Alcohol screening and alcohol interventions among patients with hypertension in primary health care: an empirical survey of German general practitioners

Background: Alcohol is one of the least intervened risk factors in the management of hypertension at the primary care level. In order to improve alcohol interventions, a better understanding of knowledge, attitudes and clinical practice of lifestyle interventions in the management of hypertension is needed.

Method: As a part of a European study (France, Germany, Italy, Spain, UK), 211 German general practitioners (GPs) were recruited in Bavaria and Hamburg and surveyed via an Internet-based questionnaire. Results were compared with the European sample (n?=?2870).

Results: One-third of the patients seen by German GPs had hypertension (36.2%, standard deviation (SD): 14.6) and among cases with hypertension, less than half were ever screened for alcohol (4.5 out of 10 patients). The foremost reasons for not screening for alcohol were that alcohol was not considered a major risk factor for hypertension plus the lack of knowledge of appropriate alcohol screening instruments. The majority of German GPs managed patients with hazardous drinking levels themselves or in their practice (71.3%, 95% confidence interval (CI): 64.6–77.2%), but only 42.0% (95% CI: 35.2–49.0%) managed alcohol dependent patients. German screening rates were slightly lower but interventions of screened positive patients higher than the European average.

Conclusions: Rates of alcohol screening in patients with hypertension in primary health care may be increased by improving GPs knowledge of alcohol as a major risk factor for hypertension, increasing GPs education on alcohol and screening instruments, and providing reimbursement. This may increase treatment of alcohol problems in patients with hypertension and reduce hypertension.     

Longitudinal patterns of antidepressant prescribing in primary care in the UK: comparison with treatment guidelines.

The objective of this study was to determine whether patients beginning therapy on the most common tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) differed in their likelihood of having antidepressant treatment that was consistent with recommended treatment guidelines in the UK. An analytical file constructed from a large general practitioner medical records database (DIN-LINK) from the UK for the years 1992-97 was constructed. A total of 16,204 patients with a new episode of antidepressant therapy who initiated therapy on one of the most often prescribed TCAs (amitriptyline, dothiepin, imipramine and lofepramine) or SSRIs (fluoxetine, paroxetine and sertraline) were analysed. A dichotomous measure was defined to indicate whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on aTCA and 32.9% of patients initiating therapy on a SSRI were prescribed antidepressant treatment that was consistent with treatment guidelines. After controlling for observable characteristics, patients who initiated therapy on a SSRI were much more likely (odds ratio=7.473, p<0.001) to have a prescribed average daily dose and duration consistent with recommended treatment guidelines within the first 6 months of initiating therapy than were patients who initiated therapy on a TCA. These findings suggest that initial antidepressant selection is an important determinant of whether the subsequent course of treatment is consistent with current national guidelines for the treatment of depression in the UK.     

Drinking patterns and alcohol dependence: a comparison of primary care patients in a southern county with the regional general population

OBJECTIVE: Alcohol-related problems are thought to be overrepresented in primary care settings compared to the general population; however, studies comparing alcohol use problems within primary care settings and within the general population from the same area are relatively rare. METHOD: Data on drinking patterns and alcohol dependence are reported on a probability sample of 767 patients in a primary care system and 1,536 general population respondents sampled from the same region. RESULTS: No differences were found regarding heavy drinking, frequency of drunkenness or prior alcohol treatment, between the primary care sample and those in the general population who reported primary care use during the previous year, although those in the primary care sample were significantly less likely to be alcohol dependent. Compared to those in the general population who reported not using primary care services during the preceding year, the primary care sample was significantly less likely to report frequent drunkenness or prior alcohol treatment. Controlling for the demographic disparity between samples in multivariate analysis, drinking characteristics were not positively predictive of belonging to the primary care sample. CONCLUSIONS: The data suggest that problem drinking does not appear to be overrepresented in this primary care sample, nor among those reporting primary care use in the general population of the region, and that all primary care settings may not hold equal promise for screening for problem drinking patients.     

Left ventricular hypertrophy in hypertensive patients in Indian primary care: prevalence and effect of treatment with sustained release indapamide

Objective: Epidemiologic studies indicate an ethnic determinant of left ventricular hypertrophy (LVH), but its prevalence in hypertensive Asian Indians at diagnosis is not known. The observation that LVH regression reduces cardiovascular risk independent of blood pressure, suggests that initial antihypertensive treatment, which also regresses LVH is a desirable goal. This study investigates the prevalence of LVH and its regression with indapamide sustained release (Natrilix SR) in untreated Indian hypertensive patients managed in the primary care setting.

