AT WHICH DRINKING LEVEL TO ADVISE A PATIENT? GENERAL PRACTITIONERS' VIEWS

Mauri Aalto1,* and Kaija Seppä1,2

1 Department of Psychiatry, Tampere University Hospital and
2 Medical School, University of Tampere, Finland

Received 4 September 2000; accepted 25 April 2001


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
— This study examined the views of 64 general practitioners (GPs) on how much a patient has to drink to be advised by them and compared the results to the recommended Finnish threshold values of heavy drinking. The levels stated by GPs were not too high to prevent early-phase intervention in heavy drinking; rather, they were so low that numerous moderate drinkers were also included. The mean (SD) level was 15.5 (6.5) drinks for male and 11.0 (4.6) drinks for female patients per week. These are about two-thirds of the Finnish threshold values of heavy drinking. Attempting to advise such high proportions of patients, including both heavy and moderate drinkers, might mean a discouraging burden for GPs. However, there may be a discrepancy between GPs’ statements about when to advise and when they actually do so.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Brief intervention represents a new perspective on responding to drinking problems. It is intended to provide early intervention, before or close to the onset of alcohol-related problems. General practitioners (GPs) in particular are in a favourable position to provide brief intervention for heavy drinkers.

In spite of substantial evidence supporting the efficacy of brief intervention in reducing heavy drinking (Bien et al., 1993Go; Wilk et al., 1997Go), there is still the question of putting research findings into practice in routine primary health care (Heather, 1995Go). In our previous study, we found that, in the area where brief intervention had been actively promoted in recent years, only 19% of heavy drinkers are advised about alcohol when seeing a GP (Aalto et al., 2001Go). Even if the reasons for this are still mostly unknown, there obviously is a problem of engaging GPs in providing competent brief intervention for their patients. One issue among many others is what GPs think of the threshold values for heavy drinking.

The present study examines GPs’ views on how much patients have to drink before advising them, in comparison to the recommended Finnish threshold values for heavy drinking. The study is part of a project which systematically attempts to identify possible obstacles to the implementation of brief intervention in routine general practice in Finland.


    METHODS AND SUBJECTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
In May 2000 a postal questionnaire with a covering letter was sent to all GPs (n = 75) working in primary health care of the Finnish city of Tampere, with a population slightly under 200 000. In Finland primary health care provides equal access services to an unselected population.

To obtain background information on the GPs, questions about gender, age, specialization in general practice and years of experience in primary health care were included. Additionally, two open-ended questions were asked: (1) ‘How many drinks should a male patient drink in a week to make you advise him to reduce his drinking? (2) ‘How many drinks should a female patient drink in a week to make you advise her to reduce her drinking?’ The GPs were asked to answer in terms of Finnish standard drinks equivalent to 12 g of ethanol. Returning the questionnaires was free of charge for the respondents.

In four mailing waves, 64 (85%) of the GPs returned the questionnaire. Of the 64 respondents, 17 (27%) were men and 47 (73%) women; age ranged from 26 to 61 years and the mean age (SD) was 41.6 (8.8) years; 29 (45%) were specialists in general practice; 18 (29 %) had worked as GPs for between 1 and 5 years, 12 (19%) for between 6 and 10 years and 33 (52%) for over 10 years. One respondent did not state the number of years she had worked.

SPSS 9.0 statistical software was used in the analyses of the data. Descriptive statistics were calculated and means of the levels at which GPs would advise were compared to the Finnish threshold values for heavy drinking, which are 24 standard drinks for men and 16 standard drinks for women per week (standard drink = 12 g of ethanol) (Sillanaukee et al., 1992Go). The means for different subgroups of GPs were compared using the Mann–Whitney test. Differences were considered statistically significant at P < 0.05. In the 11 cases when GPs gave a range rather than an exact value either for male and/or female patients (seven gave ranges for males and nine for females) the lower number was used in the analyses. The mean (SD) range was 4.7 (3.0) for male and 3.0 (1.8) for female patients.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Of the 64 respondents, eight (13%) could not state any level at which they would advise. Among the rest, the mean (SD) level of alcohol consumption at which they would advise was 15.5 (6.5) standard drinks per week for male patients and 11.0 (4.6) standard drinks per week for female patients (Fig. 1Go). Stated levels ranged between 5 and 35 standard drinks for males and 3 and 25 drinks for females.



