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Association Between Patterns of Alcohol Use and Short-Term Risk of Suicide Attempt Among Patients With and Without Reported Suicidal Ideation. J Addict Med 2021; 14:e160-e169. [PMID: 32142058 DOI: 10.1097/adm.0000000000000637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation. METHODS Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010-6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visit-level analyses, accounting for correlation between individuals' assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any vs none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year. RESULTS Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23-15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77-9.72). Among patients reporting no suicidal ideation, no associations were observed. CONCLUSIONS Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation.
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Blalock DV, Grubber J, Smith VA, Zulman DM, Weidenbacher HJ, Greene L, Dedert EA, Maciejewski ML. The association of alcohol use with all-cause and cardiovascular disease-related hospitalizations or death in older, high-risk Veterans. Alcohol Clin Exp Res 2021; 45:1215-1224. [PMID: 33844300 DOI: 10.1111/acer.14610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prevalence of alcohol misuse among older adults has grown dramatically in the past decade, yet little is known about the association of alcohol misuse with hospitalization and death in this patient population. METHODS We examined the association between alcohol use (measured by a screening instrument in primary care) and rates of all-cause and cardiovascular disease (CVD)-related 6-month hospitalization or death via electronic health records (EHRs) in a nationally representative sample of older, high-risk Veterans. Models were adjusted for sociodemographic and clinical characteristics, including frailty and comorbid conditions. RESULTS The all-cause hospitalization or death rate at 6 months was 14.9%, and the CVD-related hospitalization or death rate was 1.8%. In adjusted analyses, all-cause hospitalization or death was higher in older Veterans who were nondrinkers or harmful use drinkers compared to moderate use drinkers, but CVD-related hospitalization or death was similar in all categories of drinking. CONCLUSIONS These findings suggest that the complex association between alcohol and all-cause acute healthcare utilization found in the broader population is similar in older, high-risk Veteran patients. These findings do not support an association between alcohol consumption and CVD-specific hospitalizations.
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Affiliation(s)
- Dan V Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Janet Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Hollis J Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Eric A Dedert
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
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3
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Short-term risk of suicide attempt associated with patterns of patient-reported alcohol use determined by routine AUDIT-C among adults receiving mental healthcare. Gen Hosp Psychiatry 2020; 62:79-86. [PMID: 31874300 PMCID: PMC7047881 DOI: 10.1016/j.genhosppsych.2019.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the association between alcohol use routinely reported during outpatient mental healthcare visits and short-term risk of subsequent suicide attempt. METHODS Using a longitudinal retrospective-cohort design, electronic health records identified adult outpatient visits to a mental health provider (1/1/2010-6/30/2015) at Kaiser Permanente Washington with a documented Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]. Suicide attempts within 90 days of AUDIT-C documentation were defined using death certificate cause-of-death and diagnosis codes (non-lethal). Visit-level analyses used generalized estimating equations to account for correlation between multiple AUDIT-Cs for individuals. Separate models evaluated the association between (1) level of consumption and (2) frequency of heavy drinking episodes and suicide attempts, adjusted for visit year, demographics, depressive symptom, and suicidal ideation. RESULTS Of 59,382 patient visits, 0.62% (N = 371) were followed by a suicide attempt within 90 days. Patients reporting high-level alcohol use were 1.77 times (95% CI, 1.22-2.57) more likely to attempt suicide than those reporting low-level use. Patients reporting daily or almost daily heavy drinking episodes were 2.33 times (95% CI, 1.38-3.93) more likely to attempt suicide than those reporting none. CONCLUSIONS AND RELEVANCE The AUDIT-C is a valuable tool for assessing patterns of patient-reported alcohol use associated with subsequent suicide attempt.
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Brady LL, Credé M, Harms P, Bachrach DG, Lester PB. Meta-analysis of risk factors for substance abuse in the US military. MILITARY PSYCHOLOGY 2019. [DOI: 10.1080/08995605.2019.1657754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Lisa L. Brady
- Department of Management, The University of Alabama, Tuscaloosa, Alabama
| | - Marcus Credé
- Department of Psychology, Iowa State University, Ames, Iowa
| | - P.D. Harms
- Department of Management, The University of Alabama, Tuscaloosa, Alabama
| | - Daniel G. Bachrach
- Department of Management, The University of Alabama, Tuscaloosa, Alabama
| | - Paul B. Lester
- Army Analytics Group Research Facilitation Laboratory, Monterey, California
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Association Between Alcohol Use and Angina Symptoms Among Outpatients From the Veterans Health Administration. J Addict Med 2019; 12:143-149. [PMID: 29334512 DOI: 10.1097/adm.0000000000000379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alcohol use is associated with angina incidence, but associations between alcohol use and experience of angina among patients with coronary artery disease (CAD) have not been described. METHODS Outpatients with CAD from 7 clinics in the Veterans Health Administration were surveyed; alcohol use was measured using the validated Alcohol Use Disorders Identification Test-Consumption scores categorized into 6 groups: nondrinking, low-risk drinking, and mild, moderate, severe, and very severe unhealthy alcohol use. Three domains of self-reported angina symptoms (frequency, stability, and physical function) were measured with the Seattle Angina Questionnaire. Linear regression models evaluated associations between alcohol use groups and angina symptoms. Models were adjusted first for age and then additionally for smoking, comorbidities, and depression. RESULTS Patients (n = 8303) had a mean age of 66 years. In age-adjusted analyses, a U-shaped association was observed between alcohol use groups and all angina outcomes, with patients in nondrinking and severe unhealthy alcohol groups reporting the greatest angina symptoms and lowest functioning. After full adjustment, no clinically important and few statistically important differences were observed across alcohol use in angina stability or frequency. Patients in the nondrinking group had statistically greater functional limitation from angina than those in all groups of unhealthy alcohol use, though differences were small. Patients in all groups of unhealthy alcohol use did not differ significantly from those with low-risk drinking. CONCLUSIONS Alcohol use was associated with some small statistically but no clinically important differences in angina symptoms among patients with CAD. This cross-sectional study does not support a protective effect of low-level drinking on self-reported angina.
