Background
A recent WHO report showed that almost half of Irish drinkers engage in heavy drinking on a regular basis, placing Ireland’s binge drinking rates at the second highest of 174 countries studied [
1]. According to the Central Statistics Office, Dublin, the current per capita alcohol consumption in Ireland is 10.9 l per person aged over fifteen years, a figure that has trebled over four decades, while in most other countries it has fallen [
2]. The increase in per capita consumption is associated with an earlier age of commencing drinking [
3] and a recent survey showed that half of Irish 15–16 year olds had consumed alcohol and 23% had been intoxicated at least once [
4]. Furthermore, a study of third level students showed that two thirds were engaging in hazardous drinking [
5]. These figures, particularly, are alarming as people with serious drug and alcohol problems commence drinking at a much earlier age than those without problems [
6]. Ireland’s unhealthy relationship with alcohol is therefore related to both the amount and pattern of alcohol consumption.
The socio-economic impact of alcohol in this country is enormous with a cost to the state of 3.7 billion yearly in terms of health, crime and work-place [
7]. Alcohol misuse permeates all facets of Irish society and is a factor in: higher-risk sexual behaviour [
8], almost half sexual assault cases [
9]; in one quarter of marital disharmony and one third of domestic abuse incidents in this country [
10]. There is a proven link to suicide [
11], with alcohol detected in the blood of a half of suicide deaths in Ireland [
12]. From a health perspective, alcohol is a causal factor in more than 60 medical conditions including hypertension, liver cirrhosis and depression [
13] and is one of the most important causes of cancer in Ireland. It is a proven factor in the aetiology of cancers of the mouth, throat, stomach, liver and breast [
14]. 28% of emergency department admissions to six of Ireland’s main hospitals are due to alcohol with half of these being in the 18–30 year old age-group [
15], mostly due to binge drinking.
Successive legislation has been largely ineffective in addressing the alcohol crisis but the seriousness of the problem has been recognised in recent legislation (Public Health [Alcohol] Bill, 2015) which includes evidence-based measures such as minimum unit pricing. Health strategy has emphasised the importance of resources and training for the preventative role of primary care. It is recognised that general practitioners (GPs) commonly see patients with a range of alcohol-related risks and problems (8–18% of patients presenting to primary care) and screening and brief interventions in this setting are proven to reduce misuse levels [
16]. GPs have been identified as appropriate professionals to screen for those at risk of problem alcohol use and to conduct brief interventions to influence patients to think more actively about their alcohol consumption [
17]. Despite the magnitude of the national alcohol problem and the detrimental effects on health and society, there is a surprising lack of data from general practice on the documentation of alcohol use and treatment.
The aims of this study, therefore, were to investigate the prevalence of documentation of problem alcohol use in patient records in Irish general practice, to describe the documented treatment of patients with problem alcohol use and their psychological co-morbidities.
Methods
Participants
This study is part of a larger study on prevalence of psychological morbidity in adults attending general practice in Ireland, the methodology of which has been previously described [
18]. All general practices affiliated with the University of Limerick Graduate Entry Medical School with a senior medical student on clinical placement in 2013 (
n = 56 practices) were invited to participate in the study. As part of the medical school professional competencies curriculum, third year medical students are required to complete a clinical audit or research project and may do this while on any placement. A unique aspect of the curriculum is an 18-week general practice placement where faculty provide a standardised project for students with ethical approval, instructions on data retrieval and analysis, a coding sheet and supervision for the duration of the project. With this level of support and the suitability of electronic records to audit and research, the majority of students opt for the standardised project in general practice in conjunction with their GP tutors.
Practices affiliated with the School are broadly representative of practices nationally by size, urban/rural and patient eligibility for free care. Reporting functions of electronic practice management systems in all participating practices were used to generate a list of all patients aged 18 and over with a documented contact to the practice in the previous two years. A random sample of 100 adult patients was selected from this list in each practice using a random number function in Microsoft Excel. Inactive patients, e.g. temporary visitors or those known to have recently moved away or died were excluded from the sample.
Measures
Clinical records for a two year time period (2011–2013) were reviewed for the sample of patients by the senior medical student on placement in the practice and their supervising GP for any evidence of attending the practice with problem alcohol and/or substance use other than alcohol. Evidence included text in consultation notes; evidence of a pharmacological treatment or psychological intervention by the GP; evidence of a referral to another primary healthcare professional or specialist agencies and/or diagnostic coding.
