Burden of Alcohol Disorders on Emergency Department Attendances and Hospital Admissions in England

Factors associated with discharge against medical advice in alcohol withdrawal patients

This study aimed to examine characteristics associated with discharge against medical advice from the hospital in alcohol withdrawal patients, supporting the work of hospital staff and Alcohol Care Teams and identifying characteristics that may help target patients most likely to discharge against medical advice. We used Hospital Episode Statistics Data to identify demographic and clinical variables and compare these in alcohol withdrawal patients who discharged against medical advice from hospital, compared with those who were discharged by the clinical team. Factors significantly associated with alcohol withdrawal patients discharging against medical advice from hospital were: being admitted as an emergency; discharged on a weekend; living with no fixed abode; being male; being younger and having a shorter length of stay. This study identifies characteristics that can be used to support acute hospitals and Alcohol Care Teams, particularly in the allocation of resources to reduce discharges against medical advice and subsequent readmissions to the hospital. Particular consideration should be given to clinical provision in hospitals in emergency departments and on weekends, and also those patients who are admitted and are of no fixed abode.

Examining the Attitudes of Non-Psychiatric Practicing Healthcare Workers Towards Patients With Alcohol Problems in General Hospital Setting

BACKGROUND AND OBJECTIVES

Problematic alcohol-use affect the physical and mental well-being of hospitalised individuals and may receive screening and brief-intervention during treatment. Non-psychiatric doctors and nurses might respond inadequately due to negative attitudes and beliefs. This study aimed to examine these attitudes of non-psychiatric workers in the medical and surgical wards.

METHODS

A total of 457 doctors and 1643 nurses were recruited from the medical, surgical and orthopaedic disciplines over a period of 4 months. Three questionnaires were administered: demographics, Alcohol & Alcohol-Problems Perceptions Questionnaire (AAPPQ) and Staff Perception of Alcohol Treatment Resources.

RESULTS

About 128 doctors and 785 nurses responded. Around 75.5% doctors and 51.9% nurses endorsed role-legitimacy in the AAPPQ. Both the doctor (86.7%) and nurse (77.6%) groups agreed on the importance to initiate intervention for patients with problematic alcohol-use in daily work. Both groups were sceptical and negative towards these patients endorsing low-level role-adequacy (41.2%), role-support (36.9%), motivation (36.5%), task-specific self-esteem (25.1) as well as work satisfaction (20.5%).

CONCLUSION/DISCUSSION

Doctors and nurses demonstrated low levels of therapeutic commitments towards patients with problematic alcohol-use thereby necessitating the introduction of in-house programmes to educate, empower and emphasise the importance of therapeutic contact with patients for alcohol intervention.

SCIENTIFIC SIGNIFICANCE

The prompt identification and treatment of patients with alcohol problems are contingent on the workers' attitudes towards them. This study's results should spark a nation-wide interest to improve the training and recognition of such patients and providing adequate educational resources.

Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background

Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components.

Objectives

This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use.

Design

We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect.

Setting

Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3).

Participants

Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups.

Intervention

Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers.

Results

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas.

Limitations

The short interval between policy announcement and implementation left limited time for pre-intervention data collection.

Conclusions

Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context.

Future work

Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts.

Trial registration

Current Controlled Trials ISRCTN16039407.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Improving identification and brief advice for alcohol in hospital patients: a new sustainable model using medicine management technicians

Alcohol identification and brief advice (IBA) is effective for reducing increased risk alcohol consumption, but systematic sustainable screening systems in hospitals are often lacking. University Hospital Southampton NHS Foundation Trust implemented a trust-wide IBA system by integrating it into a patient's medicines reconciliation review undertaken by medicines management technicians (MMTs) on admission. After an initial pilot, this model was rolled out across the trust and has resulted in a substantial increase in the number of patients screened and accurately coded for alcohol use. Surveys of MMTs have shown their confidence and competence in asking patients about their alcohol has increased since implementation.

Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship

AIMS

We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012.

METHODS

Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings.

RESULTS

A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings.

CONCLUSIONS

The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Course and outcome of patients with alcohol use disorders following an alcohol intervention during hospital attendance: mixed method study

BACKGROUND

Alcohol-related presentations to acute hospitals in the UK are increasing, but little is known of the clinical characteristics or natural history of this patient group.

