Barriers and levers in screening and care for alcohol use disorders among French general practitioners: results from a computer-assisted telephone interview-based survey

Alcohol use disorders (AUD) is a major public health concern. General practitioners (GP) must play a key role in identifying this disorder and offering appropriate interventions. The authors conducted a survey among French GP in the Provence – Alpes – Côte-d’Azur (PACA) region to better understand their practices regarding AUD. Random sampling was used to enrol 101 GP in a 15-minute survey. A Computer-Assisted Telephone Interview exploring demographic and professional characteristics was conducted using a questionnaire. One third (31.7%) of the participants systematically addressed alcohol use with their patients whereas six (5.9%) never addressed it. Logistic regression analyses showed that after adjustment for the number of AUD patients followed up (odds ratio [OR] = 1.92; 95% confidence interval [CI] [1.19, 3.08]) and GP interest in addiction medicine (5.41 [2.17, 13.40]), GP who systematically screened patients for AUD were more likely to accept controlled drinking as a therapeutic goal (5.41 [2.17, 13.33]), and to perceive patient denial of AUD as a major barrier to care (1.39 [0.60, 3.22]). GP providing care for AUD were more likely to monitor tobacco cessation (9.08 [2.60, 31.64]) and to prescribe opioid maintenance treatment (7.35 [2.52, 21.41]). Alcohol screening is insufficient in general practice in France. Providing updated guidelines is essential to foster experience in this field among GP.     

Colorectal cancer screening: a survey of French general practitioners

AIM: To determine knowledge, beliefs, self-reported practices and wishes of French general practitioners regarding colorectal cancer screening before the start of an organized screening program. METHODS: A postal survey of the 600 general practitioners of the Haut-Rhin area was made in 2002. RESULTS: Response rate was 62%. Eighty-five% asked routinely their patients about their family history of colorectal cancer. Colorectal cancer screening was routinely proposed by 92% of practitioners to individuals with a family history (86% with colonoscopy) and by 20% to individuals without family history (69% with faecal occult blood test). Seventy-five% did not know French consensus conference guidelines on colorectal cancer screening. Fifty-three% ordered routinely faecal occult blood testing, mostly for the screening of individuals with family history and for the evaluation of symptoms, mainly iron-deficiency anemia and weight loss. Seventy-seven% would explore with colonoscopy subjects with positive faecal occult blood test. Fifty-four% had personally undergone screening. Fifty-six% considered that mass screening could reduce a lot colorectal cancer mortality and most of them agreed with the forthcoming organized colorectal cancer mass screening program. CONCLUSIONS: Screening for colorectal cancer is ordered less often than screening for female cancers. General practitioners are unaware of current guidelines. Beliefs and practices vary considerably and faecal occult blood testing is often inappropriately prescribed. Medical education concerning screening is needed. Colorectal cancer screening guidelines and policy should be clarified in France.     

On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Effectiveness of a collaborative diabetes screening campaign between community pharmacies and general practitioners

AimTo evaluate the impact of a collaborative screening campaign on the prevalence of pre-diabetes and diabetes among the screened population.MethodsA Longitudinal, multicentre study was developed. The Finnish Diabetes Risk Score (FINDRISC) was applied to the eligible population in the participating community pharmacies. Individuals with a FINDRISC score ≥ 15, were eligible to measure their glycated haemoglobin (HbA1c) level at the community pharmacy. If HbA1c≥ 5.7%, participants were referred to a general practitioner (GP) appointment for potential diagnosis of Diabetes.ResultsOut of 909 screened subjects, 405 (44.6%) presented a FINDRISC score ≥ 15. Among the latter, 94 (23.4%) had HbA1c levels that made them eligible for GP referral, of which 35 (37.2%) completed the scheduled appointments. 24 participants were diagnosed with pre-diabetes, and 11 with diabetes. The prevalence was estimated at 2.5% (CI95% 1.6–3.8%) and 7.8% (CI95% 6.2–9.8%) for diabetes and pre-diabetes, respectively.ConclusionThis collaborative model has proved to be effective in the early detection of diabetes and pre-diabetes. Joint initiatives between health professionals can play a pivotal role in the prevention and diagnosis of diabetes, which may lead to a reduction on the burden to health system and society.     

Trazodone for sleep disturbance after alcohol detoxification: a double-blind, placebo-controlled trial

Background:  Trazodone is a commonly prescribed off-label for sleep disturbance in alcohol-dependent patients, but its safety and efficacy for this indication is unknown.
Methods:  We conducted a randomized, double-blind, placebo-control trial of low-dose trazodone (50 to 150 mg at bedtime) for 12 weeks among 173 alcohol detoxification patients who reported current sleep disturbance on a validated measure of sleep quality or during prior periods of abstinence. Primary outcomes were the proportion of days abstinent and drinks per drinking day over 6-months; sleep quality was also assessed.
Results:  Urn randomization balanced baseline features among the 88 subjects who received trazodone and 85 who received placebo. The trazodone group experienced less improvement in the proportion of days abstinent during administration of study medication (mean change between baseline and 3 months: −0.12; 95% CI: −0.15 to −0.09), and an increase in the number of drinks per drinking day on cessation of the study medication (mean change between baseline and 6 months, 4.6; 95% CI: 2.1 to 7.1). Trazodone was associated with improved sleep quality during its administration (mean change on the Pittsburgh Sleep Quality Index between baseline and 3 months: −3.02; 95% CI: −3.38 to −2.67), but after it was stopped sleep quality equalized with placebo.
Conclusions:  Trazodone, despite a short-term benefit on sleep quality, might impede improvements in alcohol consumption in the postdetoxification period and lead to increased drinking when stopped. Until further studies have established benefits and safety, routine initiation of trazodone for sleep disturbance cannot be recommended with confidence during the period after detoxification from alcoholism.     

Evidence of a structural effect for alcohol outlet density: a multilevel analysis

BACKGROUND: Ecological studies reveal that alcohol-related outcomes tend to occur in high alcohol outlet density neighborhoods. The ecological design of these studies limits the interpretation of the findings in terms of the level of the effect. The effect of alcohol outlet density could be related to greater individual access to alcohol, an individual level effect, or to the grouping of drinkers by neighborhood, a structural effect at the neighborhood level. METHODS: To differentiate between individual and neighborhood level possibilities, we conducted a multilevel study. Individual distance to the closest alcohol outlet was the individual level measure of the effect of alcohol outlet density, whereas the mean distance to the closest alcohol outlet for all individuals within a census tract was the neighborhood level measure for the effect of alcohol outlet density. We analyzed telephone surveys of 2604 telephone households within 24 census tracts stratified by poverty status and alcohol outlet density. Individual distance to alcohol outlets, age, sex, race/ethnicity, and level of education were entered as individual level covariates, and their corresponding aggregated means were entered as census tract level covariates (i.e., mean distance to outlets, mean age, percentage male, percentage Black, mean education). RESULTS: Analysis of variance revealed that 16.2% of the variance in drinking norms and 11.5% of the variance in alcohol consumption were accounted for at the census tract level. In multivariate hierarchical analysis, individual distance to the closest alcohol outlet was unrelated with drinking norms and alcohol consumption, whereas mean distance to the closest alcohol outlet demonstrated a negative relation with drinking norms (betae = -5.50+/-2.37) and with alcohol consumption (betae = -0.477+/-0.195); that is, the higher the mean distance to the closest alcohol outlet, the lower the mean drinking norms score and mean level of alcohol consumption. CONCLUSIONS: The findings suggest that the effect of alcohol outlet density on alcohol-related outcomes functions through an effect at the neighborhood level rather than at the individual level. Problem drinkers tend to be grouped in neighborhoods, an effect predicted by alcohol outlet density.     

Barriers to and promoters of screening for falls in elderly community-dwelling patients by general practitioners: a large cross-sectional survey in two areas of France