Data was collected using an instrument validated for morbidity surveys in primary care in Ireland [
19] which recorded the following information on all patients in the sample:
Data was entered to an Excel file in each practice and anonymised datasets from all practices were merged together with practice characteristics (urban or rural, number of patients, number of staff). Ethical approval for the study was granted by the University Hospital Limerick Research Ethics Committee.
Statistical analysis
The proportion of patients with problem alcohol or substance use documented in the previous two years was estimated with a 95% confidence interval for the proportion, accounting for the structure of the dataset with patients clustered within practices. Demographic and healthcare utilisation variables were summarised using graphical and numeric descriptive statistics. For those patients with problem alcohol and/or substance use documented, information on treatment was summarised using graphical and numeric descriptive statistics. The association between categorical variables was tested using chi-square tests and median consultations rates were compared across groups using non-parametric tests. A 5% level of significance was used for all statistical tests. SPSS Statistics Version 21 for Windows and SAS software Version 9.2 for Windows (SAS Institute, Inc.) were used to carry out the analysis with the SAS procedure SURVEYFREQ used to account for clustering.
Results
Forty (71%) of the 56 practices affiliated with the Medical School agreed to participate. Practice characteristics of those who did not participate were similar to those who participated. Practice size ranged from less than one thousand to over three thousand registered patients. Twenty two (54%) practices indicated they were urban, 13 (33%) indicated they were rural and 5 (13%) indicated they were mixed urban/rural practices. Of the 4000 patient records sampled across 40 practices, 155 (4%) temporary visitors to the practice or those who were known to have died or moved away were excluded giving a sample of 3845 ‘active’ patients.
Problem alcohol use
Fifty-seven (1.5%, 95% confidence interval 1 to 2%) were identified as having problem alcohol use documented in the previous two years. Of the 40 participating practices, 14 (35%) had no patients in their sample with documented problem alcohol use, 16 (40%) had up to 2% of their sample with documented problem alcohol use and 10 (25%) had between 2 and 8% of their sample with documented problem alcohol use. Patients with problem alcohol use were more likely to be male than those without any problem alcohol use documented (65% vs. 47%,
p = 0.007). They were also more likely to be eligible for free GP care (72% vs 48%,
p < 0.001), have been referred or attended secondary care in the past year (79% vs 50%, p < 0.001) and attend the GP more frequently (median of 5 vs 2 consultations a year,
p = 0.02) (see Table
1).
Table 1
Demographics and healthcare utilisation by whether problem alcohol use was documented
Median Age (25th, 75th percentile) | 46 (32, 61) | 49 (36, 58) | 0.45 |
Male | 1777 (47%) | 37 (65%) | 0.007 |
Eligible for free GP care | 1828 (48%) | 41 (72%) | < 0.001 |
Any referral/attendance to secondary care in the past year | 1910 (50%) | 45 (79%) | < 0.001 |
Median GP consultations (25th, 75th percentile) in the past year | 2 (1, 6) | 5 (2, 7) | 0.02 |
The majority (72%) of those with problem alcohol use were identified from free text in consultation notes. Six patients (11%) had a diagnostic code entered for problem alcohol use. Four (7%) patients were identified from referral letters, four (7%) from both referral letters and consultation notes, one (2%) from a ‘past history’ page and one (2%) from a psychological assessment. Of the 57 patients with documented problem alcohol use, 22 (39%) also were documented as having depression, 21 (37%) stress and anxiety and 3 (5%) psychosis.
Twenty-three (0.6%, 95% confidence interval 0.4 to 0.9%) were identified as having substance use other than alcohol documented in the previous two years. The majority of practices (n = 25 practices, 63%) had no patients in their sample with documented problem substance use. Of the 23 patients with problem substance use, two (9%) were also identified as having problem alcohol use.
Twenty-nine (51%) of those with documented problem alcohol use were referred to other specialist services. 28 (49%) received a psychological intervention, mostly counselling or a brief intervention. The psychological intervention was given in a diverse range of settings including primary care teams (32%), rehabilitation or addiction services (21%), and Alcoholics Anonymous (4%). 40 (70%) were prescribed psychotropic medications during the two-year timeframe of the study, most commonly antidepressants (47%) and benzodiazepenes (37%). 16 (28%) had two or more drugs prescribed for psychological problems.
Acknowledgements
The authors would like to acknowledge the contribution of the GPs affiliated to the Graduate Entry Medical School and senior medical students on placement in general practice who contributed to this project.
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