From the Journals

Alcohol misuse universal screening effective and efficient



Universal screening for alcohol misuse in acute medical admissions is feasible and can reduce readmissions for liver disease, according to a new study.

Detecting patients’ alcohol misuse early can help treat or prevent alcohol-related liver disease, such as cirrhosis; however, screening is not being used in a routine, effective way, according to Greta Westwood, PhD, head of Nursing, Midwifery, and AHP Research at Portsmouth (England) Hospitals and her fellow investigators.

“In primary care, screening is highly variable, and treatment rates are low, often focusing on patients who already have advanced psychiatric or physical illness,” Dr. Westwood and her colleagues wrote. “In addition, many patients with alcohol use disorders do not fully engage with primary care services for a variety of reasons, often leading to excessive use of the hospital ED as the first point of contact.”

Investigators conducted a retrospective, observational study of 53,165 patients who were admitted to the acute medical unit at Queen Alexandra Hospital, Portsmouth, England, between July 2011 and March 2014 (J Hepatol. 2017 Sep;67[3]:559-67).

Man with a bottle and glass of alcohol. Katarzyna Bialasiewicz/ThinkStockPhotos

More than half of patients were male (52%), the average patient age was 67 years, and the patients had an average of three previous hospital admissions.

Of the patients observed, 48,211 (90.68%) completed the screening test, while the remaining 4,934 (9.32%) did not.

Those who were not screened had a higher mortality rate than did those who were (8.30% vs 6.17%; P less than .001), were more likely to be discharged the same day (3.37% vs. 1.87%; P less than .001), and were more likely to discharge themselves (29.67% vs. 13.31%; P less than .001).

The screening process, an electronic modified version of the Paddington Alcohol Test, consisted of the nurses’ asking a series of questions about types of alcohol consumed, frequency and maximum daily amount, whether the admission was considered alcohol related, and they documented signs of alcohol withdrawal.

Patients were then given a score based on how the answers compared with the healthy level of alcohol consumption, with 0-2 points considered “low risk,” 3-5 points considered “increasing risk,” and 6-10 points considered “high risk.”

Those assigned a low-risk status were not referred to intervention, but doctors recommended increasing-risk patients attend a community alcohol intervention team for brief intervention, while high-risk patients were automatically referred to an Alcohol Specialist Nursing Service (ASNS).

Of those screened, there were 1,135 patients (2.33%) considered at increasing risk of alcohol misuse and 1,921 (3.98%) at high risk.

While 68.5% of patients with a high-risk score were referred to the ASNS, all those who were referred completed the medical detoxification course, according to investigators.

High-risk patients were found to have had, on average, more hospital visits than increasing- and low-risk patients – 4.74 visits, compared with 2.92 and 3.00, respectively; they also reported more ED trips – 7.68 visits, compared with 3.81 and 2.64, respectively.

Dr. Westwood and her colleagues found that, when using the screening tool, investigators were more likely to find signs of alcohol-related liver disease among those with higher scores.

Liver, pancreatic, and digestive disorders accounted for 22.1% of primary admission codes of high-risk patients, compared with 3.2% of low-risk patients.

Investigators wrote that this tool can help doctors identify at-risk patients early and attack the problem of alcohol misuse head on and in a timely manner.

“It is vital that patients with cirrhosis who continue to drink are identified and referred to dedicated hospital alcohol care teams,” Dr. Westwood and her colleagues wrote. “Screening can identify patients at an increased risk of alcohol-related harm whose range of diagnoses is not dissimilar to lower-risk patients and whose misuse of alcohol might otherwise have not been identified.”

Investigators did not account for decreased scores or testing effectiveness in patients readmitted and retested. Additionally, the long-term impact of ASNS care is still being studied.

Two investigators reported affiliations with the Learning Clinic, which created and licensed the analysis program that is part of the screening tool. All other investigators, including Dr. Westwood, reported no relevant financial disclosures.

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