The objective was to determine the factors affecting French GPs' implementation of annual screening for falls among patients of 75 years old and over. We conduct a cross-sectional study in two areas in the South-east of France (Savoie and Isère). An anonymized survey was sent by e-mail and/or post in May 2008 to all GPs with a large practice. Reminder letters were sent to GPs who hadn't answered between June and July 2008. Potentials barriers were measured by dichotomous scale. On GPs characteristics (socio-demographic, knowledge, attitude and practice), a multiple logistic regression was performed to identify others factors affecting falls screening. 493 questionnaires were analyzed (26.8%). 65.3% of respondents considered annual screening for falls to be useful, though only 28.8% of them implemented it each year and 9.3% every two to five years. Barriers to achieving annual screening included patient selecting (56.3%), forgetting to screen (26.6%), unsuitable working conditions (18.5%), lack of time (13.3%), of knowledge (13.3%), or of financial compensation (11.1%). Perception of the usefulness of annual screening for falls (OR = 5.38 (2.07–14.08); p = 0.001), satisfaction with medical care for falls (OR = 1.34 (1.09–1.65); p = 0.006) and increased consultation time (OR = 2.65 (1.37–5.13); p = 0.004), were found to have a significant impact on the implementation of annual screening for falls. Asking your patient each year if s/he has had any falls, inquiring about gait and balance disturbance is not time consuming. Finally, to improve a health-related quality of life, GPs should consider fall assessment as a fundamental feature of medical care.     

Lifestyle intervention in general practice for physical activity,smoking, alcohol consumption and diet in elderly: A randomized controlled trial

The purpose of the study was to compare the effectiveness of programmed and intensified intervention on lifestyle changes, including physical activity, cigarette smoking, alcohol consumption and diet, in patients aged ≥65 with the usual care of general practitioners (GP). In this multicenter randomized controlled trial, 738 patients aged ≥65 were randomly assigned to receive intensified intervention (N = 371) or usual care (N = 367) of a GP for lifestyle changes, with 18-month follow-up. The main outcome measures were physical activity, smoking, alcohol consumption and diet. The study was conducted in 59 general practices in Croatia between May 2008 and May 2010. The patients’ mean age was 72.3 ± 5.2 years. Significant diet correction was achieved after 18-month follow-up in the intervention group, comparing to controls. More patients followed strictly Mediterranean diet and consumed healthy foods more frequently. There was no significant difference between the groups in physical activity, tobacco smoking and alcohol consumption or diet after the intervention. In conclusion, an 18-month intensified GP's intervention had limited effect on lifestyle habits. GP intervention managed to change dietary habits in elderly population, which is encouraging since elderly population is very resistant regarding lifestyle habit changes.     

B-type natriuretic peptide testing for structural heart disease screening: a general population-based study

BACKGROUND: Several types of structural heart disease are important precursors for congestive heart failure or cardioembolic stroke. We have previously demonstrated that plasma B-type natriuretic peptide (BNP) measurement is useful for detection of structural heart disease in a multiphasic health screening setting. To extend our hypothesis to the general population, the utility of BNP testing for identifying structural heart disease was assessed in a general population and in subgroups divided by sex, age, and presence/absence of risk factors. METHODS AND RESULTS: This cross-sectional cohort study measured plasma BNP concentrations in 993 randomly selected community-dwelling adults (mean age 58 years). All subjects underwent plasma BNP measurement and transthoracic echocardiography. Using prejudged criteria, 41 subjects were diagnosed to have some form of structural heart disease (mild left ventricular systolic dysfunction in 11, valvular heart disease in 9, hypertensive heart disease in 3, hypertrophic cardiomyopathy in 2, ischemic heart disease in 2, lone atrial fibrillation in 14). The utility of BNP testing was evaluated by receiver operating characteristic (ROC) analysis and by cost analysis for detection of 1 case within each subgroup of the cohort. Overall, the sensitivity and specificity of BNP testing for identification of structural heart disease were 61% and 92%, respectively. The area under the ROC curve was 0.77 (95% CI; 0.74-0.79). When sex-specific ROC analyses were performed, sensitivity and specificity were 61% and 91% in men, and 50% and 95% in women, respectively. Although the performance of BNP testing on the basis of these figures might be suboptimal, efficacy was improved in subgroups with a high prevalence of heart disease (>8%) such as the cohort aged > or =65 years (men, area under ROC curve = 0.88; cost 相似文献   

Screening for hazardous alcohol consumption in a sexual health clinic: a service evaluation

On the basis of National Institute for Health and Clinical Excellence (NICE) guidance we conducted a survey in a sexual health clinic to assess acceptability of an alcohol screening questionnaire, rates of hazardous drinking and success of referral to a specialist alcohol service (Aquarius). Seventy-two percent of patients accepted the offer of screening, of whom 34% were hazardous drinkers; 2.6% consented to referral to Aquarius but failed to attend. We estimate the cost range to screen and deliver a five-minute brief intervention at ￡3.62-￡9.19 per case. Opportunistic alcohol screening identifies high rates of hazardous drinkers and is acceptable to patients, but onward referral by untrained staff to an external specialist alcohol service is unsatisfactory to patients. Research into the cost-effectiveness of screening and delivery of brief interventions within sexual health clinics is required.     

Electrocardiogram as a screening tool in the general population: A strategic review

Sudden cardiac death (SCD) is a major public health concern, accounting for 400,000 deaths in the US each year. Clinical and autopsy studies have consistently demonstrated a predominant, common pathophysiology in Western populations, showing that the most common electrophysiological mechanism of SCD is ventricular fibrillation, and the most common pathologic substrate is coronary heart disease (CHD). In about half of SCD cases, death is the first clinical manifestation of CHD. Yet risk factors of SCD early in the natural history of conditions predisposing SCD have not been fully identified, and SCD risk stratification strategy in the general population has not been developed. ECG is an easily available, non-expensive and non-invasive tool, which carries valuable information on electrophysiological properties of the heart. However, traditional analysis of ECG includes very limited assessment of the arrhythmogenic substrate. In this review rationale for development of ECG SCD risk score for screening in the general population is discussed.     

Knowledge on arterial hypertension in general population: Results from a community pharmacy screening program

Backgrounds and aimsHypertension is a risk factor for renal, cardiovascular and cerebrovascular diseases. It is responsible for a large proportion of overall morbidity and mortality every year. Hypertension-mediated organ damage is largely not reversible. For these reasons, prevention has primary importance: sensibilization of population on hypertension-related consequences is essential for therapeutic adherence and reduction of unhealthy lifestyle behaviour. This study aimed to evaluate awareness about hypertension among community pharmacies customers.Methods and resultsA questionnaire about hypertension was collected by 2731 customers from 94 community pharmacies in North West Italy, during a hypertension screening program. Hypertension awareness was unsatisfactory in a large proportion of the sample, with only 15% of subjects having an overall good level of knowledge. Furthermore, lower awareness was associated to higher blood pressure values (132/79 ± 19/11 mmHg vs 128/78 ± 18/10 mmHg, p < 0.001) and subjects resulted hypertensive or uncontrolled despite antihypertensive therapy, presented worse questionnaire scores (4.7 ± 1.9 vs 4.9 ± 2.0, p = 0.03).ConclusionKnowledge about hypertension is largely unsatisfactory among population. Community pharmacies may play as a setting for health education and hypertension screening.     

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme

Aims To assess the effect of a tailored multi‐faceted improvement programme on general practitioners' (GPs') behaviour towards prevention of hazardous and harmful alcohol consumption. The improvement programme consisted of activities aimed at the GP, organization and patient. Educational training sessions and visits by a facilitator were tailored to the GPs' needs and attitudes. Design Cluster randomized controlled trial. Setting General practices in the Netherlands. Participants Seventy‐seven general practices; 119 GPs participated. Data from 6318 patients were available, of whom 765 (12.1%) were at risk. A total of 1502 patients' electronic medical records were reviewed. Measurements The primary outcome was the number of eligible patients who received screening and advice. Findings Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme. Although GPs in both groups became more involved after enrolment, this improvement waned during the trial. The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning (intervention group), compared to our control condition, resulting in average improvement rates of 5% (screening) and 2% (advice‐giving) at 12‐month follow‐up (not significant). Conclusions A tailored, multi‐faceted programme aimed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement. There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care.     

Alcohol intake and future incidence of hypertension in a general Japanese population: the Hisayama study

BACKGROUND: The question remains as to whether light to moderate alcohol intake is associated with an increased risk of hypertension. METHODS: In 1978, a total of 1101 residents (433 men and 668 women) in a subrural community, Hisayama, in Japan, aged 40 years or more, with normal blood pressure, who were free from cardiovascular disease, were enrolled in a 10-year follow-up study. Inquiries regarding regular drinking were made in an interview based on a self-administered questionnaire. RESULTS: During the follow-up, 101 men and 166 women developed hypertension (blood pressure > or =140/90 mm Hg or use of antihypertensive drugs). The age-adjusted incidence of hypertension among current male drinkers increased significantly even with a light intake of alcohol (<23 g of ethanol per day). In women, the incidence was also significantly higher in drinkers than in nondrinkers. In multivariate analysis, alcohol intake, in addition to age and body mass index, remained a significant independent risk factor for hypertension in men, but not in women. In men, all three categories of current drinking were found to be significant risk factors for the development of hypertension after adjustment for age and body mass index [relative risk (RR), 2.00; 95% confidence interval (CI), 1.07-3.76 for light drinking compared with nondrinking; RR, 2.60; 95% CI, 1.50-4.49 for moderate drinking (23-45 g per day); and RR, 2.24; 95% CI, 1.26-3.99 for heavy drinking (> or =46 g/day)]. CONCLUSIONS: Our results suggest that alcohol intake, even light drinking, is a predictor of future hypertension among Japanese men.     

Progression from impaired fasting glucose and impaired glucose tolerance to diabetes in a high-risk screening programme in general practice: the ADDITION Study,Denmark

AIMS/HYPOTHESIS: To estimate the 1-year progression rates from both IFG and IGT to diabetes in individuals identified in a pragmatic diabetes screening programme in general practice (the ADDITION Study, Denmark [Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care]). METHODS: Persons aged 40-69 years were screened for type 2 diabetes based on a high-risk, stepwise strategy. At baseline, anthropometric measurements, blood samples and questionnaire data were collected. A total of 1,160 persons had IFG or IGT at baseline: 811 (70%) accepted re-examination after 1 year. Glucose tolerance classification was based on the 1999 WHO definition. At follow-up, diabetes was based on one diabetic glucose value of fasting blood glucose or 2-h blood glucose. RESULTS: At baseline, 308 persons had IFG and 503 had IGT. The incidence of diabetes was 17.6 and 18.8 per 100 person-years in the two groups, respectively. CONCLUSIONS/INTERPRETATION: IFG and IGT identified in general practice during a stepwise, high-risk screening programme for type 2 diabetes have high 1-year progression rates to diabetes. Consequently, intensive follow-up and intervention strategies are recommended for these high-risk individuals.     

结直肠肿瘤早诊筛查新策略：基于液体活检技术的筛查方案

结直肠肿瘤是我国最常见的恶性肿瘤之一,严重危害国民身体健康。通过简单有效的检测方法对目标人群进行筛查,早期诊断结直肠肿瘤,是降低其危害的有效策略。然而,尽管我国结直肠癌筛查取得了较大进展,但仍存在筛查方法敏感度和特异度不足,接受度和依从性较差等问题,影响了筛查效果。液体活检作为近些年来新兴的检测技术,其内涵丰富,可选择的检测靶点多,同时具有取样方便,创伤小,人群接受度高,易于推广和开展的优点,在结直肠肿瘤筛查早诊工作中具有广阔的应用前景。血液ctDNA可提供患者体内肿瘤的全景数据,在早期肿瘤患者体内含量较高,是结直肠肿瘤早诊筛查的重要靶点。     

Screening for type 2 diabetes and pre-diabetes in general practice: A descriptive study of Maltese practices

ObjectiveThe aim of this research study was to ascertain the awareness of Maltese family doctors to the prevalence and significance of impaired glucose regulation and early diagnosis of type 2 diabetes and whether practices were influenced by employment status, post-graduate training in diabetes or years since graduation.MethodsA specially constructed questionnaire was distributed by mail to all the 298 family doctors listed as Specialists in Family Medicine in the Maltese Medical Council register. Participants had to be practising family medicine in Malta. Results were analysed using SPSS 20.0 aiming for a significance criterion of 0.05 and a power of 80%.ResultsValid replies were received from 154 GPs (51.7%). 93.2% claimed to offer their patients some form of screening. Screening levels reached up to 95.9% in the presence of specific risk factors (e.g. high previous HbA1c levels) but fell to between 46.2% and 58.7% in patients over 50, the physically inactive and those who suffer from polycystic ovarian syndrome. Screening using capillary glucose is widespread (70.8%) as opposed to the oral glucose tolerance test (23.4%). Results also show a high use of urinalysis in screening (53.2%) and a paradoxical lack of use of HbA1c in screening by young doctors and by those with recent extra training in diabetes.ConclusionsThe need for a structured screening programme in Malta and its viability need to be evaluated by further studies. Educational support to GPs together with logistic support for GPs needs to be improved.