1 Department of General Practice, Tampere University, Finland and 2 Department of Psychiatry, Tampere University Hospital, Finland
* Author to whom correspondence should be addressed to at: Medical School, Department of General Practice, FIN-33014 University of Tampere, Finland. E-mail: mekase{at}uta.fi
(Received 23 October 2003; first review notified 14 December 2003; in revised form 12 January 2004; accepted 2 February 2004)
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ABSTRACT |
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INTRODUCTION |
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The problems, however, are manifold. First, to detect alcohol abuse in this busy surrounding is difficult and time-consuming. Secondly, even if the problem is recognised, it may not be documented. This may be due to confidentiality and fear for denial of insurance coverage (Rivara et al., 2000; Sillanaukee et al., 1994). Due to the above facts, alcohol abuse seems to be seldom screened and detected at emergency clinics (Cherpitel et al., 1996
; Gentilello et al., 1999b
; Sillanaukee et al., 2002
).
Alcometer (alcohol breath analysis) is easy, non-invasive and rapid to perform (Walsh and Macleod, 1983). It would be more feasible for screening than time-consuming self-report in the busy surroundings and could thus facilitate the detection of patients' heavy alcohol use. Among emergency patients, even if its specificity may be hampered by the fact that it sometimes only measures recent alcohol consumption not related to regular heavy use, it has been reported to be an equally sensitive indicator of heavy alcohol use as patients' self-reports (Cherpitel, 1989
, 1993
, 1995
) and better than laboratory markers (Ryb et al., 1999
) and could serve as a first-line screen. It is also an objective measure, which has a good correlation with blood alcohol concentration (Antti-Poika and Karaharju, 1986
). Thus, even though it is less sensitive compared to structured questionnaires (Redmond et al., 1987
; Cherpitel, 1995
) it is a better method than the present practice, where documentation is often based on smell or appearance of the patient.
Alcohol consumption is seldom reported as an etiological factor for acute traumas. In one study, among all the university hospital patients having an alcohol-related diagnosis during a six-year period (n = 6666), there were only 32 (0.5%) who had a trauma. When a special effort was made to document alcohol abuse the percentage of trauma patients with alcohol abuse was 28% (Sillanaukee et al., 1994). In primary health care, reports of the patient's alcohol use were found in patients' records only in 7% during a one-year period; most of the documentation happened during emergency visits (Aira, 2000). These records were mostly inexact or contained only the alcometer result. Alcohol use was documented exactly only if the patient had filled in a structured questionnaire before the consultation (Aira and Kotilainen, 1998
). Education on the alcohol-related issues increased the documentation (Aira and Kotilainen, 1998
). In a recent study Rockett et al. (2003)
found that 31% of seven general hospital emergency patients during a half-year period had positive tests for substance abuse but only 1% had a recorded diagnosis of substance use (Rockett et al., 2003
).
As part of a project aimed at promoting alcohol-related skills among the personnel the present study aimed at finding out the present emergency clinic physicians' use of the alcometer and the extent to which they documented alcohol-related findings in their patients.
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MATERIALS AND METHODS |
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During one weekend in May 1999, 100 consecutive patients over 15 years-old coming to Tampere University Hospital, Finland, central emergency clinic (including surgical, internal medicine, psychiatric or neurology departments) were screened for their alcohol use. All patients whose somatic or psychiatric condition allowed filling in the questionnaire were included in screening. The written version of the Five-Shot questionnaire (Seppä et al., 1998; Aertgeerts et al., 2001
) was filled in by 96/100 of these patients. The physicians were informed that this study was part of the project ongoing at the hospital aimed at increasing staffs' skills to detect and treat patients' alcohol- and drug related problems. The information did not include details of the study protocol (e.g. searching for patients' medical records and analysing alcometer use). All diagnostic instruments (including alcometers) were easily available. The physician treating the patient did not know the results of the patient's questionnaire.
The physician treating the patient filled in another questionnaire which inquired whether the reason for the patient's consultation was disease, injury, accident or attempted suicide and whether alcohol abuse might contribute to the consultation. The physician's questionnaire was filled for 99/100 of the patients. During the weekend altogether 13 physicians were on call. Seven of them were female and six were male; five internists, four surgeons, three neurologists and one psychiatrist. Of the patients 46 were treated by a female and 52 by a male physician.
