Changes in profile of patients seeking alcohol treatment and treatment outcomes following policy changes

Alcohol has been identified by multi-criteria decision analysis to be the overall most harmful drug, with heroin and cocaine in second and third place (Nutt et al. 2010). The World Health Organization (WHO) has reported excessive alcohol consumption to be the second most important lifestyle factor (after tobacco use) affecting the overall disease burden in high-income countries such as Denmark (World Health Organization 2009). Alcohol has also been found to be a significant cause of non-communicable diseases (Room et al. 2005). In Denmark, consumption of alcohol leads to at least 3000 potentially preventable deaths each year, representing 5% of total annual deaths, and also contributes to many patient contacts with the health care system (Danish Health Authority and Statens Serum Institut 2015).

Potentially harmful drinking occurs in 20% of the Danish population, and an estimated 5% of the population has developed a dependency that jeopardizes their working career and may lead to early death (Gottlieb Hansen et al. 2011). Hence, during the last 20–30 years, the Danish Health Authority has become increasingly concerned about the quality of the treatment for alcohol use disorder available to the population.

By law, treatment for alcohol problems is offered to the Danish population as it is in most other European countries (The Danish Parliament 2016). The public outpatient treatment for alcohol dependence in Denmark is easily accessible, free of charge and open for self-referral, and patients may remain anonymous during treatment if they so wish. For decades, most treatment for alcohol dependence has been offered on an outpatient basis, with individuals being able to choose freely among the publicly funded treatment offers.

Treatment for alcohol use disorder is delivered per the Danish Health law (January 1, 2007), and for decades the treatment was offered by the Danish counties, who were also responsible for delivering health care.

However, a study in 2004, mainly focusing on how services varied according to opening hours, implementation of manualized treatment methods and use of systematic quality control, illustrated how the treatment services in the Danish regions varied significantly among the various counties (Milter et al. 2004). A network of managers of publicly funded alcohol treatment institutions, Alkoholfagligt Forum (AFF), established in 2002, therefore initiated annual joint seminars for all staff members in the treatment institutions, in addition to meetings between the managers, to discuss, inspire and learn from one another about how to implement in particular evidence-based treatment methods and strategies.

Furthermore, in 2006, a treatment of alcohol dependence assessment was performed and published (Danish Centre for Evaluation and Health Technology Assessment and National Board of Health 2006). This was in many respects the first major step in a national process aimed at improving the quality of treatment and increasing the homogeneity of treatment across the country.

In 2006, the publicly funded treatment of alcohol dependence was still managed by the counties, but became the responsibility of the individual Danish municipalities from January 1, 2007, onwards. In addition, a new law guaranteed that the waiting time for treatment should not exceed 14 days (The Danish Parliament 2016). The political argument for this change was that the local governments thereby would be able to coordinate treatment with social services and provide treatment more locally.

The change was implemented as part of a great reform, consolidating 14 former counties into 5 regions with responsibility mainly for the health care sector and reducing the number of municipalities from 271 to 98 (The Danish Parliament 2005). Hence, instead of treatment for alcohol dependence being the responsibility of 14 Danish counties (plus two local governments with the status of counties), alcohol treatment became the responsibility of 98 local governments. As a result, differences became even more profound across the country, with the number of treated patients varying between 0.08 and 8.37 per 1000 inhabitants and the organization of alcohol treatment differing depending on whether it was part of the community health services (Sundhedsforvaltning) or social services (Socialforvalting) within the municipalities or run by private distributers on behalf of the municipalities (Becker et al. 2012).

Following the reform, additional national initiatives were taken to improve the quality of the treatment for alcohol problems and to some extent to prevent the high number of relatively small local treatment institutions leading to reduced quality of treatment instead of increased quality (Danish Health Authority 2010b). The initiatives provided, for instance, advisory material for the municipalities in 2008, describing what treatment for alcohol dependence should include and what treatment institutions should be able to offer (Becker et al. 2008), based on a treatment of alcohol dependence assessment (Danish Centre for Evaluation and Health Technology Assessment and National Board of Health 2006). In addition, training courses for staff employed in public alcohol treatment has been offered by the Danish Health Authorities regularly since 2008, including basic training in evidence-based treatment, cognitive behavioral therapy and motivational interviewing, and family focus in treatment. The training was not only arranged but also funded by the Danish Health Authorities and freely available for the local governments. The training course was module-based, with five modules for a total of 16 days, and offered on a regular basis several times a year, allowing treatment institutions to dispatch newly trained staff in a timely manner. In addition to the basic 16-day training course, a series of courses in family treatment and training focusing on preventing harm to children in families with alcohol problems were also offered to staff from the alcohol treatment institutions without costs to the local governments (Danish Health Authority 2014).

