Country report PHEPA II - Slovenia Dr. Marko Kolšek 1
INTRODUCTION 1.1. Background The project Integrating Health Promotion Interventions for Hazardous and Harmful Alcohol Consumption into Primary Health Care Professionals Daily Work (or Primary Health European Project on Alcohol II [PHEPA II] for short) continues the work done in PHEPA I project and also Phase IV of the WHO Collaborative Project on the Identification and Management of Alcoholrelated Problem in Primary Health Care. This second part of the PHEPA project - Disseminating brief interventions on alcohol problems Europe-wide has started in 2006 and will be completed at the end of 2008. A total of 24 countries are taking part in the project. PHEPA I products (clinical guidelines and training manual) gave valuable ingredients for our efforts to implement early identification and brief alcohol intervention as a routine part of work done in primary health care. 1.2. Country description Slovenia is a wine-producing country on the sunny side of the Alps between Italy, Austria, Hungary, Croatia and the Adriatic Sea. It is 20.273 km2 with 2 million inhabitants. Of these, 15.6% are children under 15 years of age and 14.3% above 65 years. Average life expectancy is 71.3 years for men and 78.8 years for women. GDP in 2003 was 13.900 U$D. Total expenditure on health is estimated at 8.2% of GDP. 1.3. Health services There is compulsory health insurance. The National Health Insurance Institute of Slovenia (NHIIS) usually covers 85% of the costs of primary health care (PHC) and 95% of the costs of secondary/tertiary care for all adults, but in addition the majority of the population is voluntarily insured (at a fee of approximately 20 Euros per month) in order to obtain all medical services free. In any case, all services for children, pregnancy, emergencies, some chronic diseases (e.g. malignant diseases, diabetes mellitus, etc.) and preventive care are free. There are approximately 4,200 practicing physicians in Slovenia, equivalent to 476 inhabitants per doctor (i.e., one of the lowest ratio in EU countries). There are approximately 850 general practitioners/family physicians (GP/FP), but PHC pediatricians (ca 160), school medicine specialists (ca 70) and a few occupational health specialists are also seen as first contact doctors. They work in health centres in public health services (approximately 70%) or as individual contractors with the NHIIS in practices that may be located in health centres or in their 2
own premises. Practice and district nurses and other PHC professionals work alongside these doctors: stomatologists (mainly individual contractors with the NHIIS), a laboratory unit, X-ray technician, physiotherapists (some of them are individual contractors with the NHIIS) and usually also emergency care unit with ambulances. Health centres run also maternity and child health clinics, and arrange school, occupational health services (this last one mainly on fee for service basis) and other preventive health care. Everyone is supposed to be registered with a doctor in a health centre or in a private practice, with no financial difference between patients. To see a doctor, one can make an appointment. GP/FPs diagnose conditions, provide health care advice and prescribe medication; they also do preventive care. Doctors in PHC also serve as gatekeepers for the secondary health care services but, if necessary, they can refer patients to a specialist clinician, therapist or other health care professional based in an out-patient clinic or hospital. 3
THE USE OF ALCOHOL Alcohol drinking has been a part of Slovenian culture for centuries. Approximately one half of Slovenian families produce alcohol beverages at their homes. High alcohol consumption has been a problem for many years. The total alcohol consumption in Slovenia is one of the highest in EU countries: registered alcohol 10,5 l/inhabitant/year and 7 8 l of unregistered. While in some European wine-producing countries (e.g. France, Spain), alcohol consumption has significantly decreased in the last two decades, there was no decrease in alcohol consumption in Slovenia. Among adolescents, consumption is even increasing, according to data from the international ESPAD study (The European Schools Project on Alcohol and Drugs). Even school-children of 10 years are already drinking alcohol; only 40% are teetotallers and 14% have already been drunk. More than one third of adult men and approximately 13% of adult women are risky drinkers and approximately 10%-15% of adults are alcoholics. The result is a high standardised death rate/100,000 inhabitants over 15 years for all causes related to alcohol (39.0). Table 1. Alcohol consumption in litres of pure alcohol/inhabitant/year in Slovenia 1981 2007 Alcohol drink 1981 1991 1995 2000 2003 2006 2007* Beer 70.1 55.5 95.8 86.6 86.6 97.3 97.8 Wine 48.4 45.2 37.9 34.9 43.3 42.4 31.9 Spirits 7.5 