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Fig. 1. Distribution of general practitioners' (n = 64) statements at which drinking level they would advise their male and female patients. Arrows indicate recommended Finnish heavy drinking thresholds for males (24 drinks) and females (16 drinks).

 
The GPs’ mean level at which they would advise was 65% concerning male patients and 69% concerning female patients of the Finnish threshold values for heavy drinking (24 standard drinks for men and 16 standard drinks for women per week). Only three (5%) GPs regarding male patients and four (6%) GPs regarding female patients stated levels higher than the threshold values for heavy drinking. Conversely, 46 (72%) and 52 (81%) stated levels lower than the threshold values.

There were no statistically significant (P >= 0.05) differences in mean stated levels at which GPs would advise between the following subgroups: male vs female GPs, GPs <44 years vs older, specialists vs non-specialists and those who had <10 vs >10 working years.

Of the respondents, four (6%) stated equal levels for males and females at which to advise. The rest stated higher levels for males: the mean difference (SD) was 4.4 (2.6) drinks. This is 55% of the recommended eight drinks difference.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The aim of the study was not to test the knowledge of the threshold values for heavy drinking (Sillanaukee et al., 1992Go), but rather to evaluate what GPs state to be the alcohol consumption level which causes them to advise their patients. The GPs’ answers are based not only on the existing threshold values for heavy drinking, but also their estimation of the validity of these threshold values and their feasibility in routine work. The Finnish threshold values for heavy drinking are based on epidemiological data of alcohol health hazards and were published originally in a leading Finnish medical journal in 1992 (Sillanaukee et al., 1992Go). Since then, these threshold values have been frequently quoted in Finnish textbooks, the literature and recommendations related to alcohol. Among Finnish alcohol researchers, these threshold values are widely accepted, even though subject to debate.

The target group of this study was GPs, because they are in a very favourable position to provide brief intervention for heavy drinkers before the onset of alcohol-related problems. The response rate for the study was very good, but the sample size was relatively small. One possible bias in the present study is that some GPs may have given the type of response that they believed the investigators wanted.

In general, GPs in the present study were found to state somewhat unrealistically low levels of alcohol consumption at which to advise their patients, but only few stated levels higher than those recommended. The mean levels at which these GPs would advise were about two-thirds of the Finnish threshold values for heavy drinking. For example, ~40% of GPs stated a level (<=11 drinks per week) which would mean advising 30% of all male patients, including one-third of moderate drinkers according to the recommended threshold values for heavy drinking (Aalto et al., 1999Go). Similarly, 25% stated a level (seven or fewer drinks per week) which would also mean advising 30% of female patients, including two-thirds of moderate drinkers (Aalto et al., 1999Go).

Lack of time is often said by GPs to be an obstacle to brief intervention. Attempting to advise such high proportions of patients due to low threshold values would obviously put a heavy discouraging burden on GPs. Low threshold values could be due to attitudes, but also to lack of understanding of definitions of moderate and heavy drinking, and the concept of so-called early-phase heavy drinking (Rush et al., 1994Go). Some GPs may want to advise their patients before alcohol use reaches a risk level. This is an important issue, because, as Rush et al. (1994) concluded in their review, the perception of differences between moderate and heavy drinking is associated with the likelihood of a physicians' intervention.

In comparison with previous studies, the mean levels in the present study were about half of what GPs from Australia stated to be the level at which to advise (Roche, 1990Go), but equivalent to what GPs in the United Kingdom stated to be the threshold values for heavy drinking (Wallace et al., 1985Go). In previous studies, many GPs have also stated extremely low levels at which to advise (Roche, 1990Go) or of what the definition of heavy drinking is (Wallace et al., 1985Go; Weller et al., 1992Go). However, contrary to our results, there have also been many GPs stating disturbingly high levels (Roche, 1990Go; Weller et al., 1992Go). This difference could possibly be due to the fact that brief intervention has been actively promoted in recent years among the GPs participating in the present study.

