Evaluating recall bias in a case-crossover design estimating risk of injury related to alcohol: data from six countries

Alcohol outlets and alcohol consumption in changing environments: prevalence and changes over time

BACKGROUND

To examine whether changes in density of neighborhood alcohol outlets affected changes in alcohol consumption 1-year after regulatory changes increased alcohol availability.

METHODS

Person-level data came from a population-based cohort (aged 21-64) residing in/around the Philadelphia, Pennsylvania metropolitan area (2016-2018, N = 772). Fifty-eight percent lived in a state that began implementing new regulations (Pennsylvania) and the remainder lived in states without major regulatory changes (Delaware and New Jersey). Alcohol consumption was assessed as days per week (pw), drinks pw, high consumption (≥8 drinks pw), and binge drinking. Availability of off-premise alcohol outlets was assessed using 1-mile density and distance. Regression models adjusted for age, gender, race/ethnicity, income, education, health status, state and population density.

RESULTS

Cross-sectional analyses found that higher outlet density was associated with more alcohol consumption (days, drinks, high consumption; all p < 0.03) and residing farther from an outlet was associated with less alcohol consumption (days and drinks; all p < 0.04). In longitudinal analyses, relative to no change in outlets, exposure to more outlets was associated with 64% higher odds of drinking on more days pw (p < 0.049) and 55% higher odds of consuming more drinks pw (p < 0.081). However, the longitudinal association between changes in outlets and changes in consumption did not differ for residents in Pennsylvania vs. nearby states. In cross-sectional and longitudinal analyses, outlets were not related to binge drinking.

CONCLUSION

Off-premise outlets were associated with alcohol consumption consistently in cross-sectional analysis and in some longitudinal analyses. Results can inform future studies that wish to evaluate longer-term changes in increased alcohol availability and effects on consumption.

The interactive effect of location, alcohol consumption and non-traffic injury

AIM

This study aimed to assess the extent to which the association between recent alcohol consumption and risk of non-traffic injury varies according to location at the time of the injury.

DESIGN

Case-cross-over design.

SETTING AND PARTICIPANTS

A total of 15 625 injury patients from 49 emergency departments (EDs) in 22 countries.

MEASUREMENTS

Recent alcohol consumption and location at the time of the injury were assessed for when the injury occurred and for the same time 1 week prior to this. The confounding and interactive effects of location were examined by estimating the adjusted odds ratio (OR) of injury from alcohol consumption adjusting for location and then by examining the alcohol consumption × location interaction.

FINDINGS

There were significant interactive effects of location and alcohol consumption on injury risk. For example, the ORs for volume 0.1-3.0 drinks and street/public place each were 3.0 and 14.2, respectively, whereas the OR for their joint effect was 44.1, suggesting a positive additive interaction [relative excess risk due to interaction (RERI) = 27.9, P < 0.05] and zero multiplicative interaction (OR = 1.0, P = 0.895). The interactions of alcohol consumption with drinking establishment location, work-place and other locations were mostly additive and negative on the multiplicative scale (e.g. for interaction between volume 0.1-3.0 drinks and drinking establishment location: RERI = 1.19, P = 0.529; multiplicative interaction OR = 0.54, P < 0.05).

CONCLUSIONS

Location appears to influence the relationship between alcohol consumption and risk of injury. The association between alcohol consumption and injury appears to be greater in locations such as streets and public places compared with private residences.

Dose-Response Relative Risk of Injury From Acute Alcohol Consumption in 22 Countries: Are Women at Higher Risk Than Men?

AIMS

The risk of injury from alcohol consumption was analyzed by gender, controlling for frequency of heavy drinking occasions, and by cause of injury (traffic, violence, fall, other).

METHODS

Case-crossover analysis was conducted on 18,627 injured patients arriving at the emergency department (ED) within six hours of the event.

