Background
Hypertension (HTN) is the single most important risk factor for mortality and burden of disease, globally and especially for high income countries in Europe [
1]. Its main effect is on cardiovascular outcomes, and consequently, reduction of blood pressure is among the risk factor targets of the World Health Organisation ‘Global Action Plan for Prevention and Control of Non-communicable Diseases’ for the period 2013–2020 [
2]. Primary health care has traditionally had a key role in the detection and the management of HTN [
3]. Part of this management involves advice and interventions on lifestyle factors underlying HTN, and guidelines recommend lifestyle changes as important means to reduce blood pressure, prevent and/or avoid medication for HTN [
3‐
5]. Both epidemiology and randomized trials converge in demonstrating that alcohol consumption, in particular heavy drinking, is one of the most important lifestyle based risk factors for HTN [
6‐
9].
However, the mortality and disease burden attributable to HTN has increased globally since 1990 [
1] and large European surveys still show a large proportion of adults with uncontrolled HTN (
http://apps.who.int/gho/data/?theme=home), indicating the need for further action. Of all lifestyle factors, alcohol seems to be the least intervened in the management of HTN [
10‐
13], which is no surprise given the low screening and intervention rates for hazardous drinking and alcohol use disorder in primary health care [
14,
15]. Interventions for hazardous drinking are scarce [
15‐
17]; and alcohol use disorders have the lowest treatment rate of all mental disorders [
18‐
20], despite evidence that there are effective interventions available for both hazardous drinking and for alcohol use disorders [
21,
22], which could be implemented at the primary care level [
23,
24].
Thus, improving alcohol interventions in primary health care promises to yield substantial health benefits [
10‐
13,
25]. The main question to realize this potential is how to best implement such interventions [
23], both for hazardous drinking and for alcohol use disorders, as part of routine management of HTN. Together with primary care associations in the five largest countries in the European Union (France, Germany, Italy, Spain, and the United Kingdom (UK)), we developed a survey of general practitioners (GPs) to explore knowledge, attitudes and clinical practice of lifestyle interventions in the management of HTN and to help a potential implementation of alcohol interventions (Baseline Alcohol Screening and Intervention Survey (BASIS)).
Results
Two thousand four hundred sixty eight health professionals participated in the survey (for details see Table
1).
With respect to the indicators of good practice alcohol management (= main dependent variables), Table
2 gives the prevalence by country.
Table 2
Good practice alcohol management by country
Indicator A: | | | | | | |
Proportion of GPs screening at least 7 out of 10 hypertensive patients for alcohol % (CI) | 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) |
Indicator B: | | | | | | |
Proportion of GPs with sufficient screening (as A) and self-management of alcohol problems in patients with hazardous drinking levels % (CI) | 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) |
Indicator C: | | | | | | |
Proportion of GPs with sufficient screening (as A) and self-management of alcohol problems in patients with alcohol dependence a % (CI) | 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) |
The overview of influencing variables for good practice alcohol management are given in Table
3, where the reference country was always the UK. Clearly screening for alcohol was best implemented in the UK and Spain, management of hazardous drinking levels was best implemented in Spain (87 % of all identified GPs treated only via brief interventions/advice), and treatment of alcohol dependence was best implemented in Spain and Germany. As hypothesized, post-graduate education and the belief that lifestyle interventions were successful in avoiding HTN-related prescriptions seem to impact on all three indicators. For screening and management of hazardous drinking levels, the GPs’ knowledge about the importance of alcohol as a risk factor for HTN was also positively related.
Table 3
Prediction of good practice alcohol management
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 categoryb) | 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 categoryb) | 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 |
Discussion
Before we discuss potential conclusions of the results, we would like to highlight limitations. First, response rates are relatively low. While it is hard to compare response rates across physicians’ surveys, as there are different sampling frames and several web-based surveys do not even give response rates [
36,
37], and even though web-based surveys have comparably lower response rates [
38], an overall response rate of 6 % must be considered low. As a consequence, while the national/regional sampling frames can be considered as representative, the low response rates suggest that a convenience sample of GP’s being more motivated and interested in the topic has been drawn [
39]. Thus the screening and intervention rates reported are likely to be overestimates (for intervention rates in samples of GP’s with representative sampling and a considerably higher response rate [
14,
40]). Second, all answers were self-reports and social desirability bias may have shifted some of our key results upwards [
41]. In other words, based on the two major limitations of this study, the rates for screening and interventions among hypertensive primary health care patients in Europe are most likely lower than described in this study. However, given the low response rate, we cannot fully rule out that we have underestimated the GPs’ involvement, e.g., if engaged GPs were too busy to participate in our survey.
Conclusions
While our findings are susceptible to sample distortion, they are sufficiently robust to demonstrate that the GPs’ involvement in alcohol screening and management among patients with HTN is generally poor in the largest European countries. Thus, the situation for HTN patients is likely not better than for other primary care patients with respect to detection of and interventions for heavy drinking and alcohol use disorders [
14,
15,
17,
40]. What can be done about this? First, medical education at universities have to put more emphasis on alcohol as one of the main risk factors for many disease conditions GPs see in their daily practice [
40]. The lack of education seems a common problem in all five countries, and was also highlighted in some of the qualitative answers. Moreover, post-graduate training was shown to increase screening and intervention rates [
16,
42], and this is, where GP associations can contribute. Secondly, given the high overall workload of GPs, and the overall health burden attributable to alcohol in countries in the European Union [
20], alcohol interventions need to be prioritized and this could be done by financial incentives. A recent cluster randomized trial with 746 providers in 120 primary health care centers from five European countries has shown that modest financial incentives increase screening and intervention rates. Interestingly, there is a synergistic effect when financial incentives, training and support are offered together [
17]. We hope that the involvement of several GP associations in the current study will help overcome these barriers in the future.
Acknowledgements
The authors acknowledge all GP associations and all GPs who took the time to respond to the survey.
Competing interests
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 from Abbivie outside the submitted work.
AR: reports no conflict of interest.
BS: reports no conflict of interest.
CG: reports grants, sponsorship to attend scientific meetings, speaker honoraria and consultancy fees from Lundbeck during the conduct of the study. Consultancy fees and salaries received not related to this study received from the NHS, RCGP, Omnimedia, Pfizer, Turning Point, Locala CIC, and doctors.net.uk (all UK).
DD: reports grants from Cerin, Haute Autorité de la Santé, Ligue contre le cancer, Medtronic, Lundbeck, MSD, Novartis, Novo-Nordisk, Pfizer, and SFMG.
ES: reports sponsorship to attend scientific meetings from Lundbeck.
H-JA: reports sponsorship to attend scientific meetings, speaker honoraria and consultancy fees from Bioprojet, D&A Pharma, Ethypharm, Lundbeck, Merck-Serono, Novartis, and Pfizer.
JAAP: reports grants and personal fees from Lundbeck during the conduct of the study.
JM: reports personal fees from Lundbeck, outside of the submitted work.
JR: reports grants from Lundbeck during the conduct of this study, personal fees and serving as board member (Nalmefene) for Lundbeck.
JZ: reports personal fees from Lundbeck, and consultancy fees and salaries from Menarini, Lilly and Gilead outside of the submitted work.
LK: reports funding from Lundbeck for a research project on alcohol epidemiology unrelated to this study.
MBa: reports consulting fees received from Lundbeck (through consulting business Copentown) for organisational and process support in connection with the project. Copentown, which is owned by MB, also has other pharmaceutical/healthcare clients.
MBe: reports no direct support from Lundbeck but for foundation of BHÄV (with the aim to promote Junior GPs).