Age: 60–69 years old 0.97 (0.33–2.87) 0.89 (0.27–2.94) 1.10 (0.13–8.88) Age: at least 70 years old (reference category ) 1 .734 1 .791 1 .714 Country: only France 0.08 (0.05–0.12) 0.20 (0.12–0.32) 0.32 (0.14–0.67) Country: only Germany 0.43 (0.29–0.63) 1.04 (0.66–1.65) 2.79 (1.51–5.18) Country: only Italy 0.68 (0.49–0.96) 1.48 (0.99–2.21) 0.50 (0.23–1.08) Country: only Spain 0.98 (0.76–1.27) 2.57 (1.88–3.51) 2.45 (1.48–4.06) Country: UK (reference category ) 1 <.001 1 <.001 1 <.001 Belief: Patients successfully reduced blood pressure due to lifestyle change 1.21 (0.96–1.52) .098 1.18 (0.92–1.51) .198 1.70 (1.19–2.42) .003 Belief: Lifestyle changes successful to avoid prescribed HTN medication 1.42 (1.17–1.73) <.001 1.44 (1.15–1.79) .001 1.48 (1.07–2.06) .019 Knowledge: alcohol rated as important risk factor for HTN 1.27 (1.01–1.60) .043 1.43 (1.10–1.86) .007 1.21 (0.82–1.79) .332 Education: university education on alcohol was sufficient 1.41 (1.05–1.90) .022 1.34 (0.97–1.86) .079 1.25 (0.78–2.02) .353 Education: received post-graduate education on alcohol 1.49 (1.23–1.80) <.001 1.93 (1.55–2.40) <.001 2.49 (1.75–3.54) <.001 Education: university education on HTN was sufficient 0.91 (0.75–1.09) .301 1.04 (0.84–1.29) .702 0.95 (0.67–1.31) .752 Education: received post-graduate education on HTN 1.32 (0.98–1.75) .052 1.32 (0.93–1.89) .123 1.05 (0.59–1.87) .865 Workload: country-standardized measure of daily patient contacts 1.02 (0.94–1.12) .597 1.02 (0.92–1.12) .718 1.02 (0.90–1.16) .752 Notes. HTN Hypertension Logistic regression models predicted alcohol management using different indicators: For Model A, sufficient screening, i.e. at least 7 out of 10 HTN patients was predicted. For Model B and C, composite indicators consisting of sufficient screening (as Model A) in addition to self-management of alcohol problemsinhypertensive patients with either hazardous drinking levels (Model B) or alcohol dependence (Model C) was predicted. For Model C, treatment of alcohol problems only via brief intervention or advice did not qualify as indicator for sufficient alcohol management For age and country, the p-values refer to an omnibus test for the entire variable, i.e., testing the global hypotheses that the coefficient for any age category or country deviates from the null hypothesis of no difference above chance only via brief interventions/advice), and treatment of were marked differences between European countries alcohol dependence was best implemented in Spain and though, with most of the screening and interventions been Germany. As hypothesized, post-graduate education and given in Spain and the UK, and least in France. Compared the belief that lifestyle interventions were successful in to British GPs, only a fraction of the French colleagues avoiding HTN-related prescriptions seem to impact on reported sufficient alcohol screening (OR = 0.08), and only th all three indicators. For screening and management of every 50 French GP reported sufficient screening and al- hazardous drinking levels, the GPs’ knowledge about the cohol management in alcohol dependent patients on their importance of alcohol as a risk factor for HTN was also own. We can only speculate about the reasons for the positively related. French situation, but it may have to do with lack of guide- lines. The French guidelines for HTN treatment developed Discussion in 2005 had to be withdrawn in 2011 (http://www.has-san- In this large survey, we found that alcohol interventions te.fr/portail/jcms/c_272459/fr/prise-en-charge-des-patients- were relatively scarce in European primary health care. adultes-atteints-d-hypertension-arterielle-essentielle- Overall, about one third of the interviewed GPs reported actualisation-2005-cette-recommandation-est-suspendue) sufficient screening in cases with HTN. One out of five as the authors’ conflict of interest statements did not meet GPs screened and delivered brief interventions in HTN pa- later introduced rules (http://www.has-sante.fr/portail/up- tients with hazardous consumption and about one of 13 load/docs/application/pdf/2011-09/cp_recos_suspendues_ GPs provided treatment for HTN patients with alcohol de- 19092011_vdef.pdf). In general, the notion of the benefi- pendence other than advice or brief intervention. There cial effects of alcohol on cardiovascular outcomes is strong Rehm et al. BMC Family Practice (2016) 17:130 Page 5 