Alcoholics in acute medical settings have increased risk for other drug, mood, and personality disorders

National Prevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018

BACKGROUND

Acute healthcare utilization attributed to alcohol use disorders (AUD) and other substance use disorders (SUD) is rising.

OBJECTIVE

To describe the prevalence and characteristics of emergency department (ED) visits and hospitalizations made by adults with AUD or SUD.

DESIGN, SETTING, AND PARTICIPANTS

Observational study with retrospective analysis of the National Hospital Ambulatory Medical Care Survey (2014 to 2018), a nationally representative survey of acute care visits with information on the presence of AUD or SUD abstracted from the medical chart.

MAIN MEASURES

Outcome measured as the presence of AUD or SUD.

KEY RESULTS

From 2014 to 2018, the annual average prevalence of AUD or SUD was 9.4% of ED visits (9.3 million visits) and 11.9% hospitalizations (1.4 million hospitalizations). Both estimates increased over time (30% and 57% relative increase for ED visits and hospitalizations, respectively, from 2014 to 2018). ED visits and hospitalizations from individuals with AUD or SUD, compared to individuals with neither AUD nor SUD, had higher percentages of Medicaid insurance (ED visits: AUD: 33.1%, SUD: 35.0%, neither: 24.4%; hospitalizations: AUD: 30.7%, SUD: 36.3%, neither: 14.8%); homelessness (ED visits: AUD: 6.2%, SUD 4.4%, neither 0.4%; hospitalizations: AUD: 5.9%, SUD 7.3%, neither: 0.4%); coexisting depression (ED visits: AUD: 26.3%, SUD 24.7%, neither 10.5%; hospitalizations: AUD: 33.5%, SUD 35.3%, neither: 13.9%); and injury/trauma (ED visits: AUD: 51.3%, SUD 36.3%, neither: 26.4%; hospitalizations: AUD: 31.8%, SUD: 23.8%, neither: 15.0%).

CONCLUSIONS

In this nationally representative study, 1 in 11 ED visits and 1 in 9 hospitalizations were made by adults with AUD or SUD, and both increased over time. These estimates are higher or similar than previous national estimates using claims data. This highlights the importance of identifying opportunities to address AUD and SUD in acute care settings in tandem with other medical concerns, particularly among visits presenting with injury, trauma, or coexisting depression.

Exploring the prevalence of personality disorder and the feasibility of using the SAPAS as a screening tool for personality disorder in an emergency department in India

BACKGROUND

Personality disorders (PD) lead to frequent emergency department (ED) visits. Existing studies have evaluated high-risk ED populations in Western settings. PD screening tools, such as the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), have thus far only been validated in Western populations.

AIMS

This study aimed to establish the screened prevalence of PD, and to evaluate the performance of the SAPAS as a screening tool within an ED setting in India.

METHODS

The study took place in the ED of a private multi-speciality hospital in Kolkata, India. All attendees were approached during two days per week over three months, except those who were medically unfit to participate. The SAPAS and the International Personality Disorder Examination (IPDE) were translated into Bengali and then used as screening tools for PD and as the reference standard for PD diagnosis.

RESULTS

Out of 120 ED attendees approached, 97 participated (48 men and 49 women), of whom 24% met the criteria for a diagnosis of PD. A cut-off score of 4 on the SAPAS provided the best trade-off between sensitivity and specificity for detecting PD.

CONCLUSION

The prevalence of PD was similar to Western samples, and the SAPAS showed promise for use in a non-Western setting.

Predictors of Five-Year Readmission to an Inpatient Service among Patients with Alcohol Use Disorders: Report from a Low-Middle Income Country

BACKGROUND

Alcohol use disorder (AUD) is a relapsing-remitting disease that accounted for a sizable proportion of all-cause adult inpatient stays.

OBJECTIVES

To determine the predictors of any and multiple readmissions to inpatient care for AUD within 5 years of the index admission.

METHODS

This retrospective, register-based cohort study assessed consecutive patients with AUD admitted to a publicly-funded inpatient service between January 2007 and December 2014. Binary logistic regression was used to determine independent predictors for readmissions based on relevant demographic, clinical, and treatment variables that showed significant differences (p < 0.05) on univariate analysis.

