Gaps in addressing problem drinking: overcoming primary care and alcohol treatment deficiencies

Prävention und Kostenkontrolle im Gesundheitswesen

Hintergrund

Das deutsche Gesundheitswesen hat mit hohen Kosten zu kämpfen. Neben den aktuellen finanziellen Belastungen im Zusammenhang mit der Coronapandemie verfolgt die deutsche Bevölkerung mehrheitlich einen ungesunden Lebensstil der zukünftig zu weiteren Neuerkrankungen und assoziierten Kosten führen wird.

Ziel der Arbeit

Dieser Beitrag skizziert, wie mit Hilfe von Routinedatenanalysen der Gesetzlichen Krankenversicherung (GKV) Ansatzpunkte für Maßnahmen auf allen Ebenen der Prävention entwickelt werden können, die effektiv Krankheitsentstehungen verhindern, -progresse reduzieren und die Fähigkeit zur Beitragszahlung absichern können. Diese sollen durch effektives Gesundheitsmarketing Versicherte zu gesundheitsverbessernder Leistungsinanspruchnahme animieren.

Material und Methode

Es wird eine Idee entwickelt und diskutiert, in der ergänzend zu den bestehenden Möglichkeiten der GKV auf präventives Gesundheitsverhalten hinzuwirken, Ergebnisse der Sekundärdatenanalyse für Präventionsmaßnahmen und -verhalten nutzbar gemacht werden können.

Ergebnisse und Schlussfolgerung

Eine Machine-learning-gestützte Analyse bildet den Kern einer Klasse von Prädiktionsmodellen für die Prävention von Krankheiten. Diese Modelle setzen an unterschiedlichen Patientenmerkmalen in den Routinedaten der GKV an und liefern Empfehlungen für Präventionsmaßnahmen, die für eine zielgerichtete und kosteneffektive Ansprache beispielsweise mittels mHealth genutzt werden können. Die hohen Einsparungspotenziale im Gesundheitswesen sowie die Möglichkeiten der Gesetzlichen Krankenkassen diese datenanalytisch gestützt zu erschließen eröffnen eine sinnvolle Perspektive zu nachhaltiger Kostenkontrolle.

Stigma towards mental illness and substance use issues in primary health care: Challenges and opportunities for Latin America

Stigma towards mental illness and addictive disorders is a global problem and one of the main obstacles in tackling this issue remains the effective integration of mental health services into primary health care (PHC). In Latin America, information has significantly increased on the existence of stigma; however, little is known about effective interventions to prevent stigma and promote recovery-oriented practices in PHC. The aim of this study is to understand the existing evidence regarding mental health stigma in PHC with a special focus on the Latin American region. A scoping review of the literature related to mental health stigma in PHC was conducted. Two hundred and seventeen articles were evaluated; 74 met inclusion criteria and 14 additional articles were selected from references of search results. Results were subdivided into five different perspectives: users, family members and significant others, health professionals, contextual factors, and potential effective interventions. Only nine studies were based in Latin America, and only one described an intervention to reduce stigma in mental health services, not specifically in PHC. We found an urgent need to develop interventions to understand and reduce stigma in PHC settings, especially in Latin America.

[General practitioners' commitment to treating excessive alcohol consumption: A question of role security in treating affected patients?]

Only a few general practitioners (GPs) are committed to screen their patients for alcohol consumption and, in case of excessive alcohol consumption conduct by a brief intervention according to WHO recommendations. Apart from inadequate compensation and work load, another barrier identified by the GPs was their uncertainty about how to deal with affected patients. Most German universities presently spend no more than 90minutes lecture time on addiction medicine teaching. Our research aims to investigate the question whether medical studies and advanced medical education increases the role security of medical students and physicians and their commitment to implementing alcohol screening and brief intervention. Moreover, we will explore whether lack of therapeutic commitment can be related to lack of role security. Questionnaires were administered to pre-clinical and clinical medical students as well as senior house officers. Role security and therapeutic commitment of students and senior house officers were assessed using the Alcohol and Alcohol Problems Questionnaire (SAAPPQ) subscales "Role Security" and "Therapeutic Commitment". Analysis was based on 367 questionnaires. As expected, senior house officers reported more Role Security than clinical medical students who showed a higher level of Role Security than pre-clinical medical students. No differences could be found for Therapeutic Commitment. An association between Role Security and Therapeutic Commitment was only revealed for clinical medical students. Medical studies and advanced medical education can increase students' and senior house officers' Role Security to treat patients with excessive alcohol consumption, but not Therapeutic Commitment. Moreover, no association between Role Security and Therapeutic Commitment could be found for senior house officers. Hence, it may be assumed that educational activities aiming to increase Role Security do not promote the development of motivational aspects such as Therapeutic Commitment to the management of patients with excessive alcohol intake.

