Care for hospitalized patients with unhealthy alcohol use: a narrative review

Racial and ethnic disparities in alcohol-associated liver disease in the United States: A systematic review and meta-analysis

BACKGROUND

Alcohol-associated liver disease (ALD), encompassing alcohol-associated hepatitis and alcohol-associated cirrhosis, is rising in the United States. Racial and ethnic disparities are evident within ALD; however, the precise nature of these disparities is poorly defined.

METHODS

We conducted a search of the PubMed/MEDLINE and EMBASE databases to identify studies published from inception through September 2023 that reported ALD incidence, prevalence, and mortality within the United States, stratified by race and ethnicity. We calculated pooled prevalence and incidence by race and ethnicity, including risk ratios and ORs for ALD pooled prevalence and alcohol-associated hepatitis/alcohol-associated cirrhosis pooled proportions, and OR for ALD mortality using the DerSimonian and Laird method for random-effect models.

RESULTS

We identified 25 relevant studies (16 for quantitative meta-analysis), comprising 76,867,544 patients. ALD prevalence was highest in Hispanic (4.5%), followed by White (3.1%) and Black (1.4%) individuals. Pooled risk ratios of ALD prevalence were 1.64 (95% CI: 1.12-2.39) for Hispanic and 0.59 (95% CI: 0.35-0.87) for Black compared to White individuals. Mortality among those with ALD did not significantly differ between White and Hispanic (OR: 1.54, 95% CI: 0.9-2.5; I2=0%), Black (OR: 1.2, 95% CI: 0.8-1.6; I2=0%), or Native American (OR: 2.41, 95% CI: 0.9-2.9) individuals, while there was a significant difference between White and Asian (OR: 0.1; 95% CI: 0.03-0.5) individuals. Most data were cross-sectional and assessed to be of poor or fair quality.

CONCLUSIONS

Differences were observed in ALD epidemiology, including higher prevalence among Hispanic and lower prevalence among Black individuals, although there were smaller differences in ALD mortality. Differences in ALD prevalence and prognosis remain poorly defined based on existing data, highlighting a need for higher-quality epidemiological studies in this area.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.

Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care

OBJECTIVES

We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention.

METHODS

We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models.

FINDINGS

Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up.

CONCLUSIONS

Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.

Arrhythmias in patients with in-hospital alcohol withdrawal are associated with increased mortality: Insights from 1.5 million hospitalizations for alcohol withdrawal syndrome

Background

Atrial arrhythmias are commonly noted in patients with alcohol withdrawal syndrome (AWS), requiring inpatient admission.

Objective

The burden of arrhythmias and the association with in-hospital outcomes are incompletely defined in patients hospitalized with AWS.

Methods

The nationwide inpatient sample database was accessed from September 2015 to December 2018 to identify hospitalizations for AWS. We studied a cohort of patients with arrhythmias noted during hospitalization using the appropriate International Classification of Diseases, Tenth Revision billing codes. We compared patient characteristics, outcomes, and hospitalization costs between alcohol withdrawal hospitalizations with and without documented arrhythmias. Propensity score matching (PSM) and multivariate regression were performed to control confounders and develop odds ratios (OR), respectively.

Results

Among 1,511,155 hospitalization with AWS, 146,825 (9.72%) had concurrent arrhythmias. After PSM, we identified 135,540 cases in each group. Hospitalizations with AWS and concurrent arrhythmias had higher in-hospital mortality (4.19% vs 1.95%, OR 1.76, confidence interval [CI] 1.67–1.85, P < .0001). The most common arrhythmia was atrial fibrillation (66.7%). Arrhythmias in AWS were also associated with poorer in-hospital outcomes, including a higher risk of acute heart failure (8.40% vs 4.58%, OR 1.97, CI 1.90–2.05, P < .0001), acute kidney injury (21.32% vs 15.27%, OR 1.39, CI 1.36–1.43, P < .0001), and acute respiratory failure (9.19% vs 5.49%, OR 1.70, CI 1.64–1.76, P < .0001) requiring intubation. The length of hospital stay (6 days vs 4 days P < .0001) and cost of hospital care ($12,615 [$6683–$27,330] vs $7860 [$4482–$15,868], P < .0001) were higher in AWS with arrhythmias.

Conclusion

Arrhythmia in AWS is associated with higher in-hospital mortality and poorer in-hospital outcomes.

Screening for Unhealthy Alcohol and Drug Use in General Medicine Settings

Unhealthy alcohol and drug use are among the top 10 causes of preventable death in the United States, but they are infrequently identified and addressed in medical settings. Guidelines recommend screening adult primary care patients for alcohol and drug use, and routine screening should be a component of high-quality clinical care. Brief, validated screening tools accurately detect unhealthy alcohol and drug use, and their thoughtful implementation can facilitate adoption and optimize the quality of screening results. Recommendations for implementation include patient self-administered screening tools, integration with electronic health records, and screening during routine primary care visits.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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.