FINDINGS

Risk of injury was similar for females and males at ≤3 drinks prior to injury (OR = 2.74 vs. 2.76, respectively). At higher volume levels females were at greater risk than males, and significantly so at 3.1-6 drinks and 6.1-10 drinks (gender by volume interaction: OR = 0.60, CI = 0.39-0.93 and OR = 0.50, CI = 0.27-0.93, respectively). For those reporting 5+ ≥ monthly, females were at higher risk than males at all volume levels, and the gender by volume interaction was stronger than for those consuming 5+

CONCLUSIONS

Females are at higher risk of injury than males, regardless of frequency of heavy drinking and for all causes other than those related to traffic.

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Key Words Collapse

MESH Headings

• Accidental Falls
• Adolescent
• Adult
• Alcohol Drinking/epidemiology
• Alcohol Drinking/psychology
• Alcohol Drinking/trends
• Alcoholic Beverages
• Cross-Over Studies
• Dose-Response Relationship, Drug
• Emergency Service, Hospital/trends
• Female
• Humans
• Internationality
• Male
• Risk Factors
• Sex Factors
• Violence/psychology
• Violence/trends
• Young Adult

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Grants

• R01 AA013750 NIAAA NIH HHS

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Affiliation(s)

Cheryl J Cherpitel Alcohol Research Group, 6001 Shellmound St., Suite 450, Emeryville, CA, USA
Yu Ye Alcohol Research Group, 6001 Shellmound St., Suite 450, Emeryville, CA, USA
Maristela G Monteiro Pan American Health Organization, Washington, DC, USA

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The impact of alcohol among injury patients in Moshi, Tanzania: a nested case-crossover study

BACKGROUND

Globally, alcohol is responsible for 3.3 million deaths annually and contributes to 5.9% of the overall global burden of disease. In Sub-Saharan Africa, alcohol is the leading avoidable risk factor accounting for a substantial portion of death and disability. This project aimed to determine the proportion of injuries related to alcohol and the increased risk of injury due to alcohol among injury patients seeking care at the emergency department (ED) of Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania.

METHODS

A representative cross-sectional sample of adult patients presenting to the KCMC ED with acute injury were enrolled in this study with a nested case-crossover design. Patient demographics, injury characteristics, and severity as well as alcohol use behaviors were collected. Alcohol breathalyzers were administered to the enrolled patients. Data on activities and alcohol use were collected for the time period 6 h prior to injury and two control periods: 24-30 h prior to injury and 1 week prior to injury.

RESULTS

During 47 weeks of data collection, 24,070 patients were screened, of which 2164 suffered injuries, and 516 met the inclusion and exclusion criteria, consented to participate, and had complete data. Of the study participants, 76% were male, and 30% tested positive for alcohol on arrival to the ED. Alcohol use was associated with being male and being employed. Alcohol use was associated with an increased risk of injury (OR 5.71; 95% CI 3.84-8.50), and specifically road traffic injuries were associated with the highest odds of injury with alcohol use (OR 6.53, 95% CI 3.98-10.71). For all injuries and road traffic injuries specifically, we found an increase in the odds of injury with an incremental increase in the dose of alcohol.

CONCLUSIONS

At KCMC in Moshi, Tanzania, 3 of 10 injury patients tested positive for alcohol on presentation for care. Similarly, alcohol use conveys an increased risk for injury in this setting. Evidence-based prevention strategies for alcohol-related injuries need to be implemented to reduce alcohol misuse and alcohol-related injuries.

Risk of violence-related injury from alcohol consumption and its burden to society in Latin America and the Caribbean

OBJECTIVES

The risk for violence-related injury from drinking and attributable burden in the Latin American and Caribbean region was explored.

METHODS

A probability sample of 1024 emergency department patients reporting a violence-related injury was analyzed from 11 countries, using case-crossover fractional polynomial analysis of the number of drinks consumed prior to the event.

RESULTS

A dose-response relationship was observed with a six-fold increase in risk (RR=5.6) for less than two drinks prior to injury. Risk was higher for females than males at 10 or more drinks, and higher for those aged 30 and older compared to those younger at all volume levels. Overall, 32.7% of the violence-related injuries were attributable to alcohol. Alcohol attributable fraction (AAF) was nearly three times larger for males (38%) than for females (12.3%).

CONCLUSIONS

A dose-response relationship was found between the volume of alcohol consumed prior to the event and risk of violence-related injury. Risk was not uniform across gender or age. At higher volumes, females compared to males were at greater risk of injury but had a lower AAF due to their lower prevalence of drinking at higher levels.

A dose-response estimate for acute alcohol use and risk of suicide attempt

This study reports dose-response estimates for the relative risk and population attributable risk (PAR) between acute alcohol use and serious suicide attempt. Data were analyzed on 272 suicide attempters arriving at 38 emergency departments within 6 hours of the event in 17 countries. Case-crossover analysis, pair-matching the number of standard drinks consumed within the 6 hours prior to the suicide attempt with that consumed during the same 6-hour period of the previous week, was performed using fractional polynomial analysis for dose-response. Every drink increased the risk of a suicide attempt by 30 percent; even one-two drinks was associated with a sizable increase in the risk of a serious suicide attempt, and a dose-response was found for the relationship between drinking 6 hours prior and the risk of a suicide attempt up to 20 drinks. Acute use of alcohol was responsible for 35 percent PAR of all suicide attempts. While very high levels of drinking were associated with larger relative risk s of suicide attempt, the control and reduction of smaller quantities of acute alcohol use also had an impact on population levels of suicide attempt, as showed here for the first time with our PAR estimates. Interventions to stop drinking or at least decrease levels of consumption could reduce the risk of suicide attempt. Screening people more at risk to suffer these acute effects of ethanol and offering interventions that work to these high-risk groups are a matter of urgent new research in the area.

Alcohol and Road Traffic Injuries in Latin America and the Caribbean: A Case-Crossover Study

BACKGROUND

This study reports dose-response estimates for the odds ratio (OR) and population attributable risk of acute alcohol use and road traffic injury (RTI).

METHODS

Data were analyzed on 1,119 RTI patients arriving at 16 emergency departments (EDs) in Argentina, Brazil, Costa Rica, Dominican Republic, Guatemala, Guyana, Mexico, Nicaragua, Panama, and Trinidad and Tobago. Case-crossover analysis, pair-matching the number of standard drinks consumed within the 6 hours prior to the RTI with 2 control periods (prior d/wk), was performed using fractional polynomial analysis for dose-response.

RESULTS

About 1 in 6 RTI patients in EDs were positive for self-reported alcohol 6 hours prior to the injury (country range 8.6 to 24.1%). The likelihood of an RTI with any drinking prior (compared to not drinking) was 5 times higher (country range OR 2.50 to 15.00) and the more a person drinks the higher the risk. Every drink (12.8 g alcohol) increased the risk of an RTI by 13%, even 1 to 2 drinks were associated with a sizable increase in risk of an RTI and a dose-response was found. Differences in ORs for drivers (OR = 3.51; 95% CI = 2.25 to 5.45), passengers (OR = 8.12; 95% CI = 4.22 to 15.61), and pedestrians (OR = 6.30; 95% CI = 3.14 to 12.64) and attributable fractions were noted. Acute use of alcohol was attributable to 14% of all RTIs, varying from 7% for females to 19% for being injured as a passenger.

CONCLUSIONS

The finding that the presence of alcohol increases risk among drivers and nondrivers alike may further help to urge interventions targeting passengers and pedestrians. Routine screening and brief interventions in all health services could also have a beneficial impact in decreasing rates of RTIs. Higher priority should be given to alcohol as a risk factor for RTIs, particularly in Latin America and the Caribbean.

Recall bias across 7 days in self-reported alcohol consumption prior to injury among emergency department patients

INTRODUCTION AND AIMS

Recall bias is a concern in self-reported alcohol consumption, potentially accounting for varying risk estimates for injury in emergency department (ED) studies. The likelihood of reporting drinking for the same 6-h period each day of the week for a full week preceding the injury event is analysed among injured ED patients.