A relatively high proportion of respondents (>10%) could not state any level at which they would advise. Roche (1990) reported a similar finding. This may be due to either lack of knowledge or an opinion that it is not possible to state any specific level appropriate for all. Both of these options can be seen as obstacles to implementing brief intervention. In the case of the latter, GPs may have difficulties in understanding that the specific threshold values based on epidemiological data of alcohol-related health harms are essential in preventive work. They are needed, even if the threshold values are subject to debate and there are subgroups, such as pregnant women, with different threshold values.

Few GPs stated precisely the same consumption level at which to advise for both male and female patients. However, in comparison with the Finnish threshold values for heavy drinking, GPs reported advising female patients applying relatively higher threshold values than for male patients. Corresponding findings have been reported (Roche, 1990Go). The reason for this is only speculative, but this result might reflect different attitudes of GPs towards drinking among male and female patients.

These data do not directly permit conclusions as to the drinking level at which GPs actually advise their patients. However, based on previous findings that advising is rare in Finland, it seems that there is a discrepancy between GPs’ views regarding when to advise and what they actually do (Aalto et al., 2001Go). This conclusion is supported by a previous finding that GPs do not advise at the levels they report (Reid et al., 1986Go).

The main conclusions of the present study were that the threshold values set by GPs as to when to advise their patients are not too high to prevent wide implementation of brief intervention, but instead, the low levels set by many GPs could be an obstacle to extensive implementation and this issue has to be tackled. Elements causing obvious discrepancy between stated levels and actual performance are some of the key issues to be studied in the future.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The authors wish to thank Mr Petteri Pekuri for technical assistance. This study was part of Phase IV of the WHO Collaborative Project on Identification and Management of Alcohol-Related Problems in Primary Health Care.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed at: Piettasenkatu 12 C 40, FIN-33580 Tampere, Finland. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS AND SUBJECTS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Aalto, M., Seppä, K., Kiianmaa, K. and Sillanaukee, P. (1999) Drinking habits and prevalence of heavy drinking among primary health care outpatients and general population. Addiction 94, 1371–1379.[ISI][Medline]

Aalto, M., Pekuri, P. and Seppä, K. (2001) Primary health care professionals' activity in intervening in patients' alcohol drinking: a patient perspective. Drug and Alcohol Dependence 64, in press.

Bien, T. H., Miller, W. R. and Tonigan, J. S. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315–335.[ISI][Medline]

Heather, N. (1995) Interpreting the evidence on brief interventions for excessive drinkers: the need for caution. Alcohol and Alcoholism 30, 287–296.[Abstract]

Reid, A. L., Webb, G. R., Hennrikus, D., Faney, P. P. and Sanson Fisher, R. W. (1986) Detection of patients with high alcohol intake by general practitioners. British Medical Journal 293, 735–737.[ISI][Medline]

Roche, A. M. (1990) When to intervene for male and female patients' alcohol consumption: what general practitioners say. Medical Journal of Australia 152, 622–625.[ISI][Medline]

Rush, B., Ellis, K., Crowe, T. and Powell, L. (1994) How general practitioners view alcohol use. Clearing up the confusion. Canadian Family Physician 40, 1570–1579.[ISI][Medline]

Sillanaukee, P., Kiianmaa, K., Roine, R. and Seppä, K. (1992) Alkoholin suurkulutuksen kriteerit (Criteria of heavy drinking). In Finnish. Suomen Lääkärilehti 47, 2919–2921.

Wallace, P., Cremona, A. and Anderson, P. (1985) Safe limits of drinking: general practitioners' views. British Medical Journal 290, 1875–1876.[ISI][Medline]

Weller, D. P., Litt, J. C., Pols, R. G., Ali, R. L., Southgate, D. O. and Harris, R. D. (1992) Drug and alcohol related health problems in primary care — what do GPs think? Medical Journal of Australia 156, 43–48.[ISI][Medline]

Wilk, A. I., Jensen, N. M. and Havighurst, T. C. (1997) Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. Journal of General Internal Medicine 12, 274–283.[ISI][Medline]