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

Alcohol Withdrawal Syndrome: Improving Recognition and Treatment in the Emergency Department

Alcoholism continues to be a persistent health problem in the United States, accounting for up to 62% of emergency department (ED) visits. This quality improvement (QI) project examined whether identifying the benefit for early use of Alcohol Use Disorders Identification Test (AUDIT C) and Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIW-ar) in the ED would avoid escalation of care and offset poor outcomes of alcohol withdrawal syndrome (AWS). A preimplementation chart review (N = 99) showed an average of 12%-15% of patients requiring escalation of care at the project site. The QI project utilized a single-group, pre-/posttest design. The setting was a Southwest Veterans Affair tertiary care referral center. Thirty-five ED staff members were surveyed for baseline knowledge and attended education sessions, led by an advanced practice nurse, on the use of AUDIT-C and CIWA-ar. Posteducation, patients admitted to the hospital were screened with AUDIT-C and treated with CIWA-ar. Postimplementation, charts were reviewed for admitted patients (N = 42) on the use of AUDIT-C, CIWA-ar, length of stay (LOS), and area patient treated. Although the test scores after didactic education were statistically significant (p ≤ 0.050), there was no significant difference in the use of AUDIT-C or CIWA-ar in the ED, nor a significant decrease in LOS for those patients with CIWA-ar ordered. However, the potential for clinical benefit could not be disavowed. Barriers to implementation included survey fatigue, inability to embed AUDIT-C in the electronic medical record, inconsistency in completing AUDIT-C, interrater reliability, and patient fear of stigmatization. Advanced practice nurses provide an integral role to augment early identification and treatment of AWS in the ED.

A WHO-HPH operational program versus usual routines for implementing clinical health promotion: an RCT in health promoting hospitals (HPH)

BACKGROUND

Implementation of clinical health promotion (CHP) aiming at better health gain is slow despite its effect. CHP focuses on potentially modifiable lifestyle risks such as smoking, alcohol, diet, and physical inactivity. An operational program was created to improve implementation. It included patients, staff, and the organization, and it combined existing standards, indicators, documentation models, a performance recognition process, and a fast-track implementation model. The aim of this study was to evaluate if the operational program improved implementation of CHP in clinical hospital departments, as measured by health status of patients and staff, frequency of CHP service delivery, and standards compliance.

METHODS

Forty-eight hospital departments were recruited via open call and stratified by country. Departments were assigned to the operational program (intervention) or usual routine (control group). Data for analyses included 36 of these departments and their 5285 patients (median 147 per department; range 29-201), 2529 staff members (70; 10-393), 1750 medical records (50; 50-50), and standards compliance assessments. Follow-up was measured after 1 year. The outcomes were health status, service delivery, and standards compliance.

RESULTS

No health differences between groups were found, but the intervention group had higher identification of lifestyle risk (81% versus 60%, p < 0.01), related information/short intervention and intensive intervention (54% versus 39%, p < 0.01 and 43% versus 25%, p < 0.01, respectively), and standards compliance (95% versus 80%, p = 0.02).

CONCLUSIONS

The operational program improved implementation by way of lifestyle risk identification, CHP service delivery, and standards compliance. The unknown health effects, the bias, and the limitations should be considered in implementation efforts and further studies.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT01563575. Registered 27 March 2012. https://clinicaltrials.gov/ct2/show/NCT01563575.

An Initial Assessment of the Utility of Validated Alcohol and Drug Screening Tools in Predicting 30-Day Readmission to Adult General Medicine Wards

Previous studies have identified drug and alcohol use as risk factors for readmission using claims data, but not by using substance use screening scores. This preliminary study tested the hypothesis that prevalence of 30-day readmission would be higher among patients screening positive on the 10-item Alcohol Use Disorders Identification Test (AUDIT-10) or the 10-item Drug Abuse Screening Test (DAST-10) tools at intake than among the general patient population. Social workers screened 4708 adult inpatients using prescreening questions followed by the AUDIT-10 and/or DAST-10. Patients with positive screens were followed for readmissions within 30 days of discharge. A positive screening score on the AUDIT-10 or DAST-10 instrument at intake was associated with higher risk of readmission to the general medicine wards within 30 days; this relationship appears complex and subject to mediation. Post hoc chart review found that the majority of readmissions among patients with positive screens were not immediately attributable to substance use. Further study is needed to verify these preliminary findings.

Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems

Substance use disorders are highly prevalent and are a large driver of costly inpatient medical care; however, historically the substance use disorder has gone unaddressed during an inpatient stay. Inpatient addiction consult services are an important intervention to use the reachable moment of hospitalization to engage patients and initiate addiction treatment. Addiction consultation involves taking an addiction-specific history, motivational interviewing, withdrawal symptom management, and initiation of long-term pharmacotherapy. Addiction consult services have the potential to decrease readmissions and utilization costs for medical systems and improve substance-related outcomes for patients.

Screening, Diagnosis, and Management of Patients With Alcohol Use Disorders at Bwindi Community Hospital, Uganda

Introduction: The harmful use of alcohol is a growing global public health concern, with Sub-Saharan Africa at particular risk. A large proportion of adults in Uganda consume alcohol and the country has a high prevalence of alcohol use disorders (AUD), almost double that for the African region as a whole. Bwindi Community Hospital, in rural western Uganda, recently introduced a program of screening, diagnosis and management of AUD and we assessed how this worked.

