Alcohol and Alcoholism Vol. 34, No. 3, pp. 337-345, 1999
© 1999 Medical Council on Alcoholism
PATIENTS WITH CHRONIC ALCOHOL ABUSE IN DUTCH FAMILY PRACTICES
Academic Medical Centre, University of Amsterdam, Division of Public Health, Department of Family Medicine, Meibergdreef 15, 11 05 AZ Amsterdam, The Netherlands
Received 20 July 1998; first review notified 9 November 1998; accepted 19 November 1998
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ABSTRACT |
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 TOPFOOTNOTES ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Routine data from the Dutch Transition project on 236 027 episodes of care collected by 54 family physicians (FPs) for 93 297 patient years in their listed practices and classified with the International Classification of Primary Care, were used to analyse chronic alcohol abuse episodes of care in Dutch family practices. Data on 332 episodes are presented. In a subsample with a 4-year registration period, 70 patients were identified. Important reasons for an encounter are the patient's explicit presentation of the problem and the FPs' initiatives. FPs show considerable sensitivity to psychosocial problems, including alcohol abuse. It is concluded that over the years registered FPs actively deal with chronic alcohol abuse in approximately 2% of all visiting men aged 25–64 years. In an average Dutch family practice with 2200 listed patients, approximately 20 patients are known by the FP to have chronic alcohol abuse. Real life studies in registered family practice populations are necessary to better establish how patients with abundant alcohol consumption as a risk factor develop the chronic alcohol abuse episode of care, and what FPs can do to prevent this effectively.
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INTRODUCTION |
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The new definition of Primary Care from the Institute of Medicine (IOM) in the US requires that primary care clinicians address the large majority of personal health-care needs of their patients and this includes problems with the use of alcohol (Donaldson et al., 1996
). The unit of assessment to decide whether or not primary care clinicians fulfil the requirements of the definition is the episode of care (Lamberts and Hofmans-Okkes, 1996). This is defined as a health problem from the first encounter with a health-care provider through to the completion of the last encounter (see Fig. 1). An episode of care for a patient with chronic alcohol abuse thus differs from a disease episode of alcohol abuse as this can be established in a population survey, but may or may not be known to the family physician (FP).
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In this article, episode of care data from Dutch family practices classified with the International Classification of Primary Care (ICPC) are used to describe patients with chronic alcohol abuse in some detail (Lamberts et al., 1993
). Because in The Netherlands all patients are listed with a FP who also acts as a gatekeeper to the health-care system, sex- and age-specific incidence and prevalence rates for the episodes of care for chronic alcohol abuse in Dutch family practices can be calculated. The relationship between the reason for an encounter, the diagnostic interpretation of the FP and the interventions that follow can be analysed on the basis of episodes over time in different observation periods or time windows. This is quite important for alcohol-abuse patients, where the differences between the proportion of individuals seeking treatment in a defined observation period (often 1 year) and all potential patients, are substantial (Kamerow et al., 1986; Ormel et al., 1990; Glasser and Stearns, 1994). For other serious diseases, such as stroke, metastatic malignancy, myocardial infarction, and blindness, the prevalence rates of the episode of care and of the episode of disease are usually much closer to each other. However, in mental disorders in general and in substance abuse specifically the discrepancy between the actual delivery of care by FPs and specialized agencies, and the potential need, is usually considered to be substantial (Susman, 1995; DeGruy, 1996; Lamberts et al., 1998). The main objective of this article is to describe how FPs in The Netherlands are engaged in the care of patients with an episode of care for chronic alcohol abuse and to formulate suggestions from the available data for a policy to improve care for these patients. |
METHODS |
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Classification and definition of alcohol abuse
The ICPC has been developed by the World Organization for Family Doctors to document systematically the content of episodes of care (Fig. 1
) (Lamberts et al., 1993; WONCA International Classification Committee, 1998). Three elements in each encounter are essential for this: the patient's reasons for the encounter, the diagnostic label by the FP, and the diagnostic and therapeutic interventions. The ICPC contains two chapters on psychosocial problems: chapter P on psychological problems and mental disorders and chapter Z on social problems. The conversion structure between ICPC and ICD-10 specifies the mapping between the two systems, and also the relationship between the available inclusion and exclusion criteria of DSM-IV, ICD-10, and ICPC (Hofmans-Okkes and Lamberts, 1996; Lamberts et al., 1998). In ICPC, symptom diagnoses, like feeling depressed, feeling anxious and sleeping problems, are distinguished from the syndrome diagnoses of mental disorders, such as depressive disorder, anxiety disorder, and chronic alcohol abuse. Substance abuse in general is defined in the recently published ICPC-2 as a mental disorder due to the use of a dependence-producing psychoactive substance resulting in one or more of the following: acute intoxication; harmful use with clinically important damage to health; dependence syndrome; withdrawal state; and psychotic disorder.
In the ICPC, two codes deal with alcohol: P15 — Chronic Alcohol Abuse and P16 — Acute Alcohol Abuse. In our study, chronic alcohol abuse is coded with ICPC and defined with ICHPPC-2 (WONCA International Classification Committee, 1986; Hofmans-Okkes and Lamberts, 1996) as: ‘excessive or repeat intake of alcohol for at least six months and one of the following: (a) symptoms of withdrawal; (b) evidence of organic or psychological disorder due to alcohol toxicity; (c) pathological patterns of use; (d) interference with normal function (social relationships, job performance, legal obligations).’
Data collection
Complete data on all reasons for encounter, diagnoses and diagnostic and therapeutic interventions coded during all face-to-face encounters for at least 1 year between 54 FPs and all their listed patients are available in the Transition Project of the Department of Family Practice at the University of Amsterdam in the form of standard presentations with a 1-year time observation period (Lamberts and Hofmans-Okkes, 1996). Between 1985 and 1995, 236 023 episodes of care during 93 297 patient years were routinely registered and coded. In this database, 322 episodes of chronic alcohol abuse were identified. A 4-year time registration period in a subset of 9605 patients allows us to establish longitudinal information on 70 patients diagnosed with chronic alcohol abuse.
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RESULTS |
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The chronic alcohol abuse episode of care has a 1-year prevalence of 3.6/1000 listed patients in the Transition Project, with the highest incidence and prevalence in men aged between 25 and 64 years (Fig. 2
). The distribution for visiting patients (patients who consulted with their FP during the registration year) is similar, but understandably has considerably higher incidence and prevalence rates (5.1/1000 visiting patients). Standardization for the sex and age composition of the Dutch population in 1995 resulted in a higher proportion of adult men with alcohol abuse/1000 patients listed in absolute numbers (Fig. 3). In an observation period of 4 years, the prevalence increased to 8.1/1000 of the visiting patients. Approximately 2% of all men (25–64 years of age) are diagnosed with chronic alcohol abuse by their FP. The average list size of a full-time FP in The Netherlands is 2200, which results in approximately 20 patients per practice known to the FP for alcohol abuse.
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The reason for encounters between FPs and alcoholic patients at the start of their episodes of care is often worded as such. The family physician also frequently initiates the episodes of care during a consultation for another reason (Table 1
). In addition to this, requests for medication, tiredness, anxiety, and the result of a blood test are important reasons to start the episodes.
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During follow-up, the FP often takes the initiative, or patients indicate that they have returned because of their alcohol problem (Table 2
). Requests for medication are frequent, and with the exception of tiredness, physical symptoms, and complaints have disappeared from the 10 most frequent reasons for encounter.
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On an episode basis, interventions concentrate on advice and counselling and in one-third of the episodes medication is prescribed by the FP (Tables 3 and 4
). In one in four episodes a blood test is ordered, there are only a few referrals to another primary care provider or to a specialized agency. The time course of the episode with active care by the FP is hardly influenced by the observation window (Table 5). The registration artefact of ‘undefined’ episodes starting before the registration period and with one single encounter in the first 4 weeks practically disappears in a 4-year period (Table 4). Active involvement of the FP for more than 6 months occurs in approximately 40% of the patients, independently of the observation period. It is not clear from the data in this table which episodes of care with the FP were short because the patient was referred to a special agency or because the patient was not motivated to continue the episode with the FP.
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Co-morbidity of patients with chronic alcohol abuse was, as expected, substantial (an average of four other episodes of care) with a high prevalence of hypertension (approximately 80% more than would be expected after correction for sex and age) (Table 5
) (Groen et al., 1996; Maas et al., 1997). Of these patients, 9% are also seen for preventive (or ‘no disease’) reasons. Anxiety and sleeping problems cluster with alcohol abuse (respectively 120 and 190% more than expected). Another important co-morbid problem is cirrhosis (or another liver disorder) in 8% of these patients. It is not surprising that trauma is frequent, as are tiredness and bronchitis.
In order to better understand the extent to which the FPs in the study discuss psychosocial problems in general with their patients, the incidence and prevalence rates were calculated in the form of the number of episodes of care for a psychological or social problem/1000 visiting patients/year in each sex/age group (Figs 4 and 5). Approximately 30% of adult men and well over 40% of women discuss such a problem with their FP on an annual basis. Because alcohol problems are most frequent in men between 25 and 64 years of age, the 20 most frequent psychological episodes of care have been calculated for this group and also for women, in order to allow comparison (Table 6). Chronic alcohol abuse is a relatively frequent psychological problem for men and acute alcohol abuse is also not uncommon in Dutch family practices.
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DISCUSSION |
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The FPs in the Dutch Transition Project take care of patients with chronic alcohol abuse on a regular basis and they do so in the context of ‘the large majority of personal health care needs’. A considerable proportion (approximately 30%) of listed adult men do not consult with their family doctor in any defined observation year. In a longer observation period, this proportion, however, is much smaller (approximately 9%) and on a longitudinal basis, FPs identify approximately 2% of their visiting adult male patients as suffering from chronic alcohol abuse in a 4-year period. This percentage is lower than data from population studies indicate (Maas et al., 1997
; Bijl et al., 1997). The magnitude of the difference with active detection of serious alcohol problems in Dutch family practices, however, appears to be limited: two of every three expected patients are effectively known to the FP (Cornel, 1994). FPs seldom refer patients with an alcohol problem to mental health agencies. This may be because of the system: many patients at special agencies are self-referred or referred by other than the FP. This non-referral, however, does not imply that the FP is not aware of the alcoholism, it may relate to the fact that the alcohol problem was not labelled as a separate episode of care. The medication prescribed by FPs for chronic alcohol abuse can be at the request of the patient, who usually obtains medication through a specialized agency. The available data indicate that FPs in The Netherlands regularly deal with patients with chronic alcohol abuse; on average they have identified in their practices (average 2200 patients each) approximately 20 mainly male alcohol abusers and they treat these patients for the large majority of their health-care needs. Our study, however, gives no information about ‘problem drinking’.
In the recently published ICPC-2, the WONCA International Classification Committee (1998) of the World Organization of Family Doctors has not changed its policy with regard to alcohol problems. Chronic alcohol abuse and acute alcohol intoxication remain the clinical entities with inclusion criteria that are very much in line with both ICD-10 and DSM-IV (Lamberts et al., 1998). For other cases, e.g. patients drinking too much, not meeting strict criteria, ICPC offers Code A33 Risk Factor Nos. Clearly there is a ‘grey area’, partly caused by the fact that FPs from both Muslim and Mediterranean countries use the same classification and it is impossible to translate the national standard for instance in the form of the number of glasses per week into an inclusion criterion for a diagnostic entity. In The Netherlands, the lack of clarity about the borderline between risk factors and the diagnosis chronic alcohol abuse entity causes a dilemma, as Cornel (1994) clearly demonstrated. In a large family practice population, the FP appeared to recognize two of every three alcohol-dependent patients as such. No sufficiently clear clinical indicators were established for the FP to identify the ‘hidden patients’ other than screening all adults (Cornel, 1994; Spitzer et al., 1994; Leon et al., 1995; Adams et al., 1996).
An important question is to what extent it would be beneficial if FPs diagnosed more of their registered patients as problem drinkers, so that an episode of care for chronic alcohol abuse was established (O'Brien and McLellan, 1996; Weich et al., 1997; Piccinelli et al., 1997; Fleming et al., 1997). In this respect, the discussion about the ‘under diagnosis’ and ‘under treatment’ of depressive disorder is relevant (Dowrick and Buchan, 1995; DeGruy, 1996; Brown et al., 1997). The multiple efforts to increase the number of patients in primary care diagnosed with depression and treated with antidepressants, has resulted in less additional benefit than expected. Does the same apply to alcohol abuse? It would be of great interest to find out how a pro-active attitude of the FP, towards patients who do not fulfil the inclusion criteria of chronic alcohol abuse, but who are, according to the Dutch cultural system, ‘drinking too much’, would affect the outcome. A recent population-based study in The Netherlands established alcohol dependence during the last 12 months in 3.7% of all adults (aged 18–64 years) (Maas et al., 1997; Bijl et al., 1997). In the same study, the 12-month prevalence of alcohol ‘abuse’ (as opposed to alcohol dependence) was highest in younger men. One in every three young men fulfilled the DSM-III-R criteria for alcohol abuse, but with increase in age the prevalence rates diminished. It seems questionable whether this group of young and temporary abusers would benefit from an early diagnosis by FPs. Since the early 1980s, the use of alcohol in the Dutch population has been increasing, mainly because of the lack of popularity of hard drinks, whereas wine consumption has been increasing (Maas et al., 1997). We do not have sufficient empirical data, however, to decide how to deal best with ‘hidden’ patients with chronic alcohol abuse in family practice. Real life studies in family practice into a more effective treatment of those identified as patients with chronic alcohol abuse, should therefore have a high priority.
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FOOTNOTES |
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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* Author to whom correspondence should be addressed.
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TOPFOOTNOTESABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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