Engagement and Substance Dependence in a Primary Care-Based Addiction Treatment Program for People Infected with HIV and People at High-Risk for HIV Infection

To improve outcomes for people with substance dependence and HIV infection or at risk for HIV infection, patients were enrolled in a primary care-based addiction treatment program from 2008-2012 that included a comprehensive substance use assessment, individual and group counseling, addiction pharmacotherapy and case management. We examined whether predisposing characteristics (depression, housing status, polysubstance use) and an enabling resource (buprenorphine treatment) were associated with engagement in the program and persistent substance dependence at 6 months. At program enrollment 61% were HIV-infected, 53% reported heroin use, 46% reported alcohol use, 37% reported cocaine use, and 28% reported marijuana use in the past 30 days, 72% reported depression, 19% were homeless, and 53% had polysubstance use. Within 6-months 60% had been treated with buprenorphine. Engagement (defined as 2 visits in first 14 days and 2 additional visits in next 30 days) occurred in 64%; 49% had substance dependence at 6-months. Receipt of buprenorphine treatment was associated with engagement (Adjusted Odds Ratio (AOR) 8.32 95% CI: 4.13-16.77). Self-reported depression at baseline was associated with substance dependence at 6-months (AOR 3.30 95% CI: 1.65-6.61). Neither housing status nor polysubstance use was associated with engagement or substance dependence. The FAST PATH program successfully engaged and treated patients in a primary care-based addiction treatment program. Buprenorphine, a partial opioid agonist, was a major driver of addiction treatment engagement. Given depression's association with adverse outcomes in this clinical population, including mental health treatment as part of integrated care holds potential to improve addiction treatment outcomes.

Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: effect of telephone-administered vs. face-to-face treatment-a secondary analysis

This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.

Screening for unhealthy alcohol and other drug use by health educators: do primary care clinicians document screening results?

OBJECTIVES

Health educators are increasingly being used to deliver preventive care including screening and brief intervention (SBI) for unhealthy substance use (SU) (alcohol or drug). There are few data, however, about the "handoff" of information from health educator to primary care clinician (PCC). Among patients identified with unhealthy SU and counseled by health educators, the objective of this study was to examine (1) the proportion of PCC notes with documentation of SBI and (2) the spectrum of SU not documented by PCCs.

METHODS

Before the PCC-patient encounter, health educators screened for SU, assessed severity (Alcohol, Smoking, and Substance Involvement Screening Test), and counseled patients. They also conveyed this information to the PCC before the PCC-patient encounter. Researchers reviewed the electronic medical record for PCC documentation of SBI performed by the health educator and/or the PCC.

RESULTS

Among patients with the health educator-identified SU, only 69% (342/495) of PCC notes contained documentation of screening by the health educator and/or the PCC. Documentation was found in all encounters with patients with likely dependent SU, but only 62% and 59% of encounters with patients with risky alcohol and drug use, respectively. Documentation of cocaine or heroin use was higher than that of alcohol or marijuana use but still not universal. Although all SU-identified patients had received a brief intervention (from a health educator and possibly a PCC), only 25% of PCC notes contained documentation of a brief intervention.

CONCLUSIONS

Among patients screened and counseled by health educators for unhealthy SU, SBI was often not documented by PCCs. These results suggest that strategies are needed to integrate SBI by primary care team members to advance the quality of care for patients with unhealthy SU.