of 7 (“French paradox”; see [33]; see also the official training Union [20], alcohol interventions need to be prioritized materials of the French cardiologists [34]). The lack of and this could be done by financial incentives. A recent knowledge and training in Italian GPs with respect to cluster randomized trial with 746 providers in 120 primary screening and brief interventions has been found in several health care centers from five European countries has other European studies (INEBRIA: AMPHORA: [35]; see shown that modest financial incentives increase screening also http://www.epicentro.iss.it/alcol/apd2013/presenta- and intervention rates. Interestingly, there is a synergistic zioni/9.Cuffari.pdf), and has seemingly not improved over effect when financial incentives, training and support are the past years. offered together [17]. We hope that the involvement of Before we discuss potential conclusions of the results, several GP associations in the current study will help over- we would like to highlight limitations. First, response come these barriers in the future. rates are relatively low. While it is hard to compare re- sponse rates across physicians’ surveys, as there are differ- Additional files ent sampling frames and several web-based surveys do not even give response rates [36, 37], and even though Additional file 1: Structure of the questionnaire. Includes a table of all sections of the questionnaire (DOCX 17 kb) web-based surveys have comparably lower response rates Additional file 2: Questionnaire. Includes the entire questionnaire [38], an overall response rate of 6 % must be considered implemented in the survey (DOCX 35 kb) low. As a consequence, while the national/regional sam- pling frames can be considered as representative, the low Acknowledgements response rates suggest that a convenience sample of GP’s The authors acknowledge all GP associations and all GPs who took the time being more motivated and interested in the topic has been to respond to the survey. drawn [39]. Thus the screening and intervention rates re- ported are likely to be overestimates (for intervention Funding rates in samples of GP’s with representative sampling and The study was financially supported by an investigator initiated grant to the first author and the GWT-TUD (Gesellschaft für Wissens- und Technologietransfer a considerably higher response rate [14, 40]). Second, all der TU Dresden mbH – company with limited liabilities for transferring answers were self-reports and social desirability bias may knowledge and technology of the Dresden University of Technology) by have shifted some of our key results upwards [41]. In Lundbeck. The study sponsor has no role in study design, collection, analysis, and interpretation of data. The study sponsor also had no role in writing of the other words, based on the two major limitations of this report; and the decision to submit the paper for publication. The corresponding study, the rates for screening and interventions among author confirms that the authors had full access to the data in the study at all hypertensive primary health care patients in Europe are times, and had final responsibility for the decision to submit for publication. The corresponding author hereby states that no author has been reimbursed for most likely lower than described in this study. However, writing this manuscript. given the low response rate, we cannot fully rule out that we have underestimated the GPs’ involvement, e.g., if en- Availability of data and materials gaged GPs were too busy to participate in our survey. The dataset supporting the conclusions of this article is available in the figshare repository (doi:10.6084/m9.figshare.3505844), under the following link: https://figshare.com/articles/BASIS_data_set/3505844 Conclusions While our findings are susceptible to sample distortion, Authors’ contributions they are sufficiently robust to demonstrate that the GPs’ JR conceptualized the study and served as PI. H-JA, CG, AG, LK, ES and JR drafted the first version of the survey and JM implemented the survey online. involvement in alcohol screening and management All authors worked on the finalization of the survey. All authors except H-JA, among patients with HTN is generally poor in the lar- JM, LK, ES and JR served as site PIs and organized contacts to general gest European countries. Thus, the situation for HTN practitioners in their region/country. JM combined and cleaned all collected data, and conducted the quantitative and qualitative analyses. JR wrote patients is likely not better than for other primary care a first draft of the paper, and all authors contributed to and approved patients with respect to detection of and interventions for of the final version. heavy drinking and alcohol use disorders [14, 15, 17, 40]. What can be done about this? First, medical education at Competing interests universities have to put more emphasis on alcohol as one AG: reports grants and personal fees from Lundbeck and D&A Pharma during the conduct of the study and grants from TEVA and personal fees of the main risk factors for many disease conditions GPs from Abbivie outside the submitted work. see in their daily practice [40]. The lack of education AR: reports no conflict of interest. seems a common problem in all five countries, and was BS: reports no conflict of interest. CG: reports grants, sponsorship to attend scientific meetings, speaker also highlighted in some of the qualitative answers. honoraria and consultancy fees from Lundbeck during the conduct of the Moreover, post-graduate training was shown to increase study. Consultancy fees and salaries received not related to this study screening and intervention rates [16, 42], and this is, received from the NHS, RCGP, Omnimedia, Pfizer, Turning Point, Locala CIC, and doctors.net.uk (all UK). where GP associations can contribute. Secondly, given DD: reports grants from Cerin, Haute Autorité de la Santé, Ligue contre le the high overall workload of GPs, and the overall health cancer, Medtronic, Lundbeck, MSD, Novartis, Novo-Nordisk, Pfizer, and SFMG. burden attributable to alcohol in countries in the European ES: reports sponsorship to attend scientific meetings from Lundbeck. Rehm et al. BMC Family Practice (2016) 17:130 Page 6 of 7 H-JA: reports sponsorship to attend scientific meetings, speaker honoraria References and consultancy fees from Bioprojet, D&A Pharma, Ethypharm, Lundbeck, 1. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer Merck-Serono, Novartis, and Pfizer. M, et al. Global, regional, and national comparative risk assessment of 79 JAAP: reports grants and personal fees from Lundbeck during the conduct of behavioural, environmental and occupational, and metabolic risks or the study. clusters of risks in 188 countries, 1990–2013: a systematic analysis for the JM: reports personal fees from Lundbeck, outside of the submitted work. Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323. JR: reports grants from Lundbeck during the conduct of this study, personal 2. World Health Organization. Global Action Plan for the Prevention and fees and serving as board member (Nalmefene) for Lundbeck. Control of NCDs 2013-2020. Geneva: World Health Organization; 2013. JZ: reports personal fees from Lundbeck, and consultancy fees and salaries 3. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. from Menarini, Lilly and Gilead outside of the submitted work. Seventh report of the Joint National Committee on prevention, detection, LK: reports funding from Lundbeck for a research project on alcohol evaluation and treatment of high blood pressure. JAMA. 2003;289:2560–72. epidemiology unrelated to this study. 4. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al. 2013 MBa: reports consulting fees received from Lundbeck (through consulting ESH/ESC Guidelines for the management of arterial hypertension: the Task business Copentown) for organisational and process support in connection Force for the management of arterial hypertension of the European Society with the project. 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Friedmann PD, Rose J, Hayaki J, Ramsey S, Charuvastra A, Dubé C, et al. • We accept pre-submission inquiries Training primary care clinicians in maintenance care for moderated alcohol � Our selector tool helps you to find the most relevant journal use. J Gen Intern Med. 2006;21:1269–75. � We provide round the clock customer support � Convenient online submission � Thorough peer review � Inclusion in PubMed and all major indexing services � Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit

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BMC Family Practice – Springer Journals

Published: Sep 8, 2016

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