Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis

The Effect of Covid-19 on Alcohol Use Disorder and the Role of Universal Alcohol Screening in an Inpatient Setting: A Retrospective Cohort Control Study

AIM

To assess the impact of Covid-19 on alcohol use disorders (AUD) and the role of universal alcohol screening (UAS) in an inpatient setting.

METHODS

Retrospective cohorts were defined as pre-pandemic and pandemic admitted to Nottingham University Hospitals (April to October; 2019 and 2020) and had alcohol assessment by AUDIT-C. AUDIT-C score was assessed against age, sex, ethnicity, admission type, speciality and primary diagnosis of mental disorders. Subgroup analysis for Covid-19 positive patients was performed.

RESULTS

A total of 63,927 admissions (47,954 patients) were included. The pandemic period compared to pre-pandemic had fewer overall admissions (27,349 vs 36,578, P < 0.001), fewer with AUD (17.6% vs 18.4%, P = 0.008) but a higher proportion of alcohol dependents (3.7% vs 3.0%, P < 0.0001). In the pandemic those with AUD were more likely to be male (P = 0.003), white (P < 0.001), in relationship (P < 0.001), of higher socioeconomic background (P < 0.001), have alcohol-related mental disorders (P = 0.002), emergency admission (P < 0.001), medical speciality admission (P < 0.001) and shorter length of stay (P < 0.033) compared to pre-pandemic AUD. Covid-19 positive patients with concomitant AUD died at younger age (P < 0.05) than Covid-19 positive patients at low risk for AUD.

CONCLUSIONS

The pandemic changed the characteristics of inpatients with AUD. There was a higher proportion of alcohol-dependent admissions with evidence that a younger, less deprived group have been significantly impacted. UAS provides a useful tool to screen for AUD and to identify the change when facing sudden health crises.

Assessment of alcohol use disorder and its associated factors among alcohol users of medical and surgical outpatients attending a specialized hospital in Gondar, Ethiopia: a cross-sectional study

Background

Alcohol use disorder increase the risk of physical harm, mental or social consequences for patients and others in the community. Studies on alcohol use disorder and associated factors among medical and surgical outpatients in Ethiopia are limited. Therefore, this study is meant to provide essential data on alcohol use disorder and associated factors among alcohol user medical and surgical outpatients to intervene in the future.

Methods

An institution-based cross-sectional study was conducted by using the systematic random sampling technique. Alcohol use disorders were assessed using the World Health Organization’s 10-item Alcohol Use Disorder Identification Test (AUDIT) questionnaire. Bivariate and multivariate logistic regression analyses were performed, a P-value less than 0.05 were considered statistically significant in the multivariate analysis and the strength of association was measured at a 95% confidence interval.

Results

The prevalence of alcohol use disorder was 34.5% with a 95% CI (29.20, 39.80) among study participants. In the multivariate logistic regression analysis, male sex (AOR = 3.33, 95%CI: 1.40, 7.93), history of mental illness (AOR = 2.68, 95%CI: 1.12, 6.38), drinking for relaxation (AOR = 1.88, 95%CI: 1.02, 3.48) and history of lifetime tobacco use (AOR = 5.64, 95%CI: 1.95, 16.29) were factors significantly associated with alcohol use disorder.

Conclusion

The prevalence of alcohol use disorders among medical and surgical outpatients was found to be high. Male sex, history of mental illness, alcohol use for relaxation and lifetime cigarette smoking need more attention during the assessment of patients in the medical and surgical outpatient departments.

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.

High-performance detection and early prediction of septic shock for alcohol-use disorder patients

Background

The presence of Alcohol Use Disorder (AUD) complicates the medical conditions of patients and increases the difficulty of detecting and predicting the onset of septic shock for patients in the ICU.

Methods

We have developed a high-performance sepsis prediction algorithm, InSight, which outperforms existing methods for AUD patient populations. InSight analyses a combination of singlets, doublets, and triplets of clinical measurements over time to generate a septic shock risk score. AUD patients obtained from the MIMIC III database were used in this retrospective study to train InSight and compare performance with the Modified Early Warning Score (MEWS), the Simplified Acute Physiology Score (SAPS II), and the Systemic Inflammatory Response Syndrome (SIRS) for septic shock prediction and detection.

Results

From 4-fold cross validation, InSight performs particularly well on diagnostic odds ratio and demonstrates a relatively high Area Under the Receiver Operating Characteristic (AUROC) metric. Four hours prior to onset, InSight had an average AUROC of 0.815, and at the time of onset, InSight had an average AUROC value of 0.965. When applied to patient populations where AUD may complicate prediction methods of sepsis, InSight outperforms existing diagnