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

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 sociodemographic 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.

Keywords:

• Alcohol abuse
• diagnoses
• general practice

Transparency

Declaration of funding

This study was funded by Mondriaan Institute for Mental Health and CAPHRI School of Public Health and Primary Care.

Declaration of financial/other interests

The authors have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors are grateful to all patients that completed the questionnaires and thank them for their contribution to the study of medical information and lifestyles in Eindhoven (SMILE cohort study). The authors would like to thank The Eindhoven Corporation of Primary Health Care Centres, Job Metsemakers, Ben van Steenkiste, all members of Registratie Netwerk Huisartsen (department of Family Medicine, Maastricht University) and all those who have been involved in the data acquisition and GP management of the SMILE study.