Design and methods: Randomly selected physicians serving a defined population recruited untreated hypertensive patients to determine prevalence of LVH. All patients then received indapamide SR treatment for 6months. LVH was assessed by echocardiography. All measurements were centralized and interpreted by a single blinded observer.

Main outcome measures: The primary treatment outcomes were the percentage of patients whose LVH regressed with treatment and the number of patients who achieved a blood pressure below 140/90 mmHg.

Results: Of the 86 patients recruited, 21 (24.4%, 95% confidence interval (CI) 15.3-33.8) had LVH. There were 11 cases (26.2%) in men, 10 (22.7%) in women, and 15 (32.6%) in those above 50years. Treatment regressed LVH in 16 (76.2%, 95%CI, 58.0-94.4) by a mean of 25.4?g/m² (95%CI, 2.8-47.7, p?<?0.05). Blood pressure was controlled in 71 (82.6%, 95%CI, 74.5–90.6) patients.

Conclusion: Prevalence of LVH in untreated Indian hypertensive patients is similar to that in white western populations. Initial indapamide SR treatment is effective in both controlling blood pressure and regressing LVH in the primary care setting.     

Left ventricular hypertrophy in hypertensive patients in Indian primary care: prevalence and effect of treatment with sustained release indapamide

OBJECTIVE: Epidemiologic studies indicate an ethnic determinant of left ventricular hypertrophy (LVH), but its prevalence in hypertensive Asian Indians at diagnosis is not known. The observation that LVH regression reduces cardiovascular risk independent of blood pressure, suggests that initial antihypertensive treatment, which also regresses LVH is a desirable goal. This study investigates the prevalence of LVH and its regression with indapamide sustained release (Natrilix SR) in untreated Indian hypertensive patients managed in the primary care setting. DESIGN AND METHODS: Randomly selected physicians serving a defined population recruited untreated hypertensive patients to determine prevalence of LVH. All patients then received indapamide SR treatment for 6 months. LVH was assessed by echocardiography. All measurements were centralized and interpreted by a single blinded observer. MAIN OUTCOME MEASURES: The primary treatment outcomes were the percentage of patients whose LVH regressed with treatment and the number of patients who achieved a blood pressure below 140/90 mmHg. RESULTS: Of the 86 patients recruited, 21 (24.4%, 95% confidence interval (CI) 15.3-33.8) had LVH. There were 11 cases (26.2%) in men, 10 (22.7%) in women, and 15 (32.6%) in those above 50 years. Treatment regressed LVH in 16 (76.2%, 95%CI, 58.0-94.4) by a mean of 25.4 g/m2 (95%CI, 2.8-47.7, p< 0.05). Blood pressure was controlled in 71 (82.6%, 95%CI, 74.5-90.6) patients. CONCLUSION: Prevalence of LVH in untreated Indian hypertensive patients is similar to that in white western populations. Initial indapamide SR treatment is effective in both controlling blood pressure and regressing LVH in the primary care setting.     

Factors associated with hazardous alcohol use and motivation to reduce drinking among HIV primary care patients: Baseline findings from the Health & Motivation study

BackgroundLimited primary care-based research has examined hazardous drinking risk factors and motivation to reduce use in persons with HIV (PWH).MethodsWe computed prevalence ratios (PR) for factors associated with recent (<30 days) hazardous alcohol use (i.e., 4+/5+ drinks in a single day for women/men), elevated Alcohol Use Disorders Identification Test (AUDIT) scores, and importance and confidence (1–10 Likert scales) to reduce drinking among PWH in primary care.ResultsOf 614 participants, 48% reported recent hazardous drinking and 12% reported high alcohol use severity (i.e., AUDIT zone 3 or higher). Factors associated with greater alcohol severity included moderate/severe anxiety (PR: 2.07; 95% CI: 1.18, 3.63), tobacco use (PR: 1.79; 1.11, 2.88), and other substance use (PR: 1.72; 1.04, 2.83). Factors associated with lower alcohol severity included age 50–59 years (PR: 0.46; 0.22, 2.00) compared with age 20–39 years, and having some college/college degree (PR: 0.61; 0.38, 0.97) compared with ≤high school. Factors associated with greater importance to reduce drinking (scores >5) included: moderate/severe depression (PR: 1.43; 1.03, 2.00) and other substance use (PR: 1.49; 1.11, 2.01). Lower importance was associated with incomes above $50,000 (PR: 0.65; 0.46, 0.91) and marijuana use (PR: 0.65; 0.49, 0.87). HIV-specific factors (e.g., CD4 and HIV RNA levels) were not associated with alcohol outcomes.ConclusionsThis study identified modifiable participant characteristics associated with alcohol outcomes in PWH, including anxiety and depression severity, tobacco use, and other substance use.     