4.7 2.7 0.9 1.3 2.4 2.7 Subtotal 11.5 9.4 9.9 8.6 9.8 10.5 9.5 Unregistered 7-8 7-8 7-8 7-8 7-8 7-8 7-8 Total 19.0 16.9 17.4 16.1 17.3 18.0 17.0 preliminary data (not confirmed yet) Binge drinking is also popular in Slovenia. More than half adult men and one third of adult women get drunk at least once a year. In the 9-10 age group 14% and in the 14-15 age group more than 40% had already been drunk, 22% more than once. The European Schools Project on Alcohol and Drugs (ESPAD study) reported on in 2004 that Slovenian boys and girls aged 16 years are at the European average in terms of binge drinking and drunkenness 12% are getting drunk on a fairly regular basis. ESPAD study data for 2007 are not published yet but unofficial preliminary data show even worse situation. 4
THE HARM DONE BY ALCOHOL The harm done by alcohol is well researched throughout the world and there is strong evidence linking alcohol to a whole range of problems, including - health problems (various cancers, liver disease, cardiovascular and gastrointestinal diseases, road traffic and other accidents, neuropsychiatric conditions, suicides, and many other conditions), - social and economical problems (family disorders, divorces, physical, mental and sexual violence, invalidity, morbidity, premature mortality, lower productivity at work). 3.1. Health As already noted, there is very high alcohol consumption in Slovenia. The result is very high standardised death rate/100,000 inhabitants over 15 years for liver cirrhosis (41.0 males, 14.3 females; 28.8 both sexes). Disease conditions SDR Alcohol addiction 5.2 Accidents, intentional and self-inflicted injuries 83.8 Liver cirrhosis 28.8 Cancers: lips, mouth, throat, gullet 15.6 Pancreatitis 2.7 SDR standardized death rate over 15 years old Alcohol disorders continue to be the main cause of admission to psychiatric hospitals, especially for males. People lost on average 11,3 years because of premature deaths related to alcohol. 3.2. Crime/ public disorder 11.0% of all road accidents and 41.2% of fatal road accidents were related to alcohol. Slovenia has very high rate of road accidents/100.000 inhabitants where one of participants had alcohol in blood: 200.4 (it is 8 times higher than Europe: 24.9). Also approximately one third of assaults and public order offences were related to alcohol. 5
3.3. Productivity at work Approximately 6% of sick-leave was related to alcohol. 1.2% of all admissions to hospital and 3.6% of all hospital days were related to alcohol in the year 2006. The cost of hospitalizations and sick-leave related to alcohol was more than 10 millions EUR. 3.4. Family and social networks It is very difficult to quantify the harm done to family life. There is all sorts of evidence from practitioners, social work centres and also other professionals that partners, spouses, children and other family members suffer in the short and long term from alcohol related problems. Problems occur also with neighbours and at working places of people with problem drinking. 3.5. Summary of harms According to above mentioned data it is obvious that Slovenia is facing many problems related to alcohol drinking in such extend that politicians should be really worried about and effective complex alcohol action plan at the national level should be prepared as soon as possible. 6
MEASURES TO REDUCE THE HARM DONE BY ALCOHOL The evaluation of different measures to reduce the harm done by alcohol includes effectiveness, its extent, proof in different cultures and costs and also target group and comments. This has been done for the control of production and sale, taxation, influence drinking occasions, education, marketing regulations, prevention of drinking and driving and early intervention/treatment. The strongest policies are control of production and sale (availability), taxation and preventive actions on drinking and driving. The problem with high taxation and pricing may be in unacceptability by the population and consequently by politicians. Alcohol education doesn t look effective although most countries are doing it. Anyway, there is a question as to what would happen with alcohol consumption without any alcohol education. There has been no experiment done - the problem is a control group that would be completely without any alcohol education over a long period. An effective and acceptable strategy is Brief interventions with hazardous and harmful drinkers at primary health care but the problem is lack of training of general practitioners/family doctors, different attitudes, lack of time to do screening and interventions, and maybe also lack of support and money for doing it. 7