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Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare. AIDS Behav 2019; 23:140-151. [PMID: 29995206 DOI: 10.1007/s10461-018-2210-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.
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7
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Duryee MJ, Dusad A, Hunter CD, Kharbanda KK, Bruenjes JD, Easterling KC, Siebler JC, Thiele GM, Chakkalakal DA. N-Acetyl Cysteine Treatment Restores Early Phase Fracture Healing in Ethanol-Fed Rats. Alcohol Clin Exp Res 2018; 42:1206-1216. [PMID: 29698568 DOI: 10.1111/acer.13765] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fracture healing in alcoholics is delayed and often associated with infections resulting in prolonged rehabilitation. It has been reported that binge drinking of alcohol increases oxidative stress and delays fracture healing in rats, which is prevented by treatment with the antioxidant n-acetyl cysteine (NAC). Oxidative stress is a significant factor in pathologies of various organs resulting from chronic alcoholism. Therefore, we hypothesize that treatment with NAC reduces oxidative stress and restores fracture healing in chronic alcoholics. METHODS Rats (10 months old) were pair-fed the Lieber-DeCarli ethanol (EtOH) diet or control diet for 16 weeks. A closed fracture was performed and rats allowed to recover for 72 hours. Rats were divided into 4 groups-control, control + NAC, EtOH, and EtOH + NAC-and injected intraperitoneally with 200 mg/kg of NAC daily for 3 days. Serum and bone fracture callus homogenates were collected and assayed for traditional markers of inflammation, oxidative stress, and bone regeneration. RESULTS The oxidative stress marker malondialdehyde (MDA) was increased in both serum and bone tissue in EtOH-fed animals compared to controls. NAC treatment significantly (p < 0.01) reduced MDA to near normal levels and dramatically increased the index of antioxidant efficacy (catalase/MDA ratio) (p < 0.01). Inflammatory markers tumor necrosis factor-α, interferon-γ, and interleukin-6 were significantly decreased in serum and callus following NAC treatment. NAC treatment reduced EtOH-induced bone resorption as evidenced by significant decreases in C-telopeptide of type-I-collagen levels (p < 0.05) and band-5 tartrate-resistant acid phosphatase levels in the tissue (p < 0.001). CONCLUSIONS Oxidative stress and excessive inflammation are involved in the inhibition of fracture healing by EtOH. In this study, early short-term treatment of EtOH-fed animals with the antioxidant NAC reduced oxidative stress and normalized the innate immune response to fracture in the early phase of fracture healing, thereby restoring the normal onset of bone regeneration.
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Affiliation(s)
- Michael J Duryee
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Anand Dusad
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Carlos D Hunter
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kusum K Kharbanda
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Joseph D Bruenjes
- Department of Surgery , Creighton University Medical Center, Omaha, Nebraska
| | - Karen C Easterling
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Justin C Siebler
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Surgery , Creighton University Medical Center, Omaha, Nebraska.,Department of Orthopedic Surgery , University of Nebraska Medical Center, Omaha, Nebraska
| | - Geoffrey M Thiele
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Internal Medicine , Division of Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska.,Department of Pathology and Microbiology , University of Nebraska Medical Center, Omaha, Nebraska
| | - Dennis A Chakkalakal
- Veteran Affairs Nebraska-Western Iowa Health Care System , Omaha, Nebraska.,Department of Surgery , Creighton University Medical Center, Omaha, Nebraska.,Department of Orthopedic Surgery , University of Nebraska Medical Center, Omaha, Nebraska
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Bensley KM, McGinnis KA, Fiellin DA, Gordon AJ, Kraemer KL, Bryant KJ, Edelman EJ, Crystal S, Gaither JR, Korthuis PT, Marshall BDL, Ornelas IJ, Chan KCG, Dombrowski JC, Fortney JC, Justice AC, Williams EC. Racial/ethnic differences in the association between alcohol use and mortality among men living with HIV. Addict Sci Clin Pract 2018; 13:2. [PMID: 29353555 PMCID: PMC6389249 DOI: 10.1186/s13722-017-0103-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Increasing alcohol use is associated with increased risk of mortality among patients living with HIV (PLWH). This association varies by race/ethnicity among general outpatients, but racial/ethnic variation has not been investigated among PLWH, among whom racial/ethnic minorities are disproportionately represented. METHODS VA electronic health record data from the Veterans Aging Cohort Study (2008-2012) were used to describe and compare mortality rates across race/ethnicity and levels of alcohol use defined by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire. Within each racial/ethnic group, Cox proportional hazards models, adjusted for age, disease severity, and comorbidities, compared mortality risk for moderate-risk (AUDIT-C = 4-7) and high-risk (AUDIT-C ≥ 8) relative to lower-risk (AUDIT-C = 1-3) alcohol use. RESULTS Mean follow-up time among black (n = 8518), Hispanic (n = 1353), and white (n = 7368) male PLWH with documented AUDIT-C screening (n = 17,239) was 4.3 years. Black PLWH had the highest mortality rate among patients reporting lower-risk alcohol use (2.9/100 person-years) relative to Hispanic and white PLWH (1.8 and 2.3, respectively) (p value for overall comparison = 0.011). Mortality risk was increased for patients reporting high-risk relative to lower-risk alcohol use in all racial/ethnic groups [black adjusted hazard ratio (AHR) = 1.36, 95% confidence interval (CI) 1.12-1.66; Hispanic AHR = 2.18, 95% CI 1.30-3.64; and white AHR = 2.04, 95% CI 1.61-2.58]. For only white PLWH, mortality risk was increased for patients reporting moderate-relative to lower-risk alcohol use (black AHR = 1.09, 95% CI 0.93-1.27; Hispanic AHR = 1.36, 95% CI 0.89-2.09; white AHR = 1.51, 95% CI 1.28-1.77). CONCLUSION Among all PLWH, mortality risk was increased among patients reporting high-risk alcohol use across all racial/ethnic groups, but mortality risk was only increased among patients reporting moderate-risk relative to lower-risk alcohol use among white PLWH, and black patients appeared to have higher mortality risk relative to white patients at lower-risk levels of alcohol use. Findings of the present study further underscore the need to address unhealthy alcohol use among PLWH, and future research is needed to understand mechanisms underlying observed differences.
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Affiliation(s)
- Kara M Bensley
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA. .,VA Health Services Research and Development (HSRD) Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
| | - Kathleen A McGinnis
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - David A Fiellin
- Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Adam J Gordon
- Salt Lake City VA, 500 Foothill Dr, Salt Lake City, UT, 84148, USA.,University of Utah, 201 Presidents Cir, Salt Lake City, UT, 84112, USA
| | - Kevin L Kraemer
- VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA.,University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Ln, Rockville, MD, 20852, USA
| | | | - Stephen Crystal
- Rutgers University, 7 College Ave, New Brunswick, NJ, 08901, USA
| | - Julie R Gaither
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - P Todd Korthuis
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Brandon D L Marshall
- Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA
| | - India J Ornelas
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA
| | - K C Gary Chan
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA
| | - Julia C Dombrowski
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - John C Fortney
- Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Emily C Williams
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, 1959 NE Pacific St, Box 357660, Seattle, WA, 98195-7660, USA.,VA Health Services Research and Development (HSRD) Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA
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Chavez LJ, Liu CF, Tefft N, Hebert PL, Devine B, Bradley KA. The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition. J Behav Health Serv Res 2017; 44:602-624. [PMID: 27585803 PMCID: PMC5332352 DOI: 10.1007/s11414-016-9529-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.
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Affiliation(s)
- Laura J Chavez
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH, 43210, USA.
| | - Chuan-Fen Liu
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Nathan Tefft
- Bates College, 2 Andrews Rd, Lewiston, ME, 04240, USA
| | - Paul L Hebert
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Beth Devine
- Department of Pharmacy, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Katharine A Bradley
- Health Services Research & Development, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
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10
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Williams EC, Gupta S, Rubinsky AD, Glass JE, Jones-Webb R, Bensley KM, Harris AHS. Variation in receipt of pharmacotherapy for alcohol use disorders across racial/ethnic groups: A national study in the U.S. Veterans Health Administration. Drug Alcohol Depend 2017; 178:527-533. [PMID: 28728114 DOI: 10.1016/j.drugalcdep.2017.06.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pharmacologic treatment is recommended for alcohol use disorders (AUD), but most patients do not receive it. Although racial/ethnic minorities have greater AUD consequences than whites, whether AUD medication receipt varies across race/ethnicity is unknown. We evaluate this in a national sample. METHODS Electronic health records data were extracted for all black, Hispanic, and/or white patients who received care at the U.S. Veterans Health Administration (VA) during Fiscal Year 2012 and had a documented AUD diagnosis. Mixed effects regression models, with a random effect for facility, determined the likelihood of receiving AUD pharmacotherapy (acamprosate, disulfiram, topirimate or oral or injectable naltrexone ≤180days after AUD diagnosis) for black and Hispanic patients relative to white patients. Models were unadjusted and then adjusted for patient- and facility-level factors. RESULTS 297,506 patients had AUD; 26.4% were black patients, 7.1% were Hispanic patients and 66.5% were white patients; 5.1% received AUD medications. Before adjustment, black patients were less likely than white [Odds Ratio (OR) 0.77; 95% Confidence Interval (CI) 0.75 -0.82; (p<0.001)], while Hispanic patients were more likely than white (OR 1.09; 95% CI 1.01-1.16) to receive AUD medications. After adjustment, black patients remained less likely than white to receive AUD medications (OR 0.68; 95% CI 0.65-0.71; p<0.0001); no difference between Hispanic and white patients was observed (OR 0.94; 95% CI 0.87-1.00; p=0.07). CONCLUSIONS In this national study of patients with AUD, blacks were less likely to receive AUD medications than whites. Future research is needed to identify why these disparities exist.
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Affiliation(s)
- Emily C Williams
- Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Services Research and Development, United States; University of Washington, Department of Health Services, United States.
| | | | - Anna D Rubinsky
- The Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, United States
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States
| | - Rhonda Jones-Webb
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, United States
| | - Kara M Bensley
- Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Services Research and Development, United States; University of Washington, Department of Health Services, United States
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11
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Publisher’s Note. J Subst Abuse Treat 2017. [DOI: 10.1016/j.jsat.2016.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Racial/ethnic differences in initiation of and engagement with addictions treatment among patients with alcohol use disorders in the veterans health administration. J Subst Abuse Treat 2016; 73:27-34. [PMID: 28017181 DOI: 10.1016/j.jsat.2016.11.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/29/2016] [Accepted: 08/08/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Specialty addictions treatment can improve outcomes for patients with alcohol use disorders (AUD). Thus, initiation of and engagement with specialty addictions treatment are considered quality care for patients with AUD. Previous studies have demonstrated racial/ethnic differences in alcohol-related care but whether differences exist in initiation of and engagement with specialty addictions treatment among patients with clinically recognized alcohol use disorders is unknown. We investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA). METHODS National VA data were extracted for all Black, Hispanic, and White patients with a diagnosed AUD during fiscal year 2012. Mixed effects regression models estimated the odds of two measures of initiation (an initial visit within 180days of diagnosis; and initiation defined consistent with Healthcare Effectiveness Data and Information Set (HEDIS) as a documented visit ≤14days after index visit or inpatient admission), and three established measures of treatment engagement (≥3 visits within first month after initiation; ≥2 visits in each of the first 3months after initiation; and ≥2 visits within 30days of HEDIS initiation) for Black and Hispanic relative to White patients after adjustment for facility- and patient-level characteristics. RESULTS Among 302,406 patients with AUD, 30% (90,879) initiated treatment within 180days of diagnosis (38% Black, 32% Hispanic, and 27% White). Black patients were more likely to initiate treatment than Whites for both measures of initiation [odds ratio (OR) for initiation: 1.4, 95% confidence interval (CI) 1.4-1.4; OR for HEDIS initiation: 1.1, 95% CI: 1.1-1.1]. Hispanic patients were more likely than White patients to initiate treatment within 180days (OR: 1.2, 95% CI 1.2-1.3) but HEDIS initiation did not differ between Hispanic and White patients. Engagement results varied depending on the measure but was more likely for Black patients relative to White for all measures (OR for engagement in first month: 1.1, 95% CI: 1.0-1.1; OR for engagement in first three months: 1.2, 95% CI: 1.1-1.2; OR for HEDIS measure: 1.1, 95% CI: 1.0-1.1), and did not differ between Hispanic and White patients. CONCLUSIONS After accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage. Research is needed to understand underlying mechanisms and whether differences in initiation of and engagement with care influence health outcomes.