The researchers (T.L., S.A.), who were present at the emergency unit for the whole weekend, collected and merged the patients' and doctors' answers. After the study weekend the researchers screened the patients' medical records for information on alcohol consumption and for diagnostic use of alcometer. Altogether 98/100 of the medical records could be traced. The whole set of answers (patient's questionnaire, physician's questionnaire and medical records) was achieved from 94/100 patients. Both physicians' questionnaire and patients' medical records were available from 97 patients.
The material was divided into three groups based on the reason for consultation: trauma (including accident, injury and attempted suicide) / disease / both. Also, it was divided in two groups based on alcohol consumption measured by the Five-Shot questionnaire: non-heavy drinkers (Five-Shot total score <3 points and <7 drinks per one occasion) or heavy drinkers (Five-Shot total score 3 points or
7 drinks per one occasion).
Information from all three sources (patients' questionnaire, physicians' questionnaire and patients' medical records) was compared. Analysis was performed on SPSS statistical software 10.1.
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RESULTS |
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Alcometer
Seven patients were tested by alcometer for alcohol concentration; the value ranged between 0.95 and 2.60. All the tested were men and five of them were heavy drinkers based on the Five-Shot questionnaire. The reason for consultation was trauma in six and disease in one. Altogether, alcometer was studied from 5/26 (19%) of the heavy drinkers.
Documentation
Information on alcohol consumption was written in 17/98 (17%) patients' medical records. Information on alcohol consumption (Five-Shot questionnaire result) was available from 16 of these patients. The written information mainly included a simple mention of alcohol use; no exact amounts or no detailed information of the consumption pattern. Of the alcohol use information, 12/16 (75%) was in heavy drinkers' medical records and 4/16 (25%) in non-heavy drinkers' medical records (indicating that they were heavy drinkers). Only 12/26 (46%) heavy drinkers had written information on their alcohol use in their medical records.
The information in the physicians' questionnaire (about the relation of alcohol use and the consultation) and in patient medical records coincided in 89/97 (92%) cases (Table 1). The 6/20 patients whose visit was primarily considered by the physician to be alcohol-related but whose medical records did not show any information on this were all men and the reason for the visit was trauma. All patients who were tested by alcometer had alcohol abuse documented in their patient medical records.
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DISCUSSION |
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To avoid false-positive results we used one of the best questionnaires to detect heavy drinkers (Aertgeerts et al., 2001) and a relatively high limit for heavy episodic drinking (
7 drinks). The prevalence of heavy drinkers (26/96; 27%) and alcohol-related traumas (13/31; 42%) is similar to earlier reports, the latter ranging from 24 to 45% (Holt et al., 1980
; Sillanaukee et al., 1994) and the 33% in the Finnish study performed more than ten years earlier (Antti-Poika and Karaharju, 1986
). Using a different screening tool, the CAGE a Mexican study found that 25% of the patients at a trauma clinic were heavy drinkers (Borges et al., 1998
). In the same study the number of alcohol abusers among non-trauma emergency patients was 21% (Borges et al., 1998
).
Alcometer testing was seldom done during our study. Reports of this practice elsewhere are rare. We did not ask the physicians' reasons for not using the alcometer. It can be speculated that this may be due to work-load, a trust in one's own diagnostic skills (including smell of the patient), fear for disturbing the patientphysician relationship, fear of not knowing what to do if the test is positive or thinking that this is not their responsibility.
Documentation of alcohol abuse in the present study was infrequent and thus in agreement with earlier studies (Aira and Kotilainen, 1998; Rockett et al., 2003
). Also the fact that the documentation when done was scarce and included no figures of the drinking amounts is similar to that reported earlier (Aira and Kotilainen, 1998
).
The challenge now is to increase the emergency clinic staff's activity in detection and documenting substance abuse. Even if an intervention may not be feasible in emergency settings, alcohol-related information could be given to the patient and/or referral made to the family practice. This activity could lead to a big improvement in public health and also to a decrease in use of emergency services.
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