Alcohol-related hospital admissions: missed opportunities for follow up? A focus group study about general practitioners' experiences

Hospital admissions and mortality in the 15 years after a first-time hospital contact with an alcohol problem: a prospective cohort study using the entire Danish population

BACKGROUND

Potential benefits of preventing continued alcohol intake in individuals presenting at the hospital with an alcohol problem can be highlighted by studying their excess risk of subsequent morbidity and mortality.

METHODS

All Danish residents with a first-time hospital contact with alcohol problems (intoxication, harmful use or dependence) in 1998-2002 were followed through 2012 using healthcare registries. We compared their cause-specific rates of hospital admission and mortality to the expected rates derived from the general population by calculating standardized incidence rate ratios.

RESULTS

The 26 716 men and 12 169 women who were hospitalized with alcohol problems (median age 44 years) had more than 10 times the rate of subsequent admission to psychiatric departments and three times the rate of subsequent admission to somatic departments compared with the general population. In particular, the hospital admission rates for gastroenterological disease and injuries were high. The cumulative all-cause 10-year mortality risk was 29% [95% confidence interval (CI), 28-30] in men and 26% (95% CI, 24-27) in women with alcohol problems. The ratios of observed to expected death rate for all-cause mortality were 4.0 (95% CI, 3.8-4.1) in men and 4.3 (95% CI, 4.0-4.7) in women and, for causes of death fully attributable to alcohol, 16 (95% CI, 15-17) in men and 33 (95% CI, 29-38) in women.

CONCLUSIONS

Individuals hospitalized with alcohol problems have much higher rates of subsequent alcohol-related hospital admission and mortality than the general population. Increased focus on preventing continued alcohol consumption in these individuals may reduce their subsequent morbidity and mortality.

Mortality, morbidity and follow-up after acute poisoning by substances of abuse: A prospective observational cohort study

AIMS

Despite the excess mortality and morbidity associated with acute poisoning by substances of abuse, follow-up is frequently not organised. We assessed morbidity, including repeated poisoning, and follow-up after acute poisoning by substances of abuse through charting contacts with health services. We also charted short-term mortality.

METHODS

Patients 12 years and older treated for acute poisoning by substances of abuse at a primary care emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We retrieved information from national registers on fatalities, hospital admissions, and contacts at outpatient specialist health services and with general practitioners (GPs), during the 90 days following a poisoning episode.

RESULTS

We included 1731 patients treated for 2343 poisoning episodes. During the 90 days following the poisoning, 31% of the patients were treated at somatic hospitals, 9% admitted to psychiatric hospitals, 37% in treatment at outpatient psychiatric/addiction specialist health services, 55% saw their GP, while 34% had no follow-up. The short-term mortality rate was 2.0%, eight times higher than expected. Increasing age, suicidal intention, opioid poisoning, and severe mental illness were associated with increased risk of death. Increasing age, male gender, opioid poisoning, and severe mental illness were associated with repeated poisoning. Patients with increased risk of repeated poisoning were more likely to be in follow-up at outpatient specialist psychiatric/addiction services and in contact with their GP.

CONCLUSIONS

Follow-up measures seem targeted to those most in need, though one out of three had none. The mortality rate calls for concern.

Hospital contacts with alcohol problems prior to liver cirrhosis or pancreatitis diagnosis

AIM

To evaluate prior hospital contacts with alcohol problems in patients with alcoholic liver cirrhosis and pancreatitis.

METHODS

This was a register-based study of all patients diagnosed with alcoholic liver cirrhosis or pancreatitis during 2008-2012 in Denmark. Hospital contacts with alcohol problems (intoxication, harmful use, or dependence) in the 10-year period preceding the diagnosis of alcoholic liver cirrhosis and pancreatitis were identified.

RESULTS

In the 10 years prior to diagnosis, 40% of the 7719 alcoholic liver cirrhosis patients and 40% of the 1811 alcoholic pancreatitis patients had at least one prior hospital contact with alcohol problems. Every sixth patient (15%-16%) had more than five contacts. A similar pattern of prior hospital contacts was observed for alcoholic liver cirrhosis and pancreatitis. Around 30% were diagnosed with alcohol dependence and 10% with less severe alcohol diagnoses. For the majority, admission to somatic wards was the most common type of hospital care with alcohol problems. Most had their first contact with alcohol problems more than five years prior to diagnosis.

CONCLUSION

There may be opportunities to reach some of the patients who later develop alcoholic liver cirrhosis or pancreatitis with preventive interventions in the hospital setting.

How can professionals carry out recognition towards children of parents with alcohol problems? A qualitative interview study

AIM

The aim of this study was to explore informal adult support experienced by children with parental alcohol problems to understand how professionals can show recognition in a similar way.

METHODS

We conducted a qualitative interview study with retrospective accounts from nine adults growing up with problem-drinking parents. Data were analysed with systematic text condensation. Goffman's concept "frame" offered a lens to study how supportive situations were defined and to understand opportunities and limitations for translation of recognition acts and attitudes to professional contexts.