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Bradley KA, Rubinsky AD, Lapham GT, Berger D, Bryson C, Achtmeyer C, Hawkins EJ, Chavez LJ, Williams EC, Kivlahan DR. Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population. Addiction 2016; 111:1975-1984. [PMID: 27349855 DOI: 10.1111/add.13505] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/27/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2). DESIGN Cohort study. SETTING Twenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention. PARTICIPANTS A total of 486 115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥ 12 months apart ('baseline' and 'follow-up'). MEASUREMENTS Independent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations ('GI hospitalizations') and (3) physical trauma, each in the years after baseline and follow-up. FINDINGS Baseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI) = 41.3-41.5] to 53.5 (95% CI = 51.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CI = 0.48-0.51%) to 1.8% (95% CI = 1.3-2.3%) and trauma from 3.0% (95% CI = 2.95-3.06%) to 6.0% (95% CI = 5.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all < 0.05). For example, among those with baseline low-risk use, in those with persistent low-risk use versus severe misuse at follow-up, the probabilities of subsequent trauma were 2.65% (95% CI = 2.54-2.75%) versus 5.15% (95% CI = 3.86-6.45%), respectively. However, for patients who decreased to lower AUDIT-C risk groups at follow-up, findings were inconsistent across outcomes, with only mean HDL decreasing in most groups that decreased use (P-values all < 0.05). CONCLUSIONS When AUDIT-C screening is conducted in clinical settings, baseline AUDIT-C scores and score increases to moderate-severe alcohol misuse at follow-up screening appear to have predictive validity for HDL cholesterol, alcohol-related gastrointestinal hospitalizations and physical trauma. Decreasing AUDIT-C scores collected in clinical settings appear to have predictive validity for only HDL.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA. .,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA. .,Group Health Research Institute, Seattle, WA, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Anna D Rubinsky
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,The Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Gwen T Lapham
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA
| | - Douglas Berger
- General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Bryson
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Carol Achtmeyer
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,General Medicine Services, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Eric J Hawkins
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Laura J Chavez
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Emily C Williams
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Daniel R Kivlahan
- Health Services Research and Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Zubkoff L, Shiner B, Watts BV. Staff Perceptions of Substance Use Disorder Treatment in VA Primary Care-Mental Health Integrated Clinics. J Subst Abuse Treat 2016; 70:44-49. [PMID: 27692187 DOI: 10.1016/j.jsat.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 07/13/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Guidelines recommend that substance use disorder (SUD) treatment be available in primary care-mental health integrated clinics, which offer mental and behavioral health assessment and treatment in the primary care setting. Despite this recommendation it is unclear what barriers and facilitators exist to SUD treatment being provided in that setting. This work sought to understand current SUD services in such integrated clinics, explore other services may that be appropriate, and identify barriers to such services. METHODS We conducted qualitative interviews with 23 staff members from integrated clinics at 6 Veterans Affairs medical centers. We transcribed interviews and performed thematic analysis to identify emergent themes. RESULTS We identified seven themes affecting staff experience and ability to provide SUD services in the integrated clinic: clinical effectiveness, clinical requirements, regulatory requirements, program goals, proximity of the integrated clinic and SUD services, training on substance use disorder, and role specialization. CONCLUSIONS VA primary care-mental health integrated clinic staff members do not currently view SUD treatment as the focus of their work, but are open to offering SUD treatment including brief psychological interventions or medication. Several barriers to providing SUD treatment were identified, including the need for additional staff training around appropriate interventions for the integrated clinic setting, additional staffing and space, and a structured implementation strategy to promote the use of SUD treatments.
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Affiliation(s)
- Lisa Zubkoff
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT.
