The role of alcohol use in emergency department episodes

Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level?

INTRODUCTION AND AIMS

Acute harm from heavy drinking episodes is an increasing focus of public health policy, but capturing timely data on acute harms in the population is challenging. This study aimed to evaluate the precision of readily available administrative emergency department (ED) data in public health surveillance of acute alcohol harms.

DESIGN AND METHODS

We selected a random sample of 1000 ED presentations assigned an ED diagnosis code for alcohol harms (the 'alcohol syndrome') in the New South Wales, Australia, automatic syndromic surveillance system. The sample was selected from 68 public hospitals during 2014. Nursing triage free-text fields were independently reviewed to confirm alcohol consumption and classify each presentation into either an 'acute' or 'chronic' harm. Positive predictive value (PPV) for acute harm was calculated, and predictors of acute harm presentations were estimated using logistic regression.

RESULTS

The PPV of the alcohol syndrome for acute alcohol harm was 53.5%. Independent predictors of acute harm were ambulance arrival [adjusted odds ratio (aOR) = 3.4, 95% confidence interval (CI) 2.4-4.7], younger age (12-24 vs. 25-39 years: aOR = 3.4, 95% CI 2.2-5.3), not being admitted (aOR 2.2, 95% CI 1.5-3.2) and arriving between 10 pm and 5.59 am (aOR 2.1, 95% CI 1.5-2.8). PPV among 12 to 24-year-olds was 82%.

DISCUSSION AND CONCLUSIONS

The alcohol syndrome provides moderate precision as an indicator of acute alcohol harms presenting to the ED. Precision for monitoring acute harm in the population is improved by filtering the syndrome by the strongest independent predictors of acute alcohol harm presentations. [Whitlam G, Dinh M, Rodgers C, Muscatello DJ, McGuire R, Ryan T, Thackway S. Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level? Drug Alcohol Rev 2016;35:693-701].

The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

Background

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.

Methods and Findings

Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.

Conclusions

SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.

Trial Registration

Current Controlled Trials ISRCTN 93681536

Mental health and high-cost health care utilization: new evidence from Axis II disorders

OBJECTIVE

To analyze the associations between Axis II (A2) disorders and two measures of health care utilization with relatively high cost: emergency department (ED) episodes and hospital admissions.

DATA SOURCE/STUDY SETTING

Wave I (2001/2002) and Wave II (2004/2005) of the National Longitudinal Survey on Alcohol and Related Conditions (NESARC).

STUDY DESIGN

A national probability sample of adults. Gender-stratified regression analysis adjusted for a range of covariates associated with health care utilization.

DATA COLLECTION

The target population of the NESARC is the civilian noninstitutionalized population aged 18 years and older residing in the United States. The cumulative survey response rate is 70.2 percent with a response rate of 81 percent (N=43,093) in Wave I and 86.7 percent (N=34,653) in Wave II.

PRINCIPAL FINDINGS

Both men and women with A2 disorders are at elevated risk for ED episodes and hospital admissions. Associations are robust after adjusting for a rich set of confounding factors, including Axis I (clinical) psychiatric disorders. We find evidence of a dose-response relationship, while antisocial and borderline disorders exhibit the strongest associations with both measures of health care utilization.

CONCLUSIONS

This study provides the first published estimates of the associations between A2 disorders and high-cost health care utilization in a large, nationally representative survey. The findings underscore the potential implications of these disorders on health care expenditures.

Health-care service utilization in substance abusers receiving contingency management and standard care treatments

AIM

  To determine the impact of standard care and contingency management treatments on the utilization of general health-care services by substance abusers. PARTICIPANTS, DESIGN AND MEASUREMENTS:  This secondary analysis pooled 1028 treatment-seeking substance abusers from five randomized clinical trials that compared the effects of standard care (SC, n = 362) to standard care plus contingency management (CM, n = 666). In each trial, subjects in the CM condition showed significantly greater reductions in substance use than their SC counterparts. For each subject, utilization of 15 general health-care services was measured 1 year prior to treatment intake and up to 9 months following treatment intake. Post-intake utilization data were pro-rated to be comparable to the 1-year pre-intake data. Paired t-tests evaluated changes in service utilization pre- and post-intake, and difference-in-differences regression models were used to estimate the impact of CM, compared to SC, on changes in the utilization of each of the 15 health services.

SETTING

  Out-patient community substance abuse clinics in Connecticut and Massachusetts, USA.

FINDINGS

  Utilization of several types of out-patient services increased significantly between the pre- and post-intake periods [e.g. dental visits (0.47, P < 0.001), community health center visits (0.50, P < 0.001), visits to a mental health professional office (1.03, P = 0.001)], while in-patient hospital care for mental health problems decreased significantly (-3.50 nights, P < 0.001). A substantial portion of these changes occurred during the treatment period. No significant differences were found between the two treatment conditions.

CONCLUSIONS

  Initiating out-patient substance abuse treatment is associated with changes in general health-care service utilization, independent of the type of treatment offered.

A brief intervention reduces hazardous and harmful drinking in emergency department patients

STUDY OBJECTIVE

Brief interventions have been shown to reduce alcohol use and improve outcomes in hazardous and harmful drinkers, but evidence to support their use in emergency department (ED) patients is limited. The use of research assessments in studies of brief interventions may contribute to uncertainty about their effectiveness. Therefore we seek to determine (1) if an emergency practitioner-performed Brief Negotiation Interview or a Brief Negotiation Interview with a booster reduces alcohol consumption compared with standard care; and (2) the impact of research assessments on drinking outcomes using a standard care-no-assessment group.

METHODS

We randomized 889 adult ED patients with hazardous and harmful drinking. A total of 740 received an emergency practitioner-performed Brief Negotiation Interview (n=297), a Brief Negotiation Interview with a 1-month follow-up telephone booster (Brief Negotiation Interview with booster) (n=295), or standard care (n=148). We also included a standard care with no assessments (n=149) group to examine the effect of assessments on drinking outcomes. Primary outcomes analyzed with mixed-models procedures included past 7-day alcohol consumption and 28-day binge episodes at 6 and 12 months, collected by interactive voice response. Secondary outcomes included negative health behaviors and consequences collected by telephone surveys.

RESULTS

The reduction in mean number of drinks in the past 7 days from baseline to 6 and 12 months was significantly greater in the Brief Negotiation Interview with booster (from 20.4 [95% confidence interval {CI} 18.8 to 22.0] to 11.6 [95% CI 9.7 to 13.5] to 13.0 [95% CI 10.5 to 15.5]) and Brief Negotiation Interview (from 19.8 [95% CI 18.3 to 21.4] to 12.7 [95% CI 10.8 to 14.6] to 14.3 [95% CI 11.9 to 16.8]) than in standard care (from 20.9 [95% CI 18.7 to 23.2] to 14.2 [95% CI 11.2 to 17.1] to 17.6 [95% CI 14.1 to 21.2]). The reduction in 28-day binge episodes was also greater in the Brief Negotiation Interview with booster (from 7.5 [95% CI 6.8 to 8.2] to 4.4 [95% CI 3.6 to 5.2] to 4.7 [95% CI 3.9 to 5.6]) and Brief Negotiation Interview (from 7.2 [95% CI 6.5 to 7.9] to 4.8 [95% CI 4.0 to 5.6] to 5.1 [95% CI 4.2 to 5.9]) than in standard care (from 7.2 [95% CI 6.2 to 8.2] to 5.7 [95% CI 4.5 to 6.9] to 5.8 [95% CI 4.6 to 7.0]). The Brief Negotiation Interview with booster offered no significant benefit over the Brief Negotiation Interview alone. There were no differences in drinking outcomes between the standard care and standard care-no assessment groups. The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the Brief Negotiation Interview (38% to 29%) and Brief Negotiation Interview with booster (39% to 31%) groups than in the standard care group (43% to 42%).

CONCLUSION

Emergency practitioner-performed brief interventions can reduce alcohol consumption and episodes of driving after drinking in hazardous and harmful drinkers. These results support the use of brief interventions in ED settings.

The association between the incidence of emergency department attendances for alcohol problems and assault incidents attended by police in New South Wales, Australia, 2003-2008: a time-series analysis

AIM

To assess the short-term temporal relationship between emergency department (ED) attendances for acute alcohol problems and assaults reported to police.

DESIGN

Cross-sectional time-series analysis.

SETTING

Population of New South Wales (NSW), Australia between 2003 and 2008.

PARTICIPANTS

All patients who attended any of 56 large NSW public hospital EDs and had a recorded diagnosis of acute alcohol problems, and all persons involved in assault incidents reported to the NSW Police Force.

MEASUREMENTS

Weekly count time-series were formed for ED attendances, assault incidents and persons of interest in assault incidents. Cross-correlation analysis was used to determine any time lag in the relationship between the alcohol and the assault series. Poisson regression was used to assess the magnitude of the relationship. Splines of week controlled for seasonality.

FINDINGS

There was no time lag found between the ED and police series. A weekly increase of 100 attendances in people aged 15 years and above to EDs for alcohol problems was associated with an 11% [95% confidence interval (CI): 7-15%] increase in the number of incident assaults attended by police. The relationship was similar and statistically significant for domestic and non-domestic assaults and urban areas. The association was stronger between ED attendances and persons of interest aged 15-24 years (27%, 95% CI: 15-41%), 15-24-year-old males (39%, 95% CI: 16-66%) and 15-24-year-old females (66%, 95% CI: 20-129%).

CONCLUSIONS

There is a clear, short-term temporal association between independent population-level markers of excessive alcohol use and violence.

From pubs to scrubs: alcohol misuse and health care use

OBJECTIVE

To analyze the relationships between alcohol misuse and two types of acute health care use-hospital admissions and emergency room (ER) episodes.

DATA SOURCES/STUDY SETTING

The first (2001/2002) and second (2004/2005) waves of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC).

STUDY DESIGN

Longitudinal study using a group of adults (18-60 years in Wave 1, N=23,079). Gender-stratified regression analysis adjusted for a range of covariates associated with health care use. First-difference methods corrected for potential omitted variable bias.

DATA COLLECTION

The target population of the NESARC was the civilian noninstitutionalized population aged 18 and older residing in the United States and the District of Columbia. The survey response rate was 81 percent in Wave 1 (N=43,093) and 65 percent in Wave 2 (N=34,653).

PRINCIPAL FINDINGS

Frequent drinking to intoxication was positively associated with hospital admissions for both men and women and increased the likelihood of using ER services for women. Alcohol dependence and/or abuse was related to higher use of ER services for both genders and increased hospitalizations for men.

CONCLUSIONS

These findings provide updated and nationally representative estimates of the relationships between alcohol misuse and health care use, and they underscore the potential implications of alcohol misuse on health care expenditures.