Do general practitioners record alcohol abuse in the electronic medical records? A comparison of survey and medical record data

L. Abidi*, A. Oenema, M. van den Akker, D. van de Mheen

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

4 Citations (Web of Science)

Abstract

Objective: Primary care professionals are encouraged to screen patients for alcohol abuse. However, patients with alcohol abuse are often under-diagnosed as well as under-registered in medical records in general practices. This study aims to report on the registration rates of alcohol abuse diagnoses in general practices in comparison to patients' self-reported rates of alcohol use disorder. Research design and methods: Data of a total number of 2,349 patients were analyzed from the SMILE study, a large prospective cohort study conducted in The Netherlands. Two data collection strategies were combined: (1) Patient self-report data on alcohol consumption as well as other sociodemo-graphic characteristics; (2) Medical record (ICPC codes) data of diagnoses of chronic and acute alcohol abuse of the same patients. GPs' registrations of diagnoses were compared with the self-report data using descriptive statistics. Results: Based on the results of the patient reported data, 179 (14.8%) male participants had an alcohol use disorder. Of the total number of female patients, 82 (7.2%) had an alcohol use disorder. One of the male and none of the female patients with an alcohol use disorder were registered as such by the GP. Conclusions: This study found that 11.1% of the total patient sample reported an alcohol use disorder, of which a strikingly low number of patients were recorded as such by their GP. It is likely that low recognition due to barriers related to alcohol screening as well as registration avoidance due to the stigma around alcohol abuse play a role in low registration.
Original languageEnglish
Pages (from-to)567-572
Number of pages6
JournalCurrent Medical Research and Opinion
Volume34
Issue number3
DOIs
Publication statusPublished - 1 Jan 2018

Keywords

  • Alcohol abuse
  • diagnoses
  • general practice
  • USE DISORDERS
  • PRIMARY-CARE
  • BRIEF INTERVENTION
  • AUDIT-C
  • DOCUMENTATION
  • DEPENDENCE
  • IMPLEMENTATION
  • PROFESSIONALS
  • COMPLETENESS
  • RECOGNITION

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