| | - Brian Shiner
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT
| | - Bradley V Watts
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT
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Clark BJ, Rubinsky AD, Ho PM, Au DH, Chavez LJ, Moss M, Bradley KA. Alcohol screening scores and the risk of intensive care unit admission and hospital readmission. Subst Abus 2016; 37:466-473. [PMID: 26730984 PMCID: PMC5669033 DOI: 10.1080/08897077.2015.1137259] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The association between alcohol misuse and the need for intensive care unit admission as well as hospital readmission among those discharged from the hospital following a critical illness is unclear. This study sought to determine whether alcohol misuse was associated with (1) admission to an intensive care unit (ICU) among a cohort of patients receiving outpatient care and (2) hospital readmission among those discharged from the hospital following critical illness. METHODS This was a retrospective cohort study conducted with data from 24 Veterans Affairs (VA) health care facilities between 2004 and 2007. Scores on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire were used to identify patients with past-year abstinence, lower-risk alcohol use, moderate alcohol misuse, or severe alcohol misuse. The primary outcome was admission to a VA intensive care unit within the year following administration of the AUDIT-C. In an analysis focused on patients discharged from the ICU, the 2 main outcomes were hospital readmission within 1 year and within 30 days. RESULTS Among 486,115 veterans receiving outpatient care, the adjusted probability of ICU admission within 1 year was 2.0% (95% confidence interval [CI]: 1.7%-2.3%) for abstinent patients, 1.6% (95% CI: 1.3%-1.8%) for patients with lower-risk alcohol use, 1.8% (1.4%-2.3%) for patients with moderate alcohol misuse, and 2.5% (2.0%-2.9%) for patients with severe alcohol misuse. Among the 9,030 patients discharged from an ICU, the adjusted probability of hospital readmission within 1 year was 48% (46%-49%) in abstinent patients, 44% (42%-45%) in patients with lower-risk alcohol use, 42% (39%-45%) in patients with moderate alcohol misuse, and 55% (49%-60%) in patients with severe alcohol misuse. CONCLUSIONS Alcohol misuse may represent a modifiable risk factor for a cycle of ICU admission and subsequent hospital readmission.
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Affiliation(s)
- Brendan J. Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, U.S
| | - Anna D. Rubinsky
- Center of Excellence for Substance Abuse Treatment and Education, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, U.S
- Health Services Research and Development, Department of Veterans Affairs Puget Sound health Care System, Seattle, WA, U.S
| | - P. Michael Ho
- Division of Cardiology, Department of Medicine, Denver VAMC, Denver, CO; University of Colorado, Aurora, CO, U.S
| | - David H. Au
- Health Services Research and Development, Department of Veterans Affairs Puget Sound health Care System, Seattle, WA, U.S
| | - Laura J. Chavez
- Health Services Research and Development, Department of Veterans Affairs Puget Sound health Care System, Seattle, WA, U.S
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, U.S
| | - Katharine A. Bradley
- Center of Excellence for Substance Abuse Treatment and Education, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, U.S
- Health Services Research and Development, Department of Veterans Affairs Puget Sound health Care System, Seattle, WA, U.S
- Group Health Research Institute – Seattle, WA, U.S
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Williams EC, Frasco MA, Jacobson IG, Maynard C, Littman AJ, Seelig AD, Crum-Cianflone NF, Nagel A, Boyko EJ. Risk factors for relapse to problem drinking among current and former US military personnel: a prospective study of the Millennium Cohort. Drug Alcohol Depend 2015; 148:93-101. [PMID: 25599962 DOI: 10.1016/j.drugalcdep.2014.12.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/17/2014] [Accepted: 12/20/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Military service members may be prone to relapse to problem drinking after remission, given a culture of alcohol use as a coping mechanism for stressful or traumatic events associated with military duties or exposures. However, the prevalence and correlates of relapse are unknown. We sought to identify socio-demographic, military, behavioral, and health characteristics associated with relapse among current and former military members with remittent problem drinking. METHODS Participants in the longitudinal Millennium Cohort Study who reported problem drinking at baseline (2001-2003) and were remittent at first follow-up (2004-2006) were included (n=6909). Logistic regression models identified demographic, military service, behavioral, and health characteristics that predicted relapse (report of ≥1 past-year alcohol-related problem on the validated Patient Health Questionnaire) at the second follow-up (2007-2008). RESULTS Sixteen percent of those with remittent problem drinking relapsed. Reserve/National Guard members compared with active-duty members (odds ratio [OR]=1.71, 95% confidence interval [CI]: 1.45-2.01), members separated from the military during follow-up (OR=1.46, 95% CI: 1.16-1.83), and deployers who reported combat exposure (OR=1.32, 95% CI: 1.07-1.62, relative to non-deployers) were significantly more likely to relapse. Those with multiple deployments were significantly less likely to relapse (OR=0.73, 95% CI: 0.58-0.92). Behavioral factors and mental health conditions also predicted relapse. CONCLUSION Relapse was common and associated with military and non-military factors. Targeted intervention to prevent relapse may be indicated for military personnel in particular subgroups, such as Reservists, veterans, and those who deploy with combat exposure.
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Affiliation(s)
- Emily C Williams
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research Development, Department of Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA; Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-664, Box 357660, Seattle, WA 98195-7660, USA.
| | - Melissa A Frasco
- Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106-3521, USA.
| | - Isabel G Jacobson
- Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106-3521, USA.
| | - Charles Maynard
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research Development, Department of Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA; Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-664, Box 357660, Seattle, WA 98195-7660, USA; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, 1600 S Columbian Way MS-152E, Seattle, WA 98108, USA.
| | - Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, 1600 S Columbian Way MS-152E, Seattle, WA 98108, USA; Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street, Health Sciences Building F-250, Box 357236, Seattle, WA 98195-7236, USA.
| | - Amber D Seelig
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, 1600 S Columbian Way MS-152E, Seattle, WA 98108, USA.
| | - Nancy F Crum-Cianflone
- Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106-3521, USA; Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
| | - Anna Nagel
- Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106-3521, USA.
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, 1600 S Columbian Way MS-152E, Seattle, WA 98108, USA; Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street, Health Sciences Building F-250, Box 357236, Seattle, WA 98195-7236, USA; Department of Medicine, University of Washington School of Medicine, RR-512 Health Sciences Building, Box 356420, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA.
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Shah NP, Goel R, McGurk M, Maroo A, Sproat C. Brief advice on alcohol: as easy as A...B...I? Br Dent J 2015; 218:13-7. [PMID: 25571814 DOI: 10.1038/sj.bdj.2014.1138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 11/09/2022]
Abstract
Alcohol is widely consumed by the majority of the UK population and alcohol-related harm is estimated to cost society £21 billion per year in healthcare, lost productivity costs, crime and antisocial behaviour. The dental setting offers an ideal opportunity to screen for harmful alcohol consumption; however, current emphasis is on the management of acute complications and risk associated in treating patients with excessive alcohol intake rather than screening and patient education. This article outlines ways in which dentists could improve their recognition of 'at risk' patients and then offer practical advice to help reduce the harmful effects of alcohol.