THE EFFECTIVENESS AND COST-EFFECTIVENESS OF SCREENING AND BRIEF INTERVENTIONS FOR HAZARDOUS AND HARMFUL ALCOHOL USE IN PRIMARY HEALTH CARE There is strong evidence that screening for hazardous and harmful drinking in PHC is effective, by asking patients of their drinking habits or by giving them proper standardized questionnaires sensitivity and specificity are higher than 90%. There is also strong evidence that brief interventions are effective (NNT = 8 15). With such high effectiveness EIBI should be also costeffective since one such procedure costs 100 200 (including materials, training, marketing, support, and costs of the professionals) on one hand, and an average treatment of one alcohol related health complication (e.g. acute pancreatitis) may cost 7.000 10.000 ; theoretical calculations and studies have also shown its potential effectiveness. The problem is that EIBI is still not widely accepted by PHC professionals, as already mentioned in section 4. 8
CURRENT POLICIES AND ACTIVITIES In Slovenia there is still no comprehensive alcohol policy. In the last four years almost nothing has changed. In 2004 the Council for Alcohol Policy at the Ministry of health has been established but it had only two meetings since then. Anyway, the Ministry of Health is giving a small support to some institutions and NGOs that are running some activities to reduce alcohol consumption and its consequences (e.g. the project of the Department of family medicine at the Medical faculty, University of Ljubljana The message from the bottle and the NGO project You can choose, win or lose. In 2003 the law on reduction of alcohol consumption was introduced which put some more restrictions on the availability of alcohol: restricted hours (between 21 p.m. and 7 a.m. in stores) and locations (premises for education, medicine, sports) for sale and serving alcohol beverages, age limits for sale of alcohol (18 years), some price limits (each seller must have at least two nonalcoholic drinks with lower or same price as the cheapest alcoholic one). Selling and serving alcohol drinks to drunk people has already been banned in previous legislation. Unfortunately, in the same period another law made alcohol advertising possible again under certain conditions, while it used to be almost completely banned till then. Now, it is possible to advertise beer and wine in newspapers, posters or TV if a specific warning is included: The Minister of health is warning that immoderate alcohol drinking can harm your health. The legislation on road traffic and safety on the road has been changed this year and it imposes much higher penalties for drink driving. 9
INTEGRATING PREVENTIVE INTERVENTIONS IN PRIMARY HEALTH CARE 7.1 Principles The strategy for implementing alcohol EIBI in PHC in Slovenia is based on the following principles: - alcohol drinking is a huge problem in Slovenia - EIBI delivered in PHC settings by a variety of health care professions is effective and cost effective in reducing alcohol consumption among hazardous and harmful drinkers and hence in reducing alcohol-related harm - the widespread and routine implementation of EIBI in PHC would have large benefits for individual patients and for public health - EIBI is not yet implemented in the routine work of PHC professionals - among PHC professionals and population as well there is still some misunderstanding of basic facts on drinking alcohol (low risk hazardous harmful moderate risky healthy cultural binge drunkenness addiction) - family physicians workload is enormous and they are reluctant to take on new obligations - Slovenian patients approve asking and advising about alcohol drinking 7.2 Practice based guidelines, protocols and aids In last few years (during Phase IV of WHO collaborative project, PHEPA I project and finally PHEPA II project) a lot of materials for effective implementation of EIBI in PHC settings - considering the above-mentioned principles have been produced and finally approved this year at the National professional committee for family medicine at the Ministry of health: - Training manual for Slovenian trainers for EIBI in PHC settings - Clinical guidelines for the management of alcohol-related problems for Slovenian PHC teams - Screening tool for hazardous and harmful drinking (adapted version of WHO AUDIT questionnaire) - Practice manual for the management of alcohol related issues for family doctors - Pocket self-help brochure for hazardous and harmful drinkers 10
