Alcohol-Related Emergency Department Visits in the United States

1
Alcohol-Related Emergency Department Visits in
the United States

• Center to Prevent Alcohol Problems
• Boston University School of Public Health
• Ralph Hingson, ScD
• Michael Winter, MPH
• American Public Health Association
• Annual Meeting
• Washington, DC
• November 10, 2004

2
GentilelloBrief Motivational Alcohol
Intervention in a Trauma Center Annals of
Surgery, 1999

• 46 of injured trauma center patients age 18 and
  older screened positive for alcohol problems.
• Half (N336) randomly allocated to receive 30
  minute brief intervention to reduce risky
  drinking and offered links to alcohol treatment

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GentilelloBrief Motivational Alcohol
Intervention in a Trauma Center Annals of
Surgery, 1999

• Reduced alcohol consumption by an average 21
  drinks per week at 1 year follow up
• 47 reduction in new injuries requiring treatment
  in ED
• 48 reduction in hospital admissions for injury
  over 3 years
• 23 fewer drunk driving arrests

4
MontiBrief Intervention For Harm Reduction with
Alcohol Positive Older Adolescents in a Hospital
Emergency Department, J. Consulting and
Clinical Psychology

• 94 ED patients, mean age 18.4, injured after
  drinking
• Half randomly allocated to a 35-40 minute
  motivational intervention to reduce drinking and
  related risky behaviors such as DWI
• 89 followed at 6 months, no difference between
  groups
• Follow up rate
• Age
• gender

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Monti et al., 1999Results at 6 months
MI SC
Drinking and driving 62 85 SC had 4 times more drinking and driving occasions
Moving Violations 3 23
Alcohol-related injury 21 50 SC had 4 times more alcohol-related injury
Other alcohol-related problems M.88 1.45
Comparable drinking declines in both groups
6
Longabaugh (2001)
539 Injured Emergency Department Patients
R
Brief Intervention (BI)
Standard Care (SC)
Brief Intervention and Booster (BIB)
J. Studies on Alcohol. 62 806-816
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Longabaugh 2001Brief Intervention

• 40-60 minutes (based on Motivational Enhancement
  Intervention in Project MATCH)
• Patients queried about the connection between
  drinking and their injury
• Patients drinking compared to National Sample
• Financial cost of drinkers and negative
  consequences assessed
• Work plan to reduce drinking developed (if goal
  of patient)

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Longabaugh 2001

• Booster Session
• 7 days after Brief Intervention
• Discussed post discharge drinking and experiences

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Results Longabaugh 2001

• Standard care (SC) 6 decline in alcohol related
  injuries
• BIB 36 decline in alcohol related injuries than
  standard care
• No differences BI and SC
• Negative drinking consequences
• Number of heavy drinking days
• Injuries
• Number of heavy drinking days similar in all 3
  groups at follow up

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Recent studies showing positive benefits of
screening and brief intervention

• Crawford MJ, Patton R, Touquet R, Drummond C,
  Byford S, Barrett B, Reece B, Brown A, Henry JA.
  Screening and referral for brief intervention of
  alcohol-misusing patients in an emergency
  department a pragmatic randomised controlled
  trial. Lancet. 2004 Oct 9364(9442)1334-9.
• Spirito A, Monti PM, Barnett NP, Colby SM,
  Sindelar H, Rohsenow DJ, Lewander W, Myers M. A
  randomized clinical trial of a brief motivational
  intervention for alcohol-positive adolescents
  treated in an emergency department. J Pediatr.
  2004 Sep145(3)396-402.
• Dill PL, Wells-Parker E, Soderstrom CA. The
  emergency care setting for screening and
  intervention for alcohol use problems among
  injured and high-risk drivers a review. Traffic
  Inj. Prev. 2004 Sep5(3)278-91. Review.
• Whitlock EP, Polen MR, Green CA, Orleans T, Klein
  J U.S. Preventive Services Task Force.
  Behavioral counseling interventions in primary
  care to reduce risky/harmful alcohol use by
  adults a summary of the evidence for the U.S.
  Preventive Services Task Force. Ann Intern Med.
  2004 Apr 6140(7)557- 68. Review