Process evaluation of the implementation of a screening and brief intervention program for alcohol risk in primary health care: An experience in Brazil

Introduction and Aims. Screening and brief intervention (SBI) are considered good prevention strategies for alcohol‐related problems in Primary Health Care (PHC). The aim of this study was to evaluate the process of an SBI implementation program for alcohol risk use and evaluate the factors that facilitated or impeded this implementation, in two PHC settings at the Brazilian city of Juiz de Fora. Design and Methods. Case 1 public PHC services and case 2 the PHC service of the Military Police. Participants were trained on SBI strategies and supervised during 6 months. The qualitative methodology of action research was used. Data were analysed using thematic analysis. Results. Case 1: 70 participants; facilitating factors: good expectations about the project; simplicity of SBI technique; collaborative way the project was planned. Barriers: lack of time; discomfort in dealing with alcohol issues; focus on alcohol‐dependence; unstable political environment; other priorities; difficulties in patients' referral. Case 2: nine participants. Facilitating factors: simplicity of SBI technique; collaborative way the project was planned; importance of alcohol issues; data confidentiality and the voluntary work to do SBI. Barriers: only one health professional in the group; the variability of the institutional support; organisational culture about alcohol use. Discussion and Conclusions. The barriers and facilitators were related to two main factors: organisational culture and personal attitudes. The action research provided the opportunity to bridge the gap between research and practice, but it also showed that SBI faces significant challenges before it can be implemented as a routine procedure in PHC settings in Brazil. [Amaral MB, Ronzani TM, Souza‐Formigoni MLO. Process evaluation of the implementation of a screening and brief intervention program for alcohol risk in primary health care: An experience in Brazil. Drug Alcohol Rev 2009]     

The journey to concordance for patients with hypertension: a qualitative study in primary care

Objective We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing. Method This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison. Main outcome measures The perspectives of patients with hypertension on issues relating to concordance in prescribing. Results Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor’s advice, perceiving doctors’ attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication. Conclusions Participants indicated a willingness to be␣involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual’s medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.     

The journey to concordance for patients with hypertension: a qualitative study in primary care

Objective

We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing.

Method

This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison.

Main outcome measures

The perspectives of patients with hypertension on issues relating to concordance in prescribing.

Results

Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor’s advice, perceiving doctors’ attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication.

Conclusions

Participants indicated a willingness to be?involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual’s medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.

     

Survey of care provided by ambulatory care pharmacists to patients with chronic kidney disease.

PURPOSE: A survey was conducted to determine the role of ambulatory care pharmacists in the care of patients with chronic kidney disease (CKD). METHODS: Data from a survey of ambulatory care pharmacists in the treatment and management of patients with CKD were collected. A 22-item anonymous survey was sent to 1028 potential respondents in January 2004. Only pharmacists indicating routine provision of care to patients with risk factors for the development of CKD or with stages 1-4 of CKD were included in the analysis. Additional questions surveyed the timeliness and frequency of nephrology referrals and the pharmacists' familiarity with National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines. RESULTS: Of 1028 surveys, 535 were completed and returned. Only respondents who provided care in an outpatient setting to geriatric patients and patients with diabetes mellitus, hypertension, or decreased creatinine clearance were included in the analysis (n = 388). Initial assessment of CKD was performed by 85% of the surveyed pharmacists. Over one third of the pharmacists made nephrology referrals. However, even pharmacists who had a high percentage of patients with a known risk for CKD infrequently screened for kidney dysfunction, and only a small portion monitored the areas recommended by NFK-K/DOQI. The respondents' familiarity with the NFK-K/DOQI guidelines indicated that 7% were very familiar, 45% were somewhat familiar, 34% were not very familiar, 13% were not at all familiar, and 1% did not respond. CONCLUSION: The ambulatory care pharmacists surveyed were not consistently involved in the routine monitoring of common complications of CKD.     