DESIGN AND METHODS

Probability samples of patients 18 years old and older were interviewed in two ED sites in Vancouver and one in Victoria, BC (n = 1191). Generalized estimating equation modelling was used to predict the likelihood of reporting drinking for the same 6-h period prior to the injury event for each day of the week, compared to day 7 as the reference recall day, for a full week preceding the event. Recall by frequency of drinking and frequency of heavy drinking was analysed.

RESULTS

Drinking was significantly more likely to be reported for each of the first 3 days of recall compared to 7-day recall and highest for 1-day recall (odds ration 1.55; = 0.002). Patients who reported ≥ weekly drinking and 5+ drinking < monthly were significantly more likely to report drinking for each of the first 3 days of recall (compared to 7-day recall).

DISCUSSION

Findings suggest the first 3 days prior to injury may be a less biased multiple-matched control period than longer periods of recall in case-crossover studies.

CONCLUSION

Length of accurate recall may be important to consider in case-crossover analysis and other study designs that rely on patient self-report such as the Timeline Followback. [Cherpitel CJ, Ye Y, Stockwell T, Vallance K, Chow C. Recall bias across 7 days in self-reported alcohol consumption prior to injury among emergency department patients.

Risk of injury from alcohol, marijuana and other drug use among emergency department patients

BACKGROUND

Alcohol is known to be associated with injury, but little is known of combined use of alcohol and other drugs on injury; especially important for marijuana, given increasing legalization of use in the U.S. and Canada.

METHODS

Probability samples of patients 18 and older were interviewed in the emergency department at two sites in Vancouver and one in Victoria, BC (n=1191 injured and 1613 non-injured patients). Case-control and case-crossover analyses were used to analyze risk of injury, based on self-reported alcohol and drug use (marijuana, stimulants, depressants) prior to injury.

RESULTS

Risk of injury was significantly elevated (p<0.001) for alcohol use alone in both case-control (OR=2.72) and case-crossover analyses (OR=2.80) but not for any of the three drug classes. The interaction of alcohol with each class of drug was tested, and marginally significant only for marijuana in case-control analysis (OR=4.42; p=0.088). The interaction of alcohol and two or more drugs was also significant in case-control analysis (OR=03; p=0.035). The volume of alcohol consumed prior to injury was greater for those also using drugs during this time and positively associated with the number of drugs reported.

CONCLUSION

Given the potential issues involved with both case-control and case-crossover study designs, the inconsistent findings suggest caution in reaching any definite conclusion regarding whether there is extra risk related to combined use of alcohol and marijuana, and is an important area for future research.

Alcohol Attributable Fraction for Injury Morbidity from the Dose-Response Relationship of Acute Alcohol Consumption: Emergency Department Data from 18 Countries

AIMS

To calculate the alcohol-attributable fraction (AAF) of injury morbidity by volume of consumption prior to injury based on newly reported relative risk (RR) estimates.

DESIGN

AAF estimates based on the dose-response RR estimates obtained from previous pair-matched case-crossover fractional polynomial analysis of mean volume in volume categories were calculated from the prevalence of drinking prior to injury in each volume category.

SETTING

Thirty-seven emergency departments (EDs) across 18 countries.

PARTICIPANTS

Probability samples of patients, with equal representation of each shift for each day of the week, totaling 14,026 who arrived at the ED within six hours of injury from ED studies conducted between 2001 and 2011.

MEASUREMENTS

AAF was analyzed by gender, age (18-30; >30), cause of injury (traffic, assault, fall, other), and country detrimental drinking pattern (DDP).

FINDINGS

For the EDs analyzed, 16.4% of all injuries were estimated to be attributable to alcohol, and the AAF did not vary by age but was over twice as large for males (20.6%; 19.3-21.8) than for females (8.6%; 7.5-9.7%). While females were at greater risk of injury than males at higher volume levels, lower prevalence of women drinking at higher levels contributed to overall lower AAF for women. Assault-related injuries showed the largest AAF (44.1%; 37.6-42.6). AAF was slightly higher for injuries from falls (14.3%; 12.9-15.7) than motor vehicle crashes (11.1%; 9.3-12.9). AAF was higher in those countries with a DDP of 3 (18.6; 17.5-19.7) and 4 (19.4%; 17.3-21.6) than those with a DDP of 2 (12.0%; 10.5-13.5).