Methods: This was a cross-sectional study in three departments (out-patients, adult in-patients and sexual & reproductive health) of Bwindi Community Hospital assessing numbers of patients screened, diagnosed and treated with AUD between January 2014 and June 2017. Data sources included the hospital electronic data base and departmental case files. Frequencies and proportions are reported and odds ratios used to compare specific factors associated with medical interventions.

Results: Altogether, 82,819 patients attended or were admitted to hospital, of whom 8,627 (10.4%) were screened and 273 (3.2%) diagnosed with AUD. The adult in-patient department recorded the largest number with AUD (n = 206) as well as a consistent increase in numbers in the last 18 months of the study. Of those with AUD, there were 230 (84%) males, 130 (48%) aged 36–60 years, and 131 (48%) with medical non-alcohol related diagnostic categories. Medical/supportive interventions included guidance and counselling to 168 (62%), community social support to 90 (33%), mental health service referrals for 75 (27%), detoxification for 60 (22%) and referral to Alcoholics Anonymous for 41 (15%). There were 36 (15%) patients who received no medical/supportive interventions, with significantly higher proportions in patients with surgical alcohol-related disease and pregnancy-related conditions (P < 0.05).

Conclusion: Bwindi Community Hospital has implemented a program for AUD in three departments, with most individuals screened and managed in the adult in-patient department. While a variety of interventions were given to those with AUD, 15% received no intervention and this deficiency must be addressed. Program performance could improve through better screening processes, ensuring that 100% of those with AUD receive a medical/supportive intervention and raising public awareness.

Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers

Hospitalized patients have high rates of unhealthy substance use, which has important impacts on health both during and after hospitalization, but is infrequently identified in the absence of screening. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs, and was previously validated in primary care patients. This study assessed the diagnostic accuracy of the SUBS in comparison to longer screening instruments to identify unhealthy and high-risk alcohol and drug use in hospitalized current smokers. Participants were 439 patients, aged 18 and older, who were admitted to either two urban safety-net hospitals in New York City and enrolled in a smoking cessation trial. We measured the performance of the SUBS for identifying illicit drug and non-medical use of prescription drugs in comparison to a modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its performance for identifying excessive alcohol use in comparison to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). At the standard cutoff (response other than 'never' indicates a positive screen), the SUBS had a sensitivity of 98% (95% CI 95-100%) and specificity of 61% (95% CI 55-67%) for unhealthy alcohol use, a sensitivity of 85% (95% CI 80-90%) and specificity of 75% (95% CI 78-87%) for illicit drug use, and a sensitivity of 73% (95% CI 61-83%) and specificity of 83% (95% CI 78-87%) for prescription drug non-medical use. For identifying high-risk use, a higher cutoff (response of '3 or more days' of use indicates a positive screen), the SUBS retained high sensitivity (77-90%), and specificity was 62-88%. The SUBS can be considered as an alternative to longer screening instruments, which may fit more easily into busy inpatient settings. Further study is needed to evaluate its validity using gold standard measures in hospitalized populations.

Acute pain management in patients with drug dependence syndrome

Managing patients with dependence requires knowledge of pharmacology; an understanding of the diagnosis of dependence and recognition of withdrawal; skills in communication and collaborative working; and a nonjudgmental, empathic attitude.

Effectiveness of a psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour

AIMS AND OBJECTIVES

To evaluate the effectiveness of a psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour.

BACKGROUND

The prevalence of alcohol abuse has increased over the past 10 years, and the age of initial alcohol use has decreased gradually in Taiwan. Alcohol dependence is one of the leading causes of disability and has led to increases in the incidence of crime and violence, with alcohol abuse identified as a problem in society.

DESIGN

A quasi-experimental design with nonequivalent pre/post-testing was used.

METHODS

Alcohol-dependent inpatients undergoing alcohol treatment were selected from the psychiatric ward of a teaching hospital in northern Taiwan. The effectiveness of the psychoeducational programme in enhancing motivation to change alcohol-addictive behaviour was evaluated with the Severity of Alcohol Dependence Data Questionnaire and the Stages of Change Readiness and Treatment Eagerness Scale. In total, 24 and 51 participants were recruited to the experimental and control groups, respectively, for the baseline survey, and 14 and 17 were in the final survey, respectively.

RESULTS

After adjustment for baseline survey scores, the experimental group showed significantly greater increases in recognition and ambivalence relative to those observed in the control group.

CONCLUSIONS

The results not only showed that the psychoeducational programme was effective in reinforcing addicted inpatients' motivation for changing their drinking behaviour but also provided clinical nurses with practical methods via which to enhance patient motivation.

RELEVANCE TO CLINICAL PRACTICE

The psychoeducational programme could assist clinical nurses in helping alcohol-dependent patients to recognise the nature of their problematic drinking; increase participants' ambivalence towards their drinking behaviour, leading to the contemplation of change; and strengthen the possibility that they will change their addictive behaviour.