- Pocket information leaflet for the population on basic facts related to alcohol drinking including also drinking diary - Two series of posters addressing alcohol related problems prepared by students of the Academy of art - Two TV and cinema spots addressing alcohol drinking - Website for self-assessment of drinking behaviour with individualized feed-back 7.3 Training Some lectures on how to approach alcohol drinkers were prepared already the 1990s by psychiatrists. It looks as though family physicians didn t accept that it was their task to deal with alcohol drinkers, especially considering the fact that there was misunderstanding of hazardous and harmful drinking and its relation to addiction. With the process of customization and reframing understanding of alcohol issues (that has started during Phase IV of WHO collaborative project) the basis for training on modern principles of understanding of alcohol issues has been enabled. 7.4 Engaging PHC providers Considering experiences from the 90s, we started to engage PHC providers to help us in preparations of activities related to training of PHC professionals for EIBI. We included alcohol related issues in the undergraduate curriculum for all medical students and training for EIBI in the curriculum of specialization for family medicine. AUDIT C has been included in the questionnaire which is a part of preventive check-up for middle aged population conducted by personal family doctor every five years. We have trained trainers family doctors and nurses to deliver trainings for EIBI in continuing medical education and till now several training courses have been run in collaboration with CINDI project team, Slovene family medicine society and Department of family medicine at Medical faculty of University of Ljubljana. All the materials needed to engage PHC professionals have been prepared, adapted, approved and are already in use. Till now approximately one third of practicing family physicians and one tenth of nurses in PHC have finished the course on EIBI. 7.5 Funding and reimbursement Trainings of trainers and printing of clinical guidelines and training manual for EIBI have been funded by PHEPA II budget. Other materials for EIBI courses and courses themselves for family 11
doctors and nurses have been funded partly by CINDI project, partly by the Department of family medicine and partly by some time-limited projects funded by the Ministry of health, NHIIS and the Community of Ljubljana. However, we still don t know how such courses will be funded next year we hope there will be some funds for them because some stakeholders support the implementation of EIBI in everyday practice of PHC teams. The problem is funding of EIBI done in practice by family doctors and nurses. We succeeded in securing for them partial reimbursement for their time and work by NHIIS, only for repeated advice or counselling hazardous and harmful drinkers (at least five sessions). For wider and routine EIBI of risky drinkers this should be changed and PHC team should be reimbursed for each EIBI. 7.6 Specialist support and knowledge centres Reframing understanding of alcohol issues, training and implementation of EIBI enables PHC professionals to identify more harmful drinkers and addicted patients to alcohol than before. This leads to more collaboration with different medical specialist services. The role of different levels of health care is becoming clearer: screening for hazardous drinking is mostly the role of PHC teams, but screening for harmful drinking and addiction should be carried out at PHC level routinely as well as at other health care services besides PHC, at least in emergency, internal, neurology, psychiatry services, but also others. So, the collaboration between PHC and specialists should be stimulated further. Materials for EIBI are available for every health professional in paper form, but accessible also on the website. 7.7 Monitoring the progress of the strategy We have conducted research into addressing alcohol issues in family medicine practices before any activities on implementing EIBI have been started. This can be a useful starting point to compare activities after some period of training for EIBI. We are now designing a survey that will study attitudes, knowledge and activities on EIBI among PHC professionals. 12
7.8 Managing the strategy The management of implementation of EIBI falls to the Department of Family Medicine at the Medical faculty, University of Ljubljana in collaboration with Slovene Family Medicine Society and CINDI Slovenija. 7.9 Communicating about the strategy The strategy and the materials has been introduced and marketed at several national CME courses and congresses, it is introduced on the website of the Department of family medicine and Slovene family medicine society. 13
RESEARCH NEEDS There are many issues in EIBI that can be and should be studied quantitatively and qualitatively. When there are some funds for such research needs we will prepare studies on: - Effectiveness of different ways to implement EIBI - Frequency and quality of EIBI - Stage of change among PHC professionals, their importance and confidence in EIBI - Comparison of EIBI done by physicians and nurses - Barriers to doing EIBI - Results short-term and long-term effectiveness of EIBI - Feasibility and effectiveness of EIBI in A&E services and on the secondary health care level - Economic evaluations of EIBI - Facilitating factors for routine delivery of EIBI - Special focus should be put on EIBI for young adults 14
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