CONCLUSIONS

Alcohol-attributable injuries presenting in emergency departments are higher for males than females, for violence-related injuries compared with other types of injury, and for countries with more detrimental drinking patterns compared with those with less detrimental patterns.

An adaptation of the Yesterday Method to correct for under-reporting of alcohol consumption and estimate compliance with Canadian low-risk drinking guidelines

OBJECTIVES

To estimate compliance with Canada's Low-Risk Alcohol Drinking Guidelines (LRDG) in different groups of drinkers after adjusting for underreporting of alcohol use, and to identify which types of beverage are more likely to be consumed when LRDGs are exceeded.

METHOD

Our sample consisted of 43,242 Canadians aged 15 and over who had responded to the Canadian Alcohol and Drug Use Monitoring Survey, 2008-2010. Consumption in excess of LRDG was estimated for subgroups of drinkers after adjustment for under-reporting of consumption. Responses to Beverage-Specific Yesterday questions were used to make age-, gender- and beverage-specific corrections to under-reporting for data from the last 12 months Quantity-Frequency questions. Statistics Canada data on sales of beer, wine and spirits were also incorporated into the adjusted calculations.

RESULTS

After adjustment for under-reporting, non-compliance with weekly LRDG limits to reduce risk of long-term harm increased from 6.8% to 27.3% among drinkers, and from 42.3% to 68.3% with respect to drinks. Non-compliance with daily LRDG limits to reduce risk of short-term harm increased from 16.7% to 38.6% among drinkers, and from 53.3% to 80.5% with respect to drinks. After adjustment, over 92% of total consumption occurred on risky drinking days among underage Canadians and over 91% of consumption reported by young adults took place during risky drinking occasions. Wine was least likely to be drunk in a risky fashion, spirits were the most likely.

CONCLUSION

When corrections for under-reporting are made, most Canadian alcohol consumption occurs on days when national LRDG are exceeded, especially for underage and young adult drinkers.

Relative risk of injury from acute alcohol consumption: modeling the dose-response relationship in emergency department data from 18 countries

AIMS

To update and extend analysis of the dose-response relationship of injury and drinking by demographic and injury subgroups and country-level drinking pattern, and examine the validity and efficiency of the fractional polynomial approach to modeling this relationship.

DESIGN

Pair-matched case-cross-over analysis of drinking prior to injury, using categorical step-function and fractional polynomial analysis.

SETTING

Thirty-seven emergency departments (EDs) across 18 countries.

PARTICIPANTS

A total of 13 119 injured drinkers arriving at the ED within 6 hours of the event.

MEASUREMENTS

The dose-response relationship was analyzed by gender, age, cause of injury (traffic, violence, fall, other) and country detrimental drinking pattern (DDP).

FINDINGS

Estimated risks were similar between the two analytical methods, with injury risk doubling at one drink [odds ratio (OR) = 2.3-2.7] and peaking at about 30 drinks. Although risk was similar for males and females up to three drinks (OR = 4.6), it appeared to increase more rapidly for females and was significantly higher starting from 20 drinks [female OR = 28.6; confidence interval (CI) = 16.8, 48.9; male OR = 12.8; CI = 10.1, 16.3]. No significant differences were found across age groups. Risk was significantly higher for violence-related injury than for other causes across the volume range. Risk was also higher at all volumes for DDP-3 compared with DDP-2 countries.

CONCLUSIONS

There is an increasing risk relationship between alcohol and injury but risk is not uniform across gender, cause of injury or country drinking pattern. The fractional polynomial approach is a valid and efficient approach for modeling the alcohol injury risk relationship.