Access to health care and heavy drinking in patients with diabetes or hypertension: implications for alcohol interventions

Supported by a National Institute of Alcoholism and Alcohol Abuse grant, this study examined associations between health care access and heavy drinking in patients with hypertension and diabetes. Using a sample of 7,428 US adults from the 2007 National Health Interview Survey data, multivariate logistic regressions were performed. Better access to health care, as indicated by regular source of care and frequent use of primary care, was associated with reduced odds of heavy drinking. Alcohol interventions may be more effective if targeted at patients with chronic conditions adversely affected by drinking. Future research needs to investigate factors facilitating such interventions.     

The pharmaceutical care of patients with hypertension: an examination of service models in primary care in the US

Background: In the UK, the delivery of health care in cardiovascular disease is guided by 'national service frameworks', which are a source of standards of practice and evidence that help to define and aid the implementation of service models capable of responding to public health goals. The revised British Hypertension Society guidelines reflect a lower target blood pressure consistent with those recommended in the US and by the WHO. The lowering of the target for the control of blood pressure has increased the estimated proportion of treated patients with inadequate control in the UK from 37% to 72%. Objective: To identify the requirements for the provision of a pharmacy service that supports hypertension monitoring, and to gain insights into how such a service might be delivered as part of a wider provision of pharmaceutical care in the UK. Method: Two pharmacists followed a structured programme of observation involving three centres in the United States (Minnesota, Colorado and Iowa). Twelve clinical settings were observed, and the pharmacists who provided the services were also the subjects of documented interviews. The settings offered different models of pharmaceutical care from which issues relevant to the international development of such services were identified. Findings: Differences noted between the service models observed included; physical environment of the community pharmacy, the use and type of documentation, methods of blood pressure measurement, extent of monitoring and followup, interprofessional communication and service orientation in terms of the provision of comprehensive pharmaceutical care to patients or specific disease management. Conclusion: If clearly defined operational models of pharmaceutical care practice in the primary care setting are to form part of a national public health strategy in the UK, they must also be capable of responding to local opportunities and patients' needs. Future development of models and services must be patientcentred and more widely informed by the range of practice experience gained elsewhere.     

DOTx.MED: Pharmacist-delivered interventions to improve care for patients with diabetes

ObjectivesTo describe the development and implementation of the Discussions on Taking Medications (DOT_x.MED) Diabetes Pilot Program and to report the impact on adherence to diabetes therapy, improvement in communication of pharmacists, and satisfaction of patients, pharmacists, and health care providers.Participants10 community pharmacy residency sites across the United States enrolled 216 patients with diabetes to participate in the pilot project.InterventionPharmacists delivered behavioral interventions using motivational interviewing techniques and increased personal communication with patients during routine visits to the pharmacy during a 6-month period.ResultsDuring the initial 6-month pilot program, modest improvements in medication adherence were documented. Patients in the intervention group showed a 6.55% increase in proportion of days covered (PDC) compared with the previous 180 days preintervention and a 2.8% increase in PDC compared with the control group. Based on survey results, overall reports of satisfaction from patients, pharmacists, and health care providers were favorable.ConclusionAccess to educational programs, tools, and resources provided through the DOT_x.MED Diabetes Pilot Program improved pharmacist knowledge of diabetes care and increased the amount of time spent communicating with patients. The program demonstrated that small, focused interactions addressing issues of concern to patients can improve patient adherence to medication therapy.     

Impact of coaching by community pharmacists on drug attitude of depressive primary care patients and acceptability to patients; a randomized controlled trial.

OBJECTIVE: To investigate whether an intervention by Dutch community pharmacists improves the drug attitude of depressive patients, who are prescribed a nontricyclic antidepressant by their general practitioner (GP). METHOD: A randomized controlled trial with a 3-month follow-up was conducted among consecutive general practice patients who go to 19 pharmacists for antidepressants. The trial consisted of a control group (n=79) that received usual care and an intervention group (n=69) that received three drug coaching contacts at the pharmacy and a 25-min take-home video on the background of depression and the effects of medication. OUTCOME MEASURE: Drug attitude (DAI). RESULTS: At the baseline measurement there were no significant differences between the intervention and control group on any demographic and health status variables or on clinical symptoms. At the 3-month follow-up intervention patients had a better drug attitude (P=0.03) than their controls and evaluated the coaching of their pharmacist as more positive. They also felt the video to be useful. It had changed their ideas about medication. CONCLUSIONS: Coaching by community pharmacists is an effective way to improve drug attitude of depressive primary care patients and it is acceptable to them.