RESULTS

Among 938 patients (age 35.9 ± 10.3 years; duration of alcohol use 159.6 ± 104.5 months; dual diagnosis 19%; comorbidity of substance use disorder 49.3%; medical disorder 34.8%, 299 (31.9%) and 115 (12.3%) had any and multiple readmissions, respectively. Comorbid "severe mental illness" (Odds ratio [OR] 1.99, 95% confidence interval [CI] 1.11-3.57) and urban residence (OR 1.58, 95% CI 1.13-2.18) increased the odds of any readmission; "Improved" status at discharge (OR 0.51, 95% CI 0.35-0.72) during index hospitalization reduced odds of readmission. Additionally, any medical or psychiatric comorbidities increased (OR 2.23, 95% CI 1.26-3.97), and comorbid substance use disorder decreased (OR 0.41, 95% CI 0.19-0.89) risk of multiple readmissions.

CONCLUSIONS

Clinicians could identify patients at-risk for any and multiple readmissions during the index hospitalization. A policy aimed at reducing the risk of rehospitalization, healthcare cost, and stigma should pay attention to the predictors of readmission. Such policy should further benefit resource-limited settings.

A Systematic Review and Meta-Analysis of Personality Disorder Prevalence and Patient Outcomes in Emergency Departments

The objectives of this study were to perform a systematic review and meta-analysis of studies reporting prevalence of personality disorders (PDs) in emergency departments (EDs) and evaluate the effect of comorbid PDs on clinical outcomes. A systematic search of five databases along with manual searching and expert consultation was performed. A quality appraisal was conducted. A total of 29 articles were included. Prevalence of PDs in ED attendees varied depending on presenting complaint, Q(4) = 577.5, p < .01, with meta-analytic prevalence rates of suicide and self-harm at 35% and 22%, respectively. The assessment method had a significant effect on prevalence rates, Q(3) = 17.36, p < .01. Comorbid PD was a risk factor for repeating presenting complaint, subsequent ED return, and hospitalization. Better identification of PDs using screening tools in EDs could improve patient management and clinical outcomes. Future research should focus on PD prevalence in unselected ED populations using validated diagnostic interviews.

Predictors of Alcohol Withdrawal Readmissions

Aims

Hospital readmissions serve as a major benchmark for the quality of care and alcohol withdrawal (AW) may lead to multiple hospitalizations and readmissions. We sought to evaluate readmission rates and predictors of having AW-related readmissions in a nationally representative sample.

Short summary

In a nationally representative sample, AW readmission within 30 days and multiple readmissions during the year were high and were particularly predicted by discharge against medical advice (AMA), comorbid psychosis, comorbid depression, poor socioeconomic status, comorbid drug abuse and alcohol-related medical disease.

Methods

Subjects from the 2013 Nationwide Readmissions Database (NRD) with AW as a primary or secondary diagnosis. Cross-sectional and retrospective analyses were performed using regression methods appropriate for the NRD complex sampling design. The outcome measures were AW-related readmission, 30-day readmission and multiple readmissions.

Results

In 2013, 393,118 discharges involved ICD-9 coding for AW and 41.5% of these included AW as the primary discharge diagnosis. The rate of AW-related readmission in 2013, as estimated from first-quarter index events, was 58.8% (95% confidence interval (CI) 57.5-60.1), with an average of 1.8 readmissions (95% CI 1.7-1.9). The 30-day readmission rate, estimated from January-November index events, was 19.7% (95% CI 19.0-20.4). The strongest independent predictors of yearly, 30-day and multiple readmission were discharged AMA and comorbid psychotic disorder.

Conclusion

AW readmission within 30 days and multiple readmissions during the year were common and were particularly predicted by AMA discharge and comorbid psychotic disorder. While these and other factors can help identify high-risk patients, further study to determine causal mechanisms may aid efforts to improve both the outcomes and costs associated with acute AW treatment.

Referral to treatment for hospitalized medical patients with an alcohol use disorder: A proof-of-concept brief intervention study

Substance misuse intervention in healthcare settings is becoming a US national priority, especially in the dissemination and implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Yet, the referral to treatment component of SBIRT is understudied. This proof-of-concept investigation tested an enhanced coordinated hospital-community two session brief intervention designed to facilitate the referral to treatment of hospitalized medical patients with an alcohol use disorder. Participants (N = 9) attended the second session of the brief intervention held in the community in most cases (56%), while one out of three (33%) received some level of post-brief intervention alcohol and/or other drug treatment. Alcohol use and alcohol-related problems also statistically improved. Based, in part, on the results plus the widespread dissemination of SBIRT, next step investigations of brief interventions to help bridge hospitalized medical patients in need to community substance abuse treatment are warranted.