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Affiliation(s)
| | | | - M McGurk
- King's College London Dental Institute
| | - A Maroo
- GPT, Hillingdon Hospital, Middlesex, UB8 3NN
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Lembke A, Stanford M. Clinical management of alcohol use disorders in the neurology clinic. HANDBOOK OF CLINICAL NEUROLOGY 2014; 125:659-70. [PMID: 25307603 DOI: 10.1016/b978-0-444-62619-6.00039-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Alcohol misuse adversely affects health outcomes, but alcohol misuse and alcohol use disorders (AUDs) are often ignored by healthcare providers in primary and specialty ambulatory care clinics. Data show that early identification and brief intervention for alcohol misuse in these settings can effectively reduce alcohol consumption and its medical sequelae. The aim of this chapter is to review the epidemiology of problematic alcohol use in ambulatory care settings, the diagnostic criteria for AUDs, the approach called SBIRT (screening, brief intervention and referral to treatment) as a model program to target alcohol misuse in everyday clinical practice, when and how to refer patients to resources beyond the clinic for their alcohol use problems, and the medical illnesses associated with AUDs.
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Affiliation(s)
- Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Mark Stanford
- Addiction Medicine and Therapy Services, Santa Clara Valley Health and Hospital System, Santa Clara County, CA, USA
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Abstract
People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.
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Delaney KE, Lee AK, Lapham GT, Rubinsky AD, Chavez LJ, Bradley KA. Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples. Addict Sci Clin Pract 2014; 9:2. [PMID: 24468406 PMCID: PMC3946205 DOI: 10.1186/1940-0640-9-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 12/23/2013] [Indexed: 12/02/2022] Open
Abstract
Background The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice. Methods This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C. Results Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking. Limitations This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens. Conclusions Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.
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Affiliation(s)
| | | | | | | | | | - Katharine A Bradley
- VA HSR&D Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle WA, USA.
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Berger D, Williams EC, Bryson CL, Rubinsky AD, Bradley KA. Alcohol questionnaires and HDL: screening scores as scaled markers of alcohol consumption. Alcohol 2013; 47:439-45. [PMID: 23886863 DOI: 10.1016/j.alcohol.2013.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/18/2013] [Accepted: 07/02/2013] [Indexed: 11/17/2022]
Abstract
Improving the quality of alcohol-related care requires practical approaches to assessing alcohol consumption to guide management and monitor outcomes. Given the increasing use of alcohol screening questionnaires to identify alcohol misuse it would be ideal if scores on screening questionnaires were also indicators of average alcohol consumption. However, the questionnaires were not designed for this purpose and include dimensions of drinking that may not reflect average consumption (e.g. heavy episodic drinking, alcohol-related problems). In a general population sample, scores on the AUDIT-C screen correlated with reports of alcohol consumption in detailed interviews, but the relationship is unknown for clinical populations and other questionnaires. Serum high-density lipoprotein cholesterol (HDL) is a biomarker routinely obtained in clinical care and is known to rise with average alcohol consumption. This cross-sectional study of 11,175 male U.S. Veterans Affairs patients enrolled in a primary care study used HDL as an objective biomarker to evaluate whether average alcohol consumption increased as scores increased on 3 brief alcohol screens - the AUDIT-C, AUDIT Question #3 (a single-item screen), and the CAGE questionnaire. Mean HDL progressively increased as screening scores increased for the AUDIT-C and AUDIT Question #3: about 12 mg/dL from the lowest to the highest scores. The association was much weaker for the CAGE questionnaire. Results were minimally affected by adjustment for covariates (e.g. age, race, medical comorbidity, smoking, medication count, and depression) but the association was modified (p = 0.008) and mildly attenuated by adherent use of lipid-lowering medications. This study using HDL as a biomarker of average alcohol consumption adds to evidence that some alcohol screening scores may also serve as scaled markers of average alcohol consumption.
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Affiliation(s)
- Douglas Berger
- General Medicine Service, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
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Smoking cessation and the risk of hospitalization for pneumonia. Respir Med 2012; 106:1055-62. [DOI: 10.1016/j.rmed.2012.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/19/2012] [Accepted: 03/24/2012] [Indexed: 11/17/2022]
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Williams EC, Bradley KA, Gupta S, Harris AHS. Association between alcohol screening scores and mortality in black, Hispanic, and white male veterans. Alcohol Clin Exp Res 2012; 36:2132-40. [PMID: 22676340 DOI: 10.1111/j.1530-0277.2012.01842.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 03/11/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Scores on the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire are associated with mortality, but whether or how associations vary across race/ethnicity is unknown. METHODS Self-reported black (n = 13,068), Hispanic (n = 9,466), and white (n = 182,688) male Veterans Affairs (VA) outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1 to 4, 5 to 8, and 9 to 12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity. RESULTS Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1 to 4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p = 0.0022). Hispanic and white patients with scores of 0, 5 to 8, and 9 to 12 had significantly increased risk of death compared to those with scores of 1 to 4; Hispanic ORs: 1.93, 95% CI 1.50 to 2.49; 1.57, 1.07 to 2.30; 1.82, 1.04 to 3.17, respectively; white ORs: 1.34, 95% CI 1.29 to 1.40; 1.12, 1.03 to 1.21; 1.81, 1.59 to 2.07, respectively. Black patients with scores of 0 and 5 to 8 had increased risk relative to scores of 1 to 4 (ORs 1.28, 1.06 to 1.56 and 1.50, 1.13 to 1.99), but there was no significant increased risk for scores of 9 to 12 (ORs 1.27, 0.77 to 2.09). Post hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity. CONCLUSIONS Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically tailored feedback regarding medical consequences of drinking.