RESULTS

Analysis demonstrated frames of commonplace interaction where children experienced that adults recognised and responded to their needs. However, the silent support from an adult who recognised the problems without responding was an ambiguous frame. The child sometimes felt betrayed. Concentrating on frames of recognition which could be passed over to professional interactions, we noticed that participants called for a safe harbour, providing a sense of normality. Being with friends and their families, escaping difficulties at home without having to tell, was emphasised as important. Recognition was experienced when an adult with respect and dignity offered an open opportunity to address the problems, without pushing towards further communication.

CONCLUSIONS

Our study indicates some specific lessons to be learnt about recognition for professional service providers from everyday situations. Frames of recognition, communicating availability and normality, and also unconditional confidentiality and safety when sharing problems may also be offered by professionals in public healthcare within their current frames of competency and time.

Alcohol and prescribed psychotropic drug use among patients admitted to a department of old-age psychiatry in Norway

BACKGROUND

Although alcohol and prescribed psychotropic drug use has increased among older people, the usefulness of information provided about these substances in patients' referrals to departments of old-age psychiatry (OAPsy) is unknown.

AIMS

To examine whether patients' self-reported elevated use of alcohol and prescribed psychotropic drugs corresponds with information provided in the referrals to OAPsy departments and to explore the factors associated with elevated self-reported use of these substances.

METHODS

We recorded the information provided in referrals about the elevated use of alcohol and psychotropic drugs in a sample of 206 patients (69 men) from 12 OAPsy departments. The Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT) helped to assess self-reported use. We also collected demographic data, as well as information about cognitive functioning and symptoms of anxiety and depression.

RESULTS

Seventy-three patients (35%) scored above the cut-off for alcohol use for women/men (AUDIT ≥ 3/4) or psychotropic drugs (DUDIT ≥ 6/8), if not both. Twenty patients (10%) reported an elevated use of both alcohol and psychotropic drugs, and the referrals for eight (40%) and ten (50%) of them, respectively, included information about this use. There was a significant association between self-reported use of alcohol above the cut-off and information about elevated use in the referrals. However, no such association was found between information in the referrals and self-reported use of prescribed psychotropic drugs. Elevated alcohol use was associated with more years of education, while elevated use of psychotropic drugs was associated with younger age and severe symptoms of anxiety and depression.

CONCLUSION

The information reported in referrals about the elevated use of alcohol and psychotropic drugs demonstrated a trend in associations with self-reported use. However, the risk factors for elevated use of alcohol and psychotropic drugs in the elderly need to be examined further.

Follow-up after acute poisoning by substances of abuse: a prospective observational cohort study

Objective: To chart follow-up of patients after acute poisoning by substances of abuse, register whether patients referred to specialist health services attended, and whether patients contacted a general practitioner (GP) after the poisoning episode.Design: Observational cohort study.Setting: A primary care emergency outpatient clinic in Oslo, Norway.Subjects: Patients ≥12 years treated for acute poisoning by substances of abuse were included consecutively from October 2011 to September 2012.Main outcome measures: Follow-up initiated at discharge, proportion of cases in which referred patients attended within three months, and proportion of cases in which the patient consulted a GP the first month following discharge.Results: There were 2343 episodes of acute poisoning by substances of abuse. In 391 (17%) cases the patient was hospitalised, including 49 (2%) in psychiatric wards. In 235 (10%) cases the patient was referred to specialist health services, in 91 (4%) advised to see their GP, in 82 (3%) to contact social services, in 74 (3%) allotted place in a homeless shelter, and in 93 (4%) other follow-up was initiated. In 1096 (47%) cases, the patient was discharged without follow-up, and in a further 324 (14%), the patient self-discharged. When referred to specialist health services, in 200/235 (85%) cases the patient attended within three months. Among all discharges, in 527/1952 (27%) cases the patient consulted a GP within one month. When advised to see their GP, in 45/91 (49%) cases the patient did.Conclusion: Attendance was high for follow-up initiated after acute poisoning by substances of abuse.KEY POINTSDespite poor long-term prognosis, patients treated for acute poisoning by substances of abuse are frequently not referred to follow-up.Nearly all patients referred to specialist health services attended, indicating the acute poisoning as an opportune moment for intervention.Advising patients to contact their GP was significantly associated with patients consulting the GP, but few patients were so advised.One out of three patients was discharged without follow-up, and there seems to be an unused potential for GP involvement.

Encounters with service professionals experienced by children from families with alcohol problems: A qualitative interview study

AIM

The aim of this study was to explore encounters with service professionals experienced in childhood and adolescence by children who grew up with parental alcohol abuse. We focused on their accounts from situations indicating children's struggles or parental drinking problems.

METHODS

Semi-structured qualitative interview study was conducted with retrospective data from nine adults. Systematic text condensation was used to understand childhood experiences from encounters with professionals.

RESULTS

Participants believed that professionals rarely recognised their parents' drinking problems. The children felt abandoned by professionals who must have noticed their struggles. Participants experienced that their appearance or behaviour was ignored and that they were not invited to talk. Professionals taking part in individual family members' problems seemed to avoid subsequent involvement in underlying parental drinking. Even when problems were obvious, participants felt that professionals took no further action. Medical and social problems were managed within very confined perspectives.

CONCLUSIONS

Specific commitment to confront cultural taboos is needed to attend to children's unmet needs. Recognising each young person's situation implies not only noticing that something is wrong, but also taking action. Children's experiences of fragmented and confined approaches towards parental drinking problems may be counteracted by better collaboration between teachers, school nurses and GPs.