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

There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.

Comorbidity and temporal ordering of alcohol use disorders and other psychiatric disorders: results from a Danish register-based study

BACKGROUND

Understanding the comorbidity of alcohol use disorders (AUD) and other psychiatric disorders may have important implications for treatment and preventive interventions. However, information on the epidemiology of this comorbidity is lacking. The objective of this study was to present results on lifetime psychiatric comorbidity of AUD in a large Danish community population.

METHODS

A prospective cohort study was used, comprising 3 updated measures of sets of lifestyle covariates and 26 years of follow-up data on 18,146 individuals from the Copenhagen City Heart Study, Denmark. The study population was linked to national Danish hospital registers and a greater Copenhagen alcohol unit treatment register to detect registrations with AUD and other psychiatric disorders.

RESULTS

Of the individuals invited to the study, 7.6% were registered with AUD, and among these, 50.3% had a lifetime comorbid psychiatric disorder. Personality disorders were the most common comorbid disorders (24%) together with mood disorders (16.8%) and drug abuse (16.6%). The risk of developing a psychiatric disorder in individuals who were already registered with AUD was larger than the risk of developing AUD in individuals who were already registered with another psychiatric disorder; these differences in risk were especially noticeable for anxiety disorders, personality disorders, and drug abuse.

CONCLUSIONS

AUD is frequently comorbid with other psychiatric disorders, and it is likely that AUD is both an etiologic factor in other mental disorders and a consequence of mental disease. However, in interpreting these complex and perhaps circular causal links, it is important to consider that AUD is registered before a comorbid psychiatric diagnosis more often than the reverse temporal order.

Personality problems are considerably associated with somatic morbidity and health care utilisation

PURPOSE

To explore the associations between the presence of personality problems and somatic morbidity and health care utilisation.

METHODS

The Iowa Personality Disorder Screen was administered in order to identify persons with personality problems in a Norwegian population survey (the Oslo Health Study - HUBRO). Cases consisted of 369 individuals, 30, 40 and 45 years of age with personality problems matched on age and gender with five controls each. Data on somatic morbidity and health care utilisation were collected by questionnaires.

RESULTS

The cases more frequently reported persistent muscular pain, asthma, fibromyalgia and alcohol problems than the controls. They also more often used nonprescribed analgesics and antidepressants. The cases more frequently had consulted a general practitioner (GP) in the last 12 months, less frequently got referral to somatic specialist care and were less satisfied with their last visit to a GP.

CONCLUSION

In this population based study, personality problems in young adults based on DSM-IV personality disorder criteria were associated with increased occurrence of somatic morbidity and primary health care utilisation. The relevance for GP to take personality problems into account during consultations is underlined and a method for doing so is suggested.

Personality Disorders in Alcohol-Dependent Individuals: Relationship with Alcohol Dependence Severity

The rate of axis II disorders in alcohol-dependent individuals is suggested to be high. The aim of this investigation is to assess the rate of DSM-IV axis II diagnoses in alcohol-dependent inpatients and their correlation with clinical characteristics of alcohol dependence (AD). 1,079 inpatients with DSM-IV AD from three inpatient addiction treatment centers ('qualified detoxification', open psychiatric university hospital wards) were included. Characteristics of AD were obtained using standardized structured interviews. Diagnoses of DSM-IV personality disorders (PDs) were generated with SCID-II-PQ and SCID-II interviews. Alcoholism severity was measured using the number of DSM-IV criteria endorsed and age at first drinking. Approximately 60% of the sample had at least one PD. However, rates of Axis II disorders differed significantly across centers. The most frequent PDs were obsessive-compulsive, borderline, narcissistic and paranoid PD. Diagnosis of any PD was related to a more severe clinical profile of AD. Regression analyses revealed that obsessive-compulsive PD was related to the number of DSM-IV criteria endorsed while antisocial PD was related to early age at first drinking. The majority of alcohol-dependent individuals had one or more comorbid axis II disorders. Univariate and multivariate analyses indicate that different PDs are related to age at first dinking and alcoholism severity.