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Affiliation(s)
- Emily C Williams
- Northwest Center of Excellence for Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington 98101, USA.
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Harris AHS, Lembke A, Henderson P, Gupta S, Moos R, Bradley KA. Risk of future trauma based on alcohol screening scores: a two-year prospective cohort study among US veterans. Addict Sci Clin Pract 2012; 7:6. [PMID: 22966411 PMCID: PMC3414833 DOI: 10.1186/1940-0640-7-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 04/30/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender. METHODS Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1-4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed. RESULTS Having an AUDIT-C score of 9-12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men≤50 years, those with AUDIT-C scores≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1-4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR=1.24; 95% confidence interval [CI], 1.03-1.50). For men≥65 years with average comorbidity and education, those with AUDIT-C scores of 5-8 (adjusted prevalence, 7.9% versus 7.4%; OR=1.16; 95% CI, 1.02-1.31) and 9-12 (adjusted prevalence 11.1% versus 7.4%; OR=1.68; 95% CI, 1.30-2.17) were at significantly increased risk for trauma compared with men≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women. CONCLUSIONS Men with severe alcohol misuse (AUDIT-C 9-12) demonstrate an increased risk of trauma. Men≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5-8 and 9-12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.
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Affiliation(s)
- Alex H S Harris
- Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Anna Lembke
- Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Patricia Henderson
- Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Shalini Gupta
- Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Rudolf Moos
- Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Katharine A Bradley
- Group Health Research Institute, and Health Services Research & Development (HSR&D) Northwest Center of Excellence, Center of Excellence in Substance Abuse Treatment and Education (CESATE), Veterans Affairs (VA) Puget Sound Health Care System, 1100 Olive Way, 14th Floor, Seattle, WA, 98101, USA
- Departments of Medicine and Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
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Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between Alcohol Screening Results and Hospitalizations for Trauma in Veterans Affairs Outpatients. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 38:73-80. [DOI: 10.3109/00952990.2011.600392] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Emily C. Williams
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
| | - Chris L. Bryson
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Haili Sun
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Ryan B. Chew
- Overlake Hospitalist Practice, Overlake Hospital Medical Center,
Bellevue, WA, USA
| | - Lisa D. Chew
- Department of Medicine, University of Washington,
Seattle, WA, USA
- Adult Medicine Clinic, Harborview Medical Center,
Seattle, WA, USA
| | - David K. Blough
- Department of Pharmacy, University of Washington,
Seattle, WA, USA
| | - David H. Au
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Katharine A. Bradley
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
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Alcohol screening scores and the risk of new-onset gastrointestinal illness or related hospitalization. J Gen Intern Med 2011; 26:777-82. [PMID: 21455813 PMCID: PMC3138581 DOI: 10.1007/s11606-011-1688-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 02/05/2011] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis. OBJECTIVE To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores. DESIGN Retrospective cohort study. PARTICIPANTS Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months. MEASUREMENTS Alcohol Use Disorder Identification Test-Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0-12 points). RESULTS Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5-8 and 9-12 (OR 1.54, 95% CI = 1.27-1.86; and OR 3.27; 95% CI = 2.62-4.09 respectively), and women with AUDIT-C scores of 9-12 (OR 6.84, 95% CI = 1.85 - 25.37). Men with AUDIT-C scores of 5-8 and 9-12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30-1.71; and OR 2.82, 95% CI = 2.38-3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05-1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9-12 was also increased (OR 2.14; 95% CI = 1.54-2.97). CONCLUSIONS Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.
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Chew RB, Bryson CL, Au DH, Maciejewski ML, Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? J Behav Health Serv Res 2011; 38:3-15. [PMID: 20464519 DOI: 10.1007/s11414-010-9215-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospitalizations for ambulatory care sensitive conditions (ACSCs) are used to assess quality of care, but studies rarely adjust for health behaviors. This study evaluated whether results of smoking or alcohol screening were associated with hospitalizations for ACSCs. Participants included 33,273 male Veterans Affairs general medicine outpatients who returned mailed surveys. The main outcome was hospitalization with a primary discharge diagnosis for an ACSC in the year following screening. Analyses were adjusted for demographics, comorbidity, and other health behaviors. Current and previous smoking and abstaining from alcohol were associated with significantly increased risk of hospitalization for ACSCs, but alcohol misuse was not. However, severe alcohol misuse was associated with increased risk of hospitalizations with a primary or secondary ACSC discharge diagnosis. When ACSCs are used to evaluate the quality of care, health systems caring for populations with higher rates of smoking or nondrinking could falsely appear to have poorer quality care if alcohol and tobacco use are not considered.
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Affiliation(s)
- Ryan B Chew
- VA Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98101, USA.
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Harris AHS, Bradley KA, Bowe T, Henderson P, Moos R. Associations between AUDIT-C and mortality vary by age and sex. Popul Health Manag 2011; 13:263-8. [PMID: 20879907 DOI: 10.1089/pop.2009.0060] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1-4, 5-8, 9-12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9-12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5-8 and 9-12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or "vital sign" that might facilitate the detection and management of alcohol-related risks and problems.
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Affiliation(s)
- Alex H S Harris
- Center for Health Care Evaluation, VA Palo Alto Health Care System and Stanford University School of Medicine . Menlo Park, CA 94025, USA.