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Purpose

• To determine how many emergency department visits
  annually in the U.S. are
• Alcohol Related
• Alcohol related injuries
• To determine
• What proportion of persons admitted to emergency
  departments for alcohol related problems are
  referred to additional alcohol treatment
• Whether likelihood of referral varies by injury
  severity

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Methods

• National Hospital Ambulatory Care Survey January
  1-December 31, 2001
• Hospitals in the 2000 SMC Hospital Data Base (50
  added in 2001 new or changed eligibility)
• 4 stage Probability Sampling. Primary Sampling
  Units (PSUs) 479 Hospitals within PSUs. 395 EDs
  within Hospitals and/or clinics within obligated
  departments.
• 90 ED participation
• 85 Visit response rate
• N34, 546 completed patient record forms

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Results

• 2001 107.5 million ED visits
• 2.5 million alcohol related ED visits (2)
• 39.4 million injury/poisoning visits
• 5 alcohol related N 2 million

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Results

• 94,589,648 first time visits
• 2,162,807 alcohol related (2)
• 35,358,989 Injury related
• 5 alcohol related N 1,860,814

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Results 1st Time Admissions

• 86 treated and discharged
• 2 alcohol related N 1,712,598
• lt1 held for 23 hours observation (544,541)
• 3 alcohol related N 18,968
• 11 admitted to hospital (10,848,702)
• 3 alcohol related N 362,280
• 1 admitted to ICU/CCU (973,733)
• 6 alcohol related N 53,984
• 0.2 died (228,689)
• 6 alcohol related N 14,802

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Results

• Among ED alcohol related patients not observed or
  admitted to the Hospital ICU/CCU, 14.9 were
  referred to additional alcohol treatment
• Among ED alcohol related injury patients
  observed, only 3 were referred to alcohol or
  drug treatment
• Among ED alcohol related injury visits
  hospitalized, only 2 (N6,297) were referred for
  additional alcohol treatment
• Among ED alcohol related injury visits admitted
  to ICU/CCU none were referred to additional
  alcohol treatment

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Conclusion

• The more serious the injury the greater the
  percentage that were alcohol related
• The less serious the alcohol-related injury, the
  greater the likelihood the patient would be
  referred for alcohol treatment

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Discussion

• McDonald, Wang, Camarge. Archives of Internal
  Medicine. 1643 531-537, 2004
• Examined 2000 National Hospital Ambulatory Care
  Survey
• Assigned Alcohol Attributable Fractions to 37
  diagnoses at admission (AAF)
• AAF was calculated based on extensive review of
  clinical case series, injury surveillance studies
  available epidemiologic studies
• AAF represents the proportion disease cases,
  deaths or injuries causally linked to alcohol
  misuse
• Each of the 37 diagnosis multiplied by the number
  of ED visits for each diagnosis

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3 Groups of AAFs

1. 100 attributable to alcohol by alcohol
   dependence alcoholic cirrhosis
2. AAF lt1 disease e.g. oral cancer 50
3. AAF lt1 injuries e.g. motor vehicle injuries 42

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Key Findings

• Instead of 2.2 million alcohol related ED visits
  they estimated there are 8.4 million alcohol
  related visits
• Only 20 of patients with 100 alcohol
  attributable conditions were admitted to
  hospitals meaning many are discharged without
  alcohol treatment

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Discussion

• Emergency Departments or Trauma Centers should
  screen all patients for alcohol
• Alcohol related ED admissions offer a teachable
  moment for successful brief intervention
• 35 states have laws allowing insurance companies
  to deny medical reimbursement for treating
  patients injured under the influence
• These laws should be repealed and the effects on
  the proportions of patients screened and offered
  brief intervention for alcohol should be monitored