AIMS

To describe the clinical characteristics, drinking profile and trajectory of a cohort of patients with alcohol use disorder (AUD) attending hospital, and explore participant perspectives of the impact of hospital attendance on their relationship with alcohol.

METHOD

We conducted a mixed method, prospective, observational cohort study of patients with AUD seen in an acute hospital. Participants were interviewed with a range of questionnaires at baseline and followed up on at 6 months. A subsample also completed in-depth qualitative interviews.

RESULTS

We recruited 141 patients; 132 (93.6%) were followed up at 6 months and 26 completed qualitative interviews. Of the 141 patients, 60 (42.6%) stated the index hospital episode included the first discussion of their alcohol use in a secondary care setting. Most rated discussion of their alcohol use in hospital as 'very positive' or 'positive' (102/141, 72.3%), but lack of coordinated care with community services undermined efforts to sustain change. At 6 months, 11 (7.8%) patients had died, but in those who survived and completed assessment (n = 121), significant and clinically meaningful improvements were seen across a range of outcomes, with 55 patients (45.5%) showing a favourable drinking outcome at 6 months.

CONCLUSIONS

Patients with AUD have high levels of morbidity and mortality, yet many made substantial changes following intervention in hospital for their alcohol use. Prospective trials need to identify the effect of alcohol care teams in optimising this 'teachable moment' for patients.

Clinical Competencies for the Care of Hospitalized Patients with Alcohol Use Disorders

AIMS

The UK government aims to develop alcohol care teams (ACTs) that provide care for alcohol dependence in general hospital settings. Service descriptors have been identified to support the development of ACTs. The aim of this study was to use Delphi panel principles to identify the clinical competencies required to provide these elements of service.

METHODS

We formed an expert consensus panel of 24 senior clinical alcohol practitioners, leaders and experts by experience drawn from all regions of England. The study was divided into three distinct phases: (a) a review and synthesis of current literature in this area, (b) a face-to-face meeting of the expert panel and (c) subsequent iterations to refine the competencies until consensus was reached.

RESULTS

Our initial search strategy resulted in 555 competency statements being extracted from a range of national clinical professional and occupational standards and other sources. The research team refined these statements to 98 competencies in advance of the expert meeting. The panel identified 14 additional statements and reduced the number of competencies to 78. Subsequent iterations finalized 72 competencies across the 8 service descriptors.

CONCLUSIONS

Drawing on the existing published resources and clinical experience, the expert panel has provided consensus on the core clinical competencies required for alcohol care teams in caring for hospitalized patients with alcohol use disorders. Whilst it is acknowledged that the range of current provision is variable, these competencies provide a template for clinical practice and the development of multidisciplinary ACTs.

Evaluation of an Assertive Management and Integrated Care Service for Frequent Emergency Department Attenders with Substance Use Disorders: The Impact Project: Evaluating an assertive management service for frequent ED attenders with substance use disorders

INTRODUCTION

Frequent attenders to Emergency Departments (ED) often have contributing substance use disorders (SUD), but there are few evaluations of relevant interventions. We examine one such pilot assertive management service set in Sydney, Australia (IMPACT), aimed at reducing hospital presentations and costs, and improving client outcomes.

METHODS

IMPACT eligibility criteria included moderate-to-severe SUD and ED attendance on ≥5 occasions in the previous year. A pre-post intervention design examined clients' presentations and outcomes 6 months before and after participation to a comparison group of eligible clients who did not engage.

RESULTS

Between 2014 and 2015, 34 clients engaged in IMPACT, with 12 in the comparison group. Clients demonstrated significant reductions in preventable (p < 0.05) and non-preventable (p < 0.01) ED presentations and costs, and in hospital admissions and costs (p < 0.01). IMPACT clients also reported a significant reduction in use days for primary substance (p < 0.01). The comparison group had a significant reduction (p < 0.05) in non-preventable visits only.

CONCLUSIONS

Assertive management services can be effective in preventing hospital presentations and costs for frequent ED attenders with SUDs and improving client outcomes, representing an effective integrated health approach. The IMPACT service has since been refined and integrated into routine care across a number of hospitals in Sydney, Australia.