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Bradley KA, Lapham GT, Hawkins EJ, Achtmeyer CE, Williams EC, Thomas RM, Kivlahan DR. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med 2011; 26:299-306. [PMID: 20859699 PMCID: PMC3043188 DOI: 10.1007/s11606-010-1509-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 07/26/2010] [Accepted: 08/30/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings. OBJECTIVE The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results. DESIGN Cross sectional. PARTICIPANTS A national sample of 6,861 VA outpatients (fiscal years 2007-2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen). MAIN MEASURES Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens). KEY RESULTS Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks. CONCLUSION Use of a validated alcohol screening questionnaire does not-by itself-ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Harris AHS, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. J Bone Joint Surg Am 2011; 93:321-7. [PMID: 21325583 DOI: 10.2106/jbjs.i.01560] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The risks associated with preoperative alcohol misuse by patients before undergoing total joint arthroplasty are not well known, yet alcohol misuse by surgical patients is common and has been linked to an increased risk of complications after other procedures. The purpose of this study was to evaluate the association between a patient's preoperative standardized alcohol-misuse screening score and his or her risk of complications after total joint arthroplasty. METHODS The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is an alcohol-misuse screening instrument administered annually to all patients receiving care through the Veterans Health Administration (VHA). The scores range from 0 to 12, with higher scores signifying greater and more frequent consumption. In a study of 185 male patients who had alcohol screening scores recorded in the year preceding surgery at a Palo Alto VHA facility, and who reported at least some alcohol use, we estimated the association between preoperative screening scores and the number of surgical complications in an age and comorbidity-adjusted regression analyses. RESULTS Of the 185 patients reporting at least some drinking in the year before their total joint replacement, 17% (thirty-two) had an alcohol screening score suggestive of alcohol misuse; six of those thirty-two patients had one complication, four had two complications, and two had three complications. The screening scores were significantly related to the number of complications in a negative binomial regression analysis (exp[β] = 1.29, p = 0.035), which demonstrated a 29% increase in the expected number of complications with every additional point of the screening score above 1, although with wide confidence intervals for the higher scores. CONCLUSIONS Complications following total joint arthroplasty were significantly related to alcohol misuse in this group of male patients treated at a VHA facility. The AUDIT-C has three simple questions that can be incorporated into a preoperative evaluation and can alert the treatment team to patients with increased postoperative risk. Preoperative screening for alcohol misuse, and perhaps preoperative counseling or referral to treatment for heavy drinkers, may be indicated for patients who are to undergo total joint arthroplasty.
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Affiliation(s)
- Alex H S Harris
- VA Palo Alto Health Care System, Palo Alto, California, USA.
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Bradley KA, Rubinsky AD, Sun H, Bryson CL, Bishop MJ, Blough DK, Henderson WG, Maynard C, Hawn MT, Tønnesen H, Hughes G, Beste LA, Harris AHS, Hawkins EJ, Houston TK, Kivlahan DR. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med 2011; 26:162-9. [PMID: 20878363 PMCID: PMC3019325 DOI: 10.1007/s11606-010-1475-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. OBJECTIVE To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications. DESIGN This is a cohort study. SETTING AND PARTICIPANTS Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. MAIN OUTCOME MEASURE One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. RESULTS Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10. CONCLUSIONS AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA 98101, USA.
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Abstract
SummaryAlcohol use is common in older adults and is associated with numerous health and social problems. Recent evidence suggests that in addition to level of alcohol consumption, drinking pattern may also be important. Moderate alcohol intake may confer some cardiac benefits, while heavy episodic drinking seems particularly problematic. Detecting alcohol misuse in older adults is difficult since clinical acumen is often poor, screening questionnaires have serious limitations and laboratory tests are not diagnostic. Brief alcohol interventions to reduce alcohol consumption appear useful in younger populations, but are less studied in older adults. While there is increasing research into the issue of alcohol use among older adults, clinicians and policy-makers must rely on limited evidence when making clinical decisions.
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Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening. J Gen Intern Med 2010; 25 Suppl 1:11-7. [PMID: 20077146 PMCID: PMC2806961 DOI: 10.1007/s11606-009-1100-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND/OBJECTIVE Brief alcohol counseling is a foremost US prevention priority, but no health-care system has implemented it into routine care. This study evaluated the effectiveness of an electronic clinical reminder for brief alcohol counseling ("reminder"). The specific aims were to (1) determine the prevalence of use of the reminder and (2) evaluate whether use of the reminder was associated with resolution of unhealthy alcohol use at follow-up screening. METHODS The reminder was implemented in February 2004 in eight VA clinics where providers routinely used clinical reminders. Patients eligible for this retrospective cohort study screened positive on the AUDIT-C alcohol screening questionnaire (February 2004-April 2006) and had a repeat AUDIT-C during the 1-36 months of follow-up (mean 14.5). Use of the alcohol counseling clinical reminder was measured from secondary electronic data. Resolution of unhealthy alcohol use was defined as screening negative at follow-up with a >/=2-point reduction in AUDIT-C scores. Logistic regression was used to identify adjusted proportions of patients who resolved unhealthy alcohol use among those with and without reminder use. RESULTS Among 4,198 participants who screened positive for unhealthy alcohol use, 71% had use of the alcohol counseling clinical reminder documented in their medical records. Adjusted proportions of patients who resolved unhealthy alcohol use were 31% (95% CI 30-33%) and 28% (95% CI 25-30%), respectively, for patients with and without reminder use (p-value = 0.031). CONCLUSIONS The brief alcohol counseling clinical reminder was used for a majority of patients with unhealthy alcohol use and associated with a moderate decrease in drinking at follow-up.
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Bradley KA, Kivlahan DR, Williams EC. Brief approaches to alcohol screening: practical alternatives for primary care. J Gen Intern Med 2009; 24:881-3. [PMID: 19495888 PMCID: PMC2695519 DOI: 10.1007/s11606-009-1014-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Katharine A. Bradley
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Primary and Specialty Medical Care Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA USA
- Department of Health Services, University of Washington, Seattle, WA USA
| | - Daniel R. Kivlahan
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA USA
| | - Emily C. Williams
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA USA
- Department of Health Services, University of Washington, Seattle, WA USA
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