Opportunities for prevention of alcohol-related death in primary care: results from a population-based cross-sectional study

The mortality rate from alcohol-related conditions has risen sharply in the United Kingdom and it is not known whether opportunities for preventive interventions could be improved. The purpose of our study was to identify opportunities to detect, assess, and manage alcohol problems in primary care according to evidence-based guidelines. We carried out a cross-sectional study on patients who died from alcohol-related conditions in the calendar year 2003 within National Health Service Greater Glasgow Health Board area, Scotland (population 920,000). We described patient characteristics and care recorded in health service records, comparing it with best evidence-based practice in Scottish Intercollegiate Guidelines Network and Health Technology Board for Scotland recommendations on the management of harmful drinking and alcohol dependence. 501 deaths occurred from an alcohol-related cause. The mean age at death was 57.5 years and 72% were male. The most common causes of death, recorded by the International Classification of Diseases, revision 10, excluding accidents, were alcoholic liver disease (290, 57.9%) and mental and behavioural disorders due to alcohol (70, 14.0%). Lifetime mean consultations at primary care general practitioner and hospital outpatient departments were 24 in males and 5 in females. All individuals who died from an alcohol-related cause had at least one biochemical or physical indicator suggestive of alcohol misuse. 21% (95% CI 13-33%) had no record of having been advised to abstain from alcohol and 23% (95% CI 15-35%) had received brief interventions. 58% (95% CI 46-70%) had been referred to specialist alcohol services but a third of them did not attend. The majority of patients (83%, 95% CI 72-90%) had no evidence of shared health service and social work care. We concluded that individuals who died from alcohol-related conditions were usually in contact with statutory and voluntary services but further efforts were required to use these opportunities to detect, assess, and manage serious alcohol problems according to evidence-based guidelines.

Usefulness of Alcohol-screening Instruments in Detecting Problem Drinking among Elderly Male Drinkers

BACKGROUND

In Korea, few studies have been performed on screening instruments for the detection of at-risk drinking and alcohol use disorders in the elderly. This study evaluated the validity of three screening instruments in elderly male drinkers.

METHODS

The subjects were 242 Korean men aged ≥ 65 years. Face-to-face interviews were used to identify at-risk drinking and alcohol use disorders. At-risk drinking was defined according to the criteria for heavy or binge drinking of the National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders IV-text revision. The Alcohol Use Disorder Identification Test (AUDIT), Short Michigan Alcoholism Screening Test-geriatric version (SMAST-G), and cut down, annoyed, guilty, eye-opener (CAGE) questionnaire were used as the alcohol-screening instruments. Based on the diagnostic interview results, sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) of the instruments were compared.

RESULTS

For identification of at-risk drinking, the AUDIT AUROC demonstrated greater diagnostic power than did those of SMAST-G and CAGE (both P < 0.001). In screening for alcohol use disorders, the AUDIT AUROC was also significantly higher than those of SMAST-G and CAGE (both P < 0.001). The sensitivity and specificity of screening for at-risk drinking with an AUDIT score ≥ 7 were 77.3% and 85.1%, respectively, whereas those for the alcohol use disorders with an AUDIT score ≥ 11 were 91.3% and 90.8%, respectively.

CONCLUSION

The results suggest that the AUDIT is the most effective tool in identifying problem drinkers among elderly male drinkers.

Destigmatizing alcohol dependence: the requirement for an ethical (not only medical) remedy

The disease model of alcohol dependence or "alcoholism" is often presented as the linchpin in addressing the condition successfully. It has been argued, for example, that adopting a medical approach will reduce the stigma that impedes the provision and acceptance of treatment. However, the medical paradigm has existed for many years without significantly affecting the negative social attitudes that surround dependence. I argue that a reductive scientific approach is not equipped to address the socioethical tensions that dependence creates. To lessen the stigmatization of dependence, it is important to integrate ethical analysis into policy debates on the condition.

Stigma and treatment for alcohol disorders in the United States

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (β = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (β = 1.0; P < 0.01), education (β = 1.48; P < 0.01), and being previously married (β = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (β = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.