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Why I want alcohol misuse added to QOF

With the quality and outcomes framework review now in full swing, this series provides a platform for GPs to make the case for inclusion of new diseases ­

this week, Dr Clare Gerada argues alcohol abuse should be recognised in the QOF

Alcohol should be in the QOF both as a clinical indicator in its own right (identification, screening and brief intervention) and within the hypertension section (identification, brief intervention).

Last week a patient came to see me for follow-up of his hypertensive disease. He was only 45 years old and his hypertension had been identified two weeks previously.

What emerged was that he regularly drank eight pints of beer ­ 'not the strong stuff, doctor' ­ every night and thought nothing of it. What he did not know, and what many health professionals unfortunately fail to realise, is that high alcohol consumption is closely linked with hypertension and that roughly 10 per cent of deaths due to hypertension are attributable to alcohol.

The incidence of hypertension approximately doubles in those regularly drinking more than six units per day. Drinkers who already have hypertension may run significant increased additional risk from hypertension-related diseases, specifically as a result of their drinking.

In 11 per cent of all cases, alcohol consumption is the main cause of men's hypertension and is second only to obesity as an acquired determinant of this condition.

Of course it is not just hypertension that excess alcohol consumption causes. When I teach medical students, I ask them to think of any system or organ in the body and list the problems associated with excess alcohol use.

The list is endless and a textbook highlighting the complications of alcohol will run into many volumes.

GPs identify only one in 67 male and one in 82 female hazardous/harmful drinkers when the actual alcohol dependency rate is one in 28 and one in 20. Drinking alcohol is almost a universal pastime; only 7 per cent of men and 13 per cent of women are non-drinkers. Identification can be by simply asking a patient about their average weekly intake.

Or better still a more accurate analysis can be achieved by using a simple self-administered screening tool, most would recommend the AUDIT PC (five questions) or AUDIT FAST (four questions) documents/manual_fastalcohol.pdf

Both take a couple of minutes to complete and are simple and sensitive.

Having identified harmful drinkers, simple brief interventions delivered within primary care are effective in reducing drinking to low-risk levels among hazardous and harmful drinkers1. The intervention can be as basic as structured advice and the effect can still be shown in follow-ups for up to two years2.

There are a number of large-scale systematic reviews and meta-analyses showing brief intervention is effective. The results of these are summarised in the Health Development Agency, prevention and reduction of alcohol misuse, evidence briefing, June 2002 alcoholtxt.pdf

The direct cost of a brief intervention delivered to hazardous or harmful drinkers has been calculated to be £20 in 19933. A recent WHO study estimate the cost-effectiveness is approximately £1,300 per year of ill-health or premature death averted. This is similar to the cost-effectiveness of smoking cessation interventions in primary health care, which is about £1,200. Other medical interventions have an average cost-effectiveness of £30,0004.

Many of the problems we encounter in our daily clinical practice are directly or indirectly attributed to excess alcohol consumption. Only by including alcohol in the QOF can we begin to make inroads into the enormous morbidity caused by 'our nation's favourite drink'.

Clare Gerada is a GP in Kennington, south London ­ she is director of primary care for the NHS clinical governance support team and director of the RCGP's national drug misuse training programme


1 Possibly the best summary of the effectiveness is found in Scottish Intercollegiate Guidelines Network (SIGN). The Management of harmful drinking and alcohol dependence in primary care. National Clinical guidelines. September 2003

2 Bien et al 1993. Kahn et al 19965. Wilk et al 1997, Poikolainene 1999. Moyer et al 2002

3 Freemantle N et al (1993). Brief interventions and alcohol use. Effective Healthcare bulletin number 7 University of Leeds; Nuffield Institute for Health

4 WHO-CHOICE Cost effectiveness analyses. WHO European Region, Addictive substances

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