In 2010, the Danish Health Authority launched a nationwide project for local quality improvement projects in the municipalities, aimed at securing the quality of alcohol treatment and implementing strategies to involve the families (significant others) in the treatment rather than only involving the drinker.

In 2015, the Danish Health Authorities devised and published National Guidelines for the treatment of alcohol dependence (Danish Health Authority 2015) and for treatment of alcohol dependence and concurrent mental illness (Danish Health Authority 2016). Finally, the national parliament decided in 2015 that all alcohol treatment institutions should undergo public supervision on a regular basis.

Several reports (Becker et al. 2012; Milter et al. 2004) have investigated the quality of treatment during the decade that followed public reform and changes in the organization of the alcohol treatment field with a focus on securing the quality of treatment in Denmark. They primarily describe changes in staff composition, treatment offers and collaboration with general practice (Becker et al. 2012). Little, however, is known about whether implementation of the broad national strategies for improving and homogenizing the quality of treatment has, in fact, led to more uniform and effective treatment.

The aim of this article was to (1) investigate whether the profile of the patients seeking and receiving alcohol treatment in Denmark has changed during the last decade and (2) investigate whether there were differences in the outcome of the treatment across regions and over time.

A total of 88,057 contacts with the alcohol treatment centers were found from 2006–2014. After cleaning up the data set, 452 observations were removed [299 because of an invalid municipal code, 223 because of invalid age (below 15 or above 100) and 106 empty registrations]. After narrowing the data set to the patients’ first contact with the alcohol treatment centers only, 44,516 observations were left.

We found that treatment for alcohol use disorder seems to have become more homogeneous across the regions in Denmark over time, and by 2014 it was difficult to identify differences across the country. This increased homogeneity was seen in both relation to the mean length of treatment courses and the number of treatment courses that were concluded in agreement between staff and patient. This may be due to the strong focus on quality assurance and development and series of initiatives from the network of managers (AFF) in general and the Danish Health Authority in particular. In the 1990s there was a rather strong tradition in Denmark for very long, outpatient treatment courses, and this seems to have changed as well. This may be due to an increased common understanding in Denmark of alcohol treatment as something that not only begins, but also has a planned conclusion compared to being a permanent offer.

Many alcohol treatment institutions became part of social services in the municipalities because of the reform in 2006; hence, we had expected the number of referrals to treatment for alcohol use disorder from social services to increase with the reform, but this did not seem to be the case. The pattern of referrals was instead rather stable throughout the investigatory period.

The limitations of the present study relate primarily to the National Alcohol Treatment Register itself (NAB). The NAB is relatively new (from 2006), and especially in the first few years there were registration problems in the different regions in Denmark. For instance, the ‘other’ category for the question of the end outcome was initially used more heavily especially in the North Denmark Region, but this picture changed after a few years.

Another weakness is that when the patients arrive at the alcohol treatment centers, they can choose to remain anonymous. However, only very few patients do so. Also, the majority of the variables in the NAB require mandatory reporting from the alcohol treatment centers, but some variables are not; therefore, these variables are less reliable to look at as they are not consistently reported.

There are of course also strengths of the study. The registration problems that were present in the first years of the register seem to have stabilized. The NAB is a very comprehensive register covering a large amount of information that the patients themselves report. The personal identification number makes it possible to link the information from the NAB to other registers, thus facilitating larger studies involving more registers in the future.

The profiles of the patients do not vary across the country and hardly vary over time. Thus, the many years with a strong focus on and initiatives within the alcohol treatment field seem to have resulted in largely homogeneous treatment offers across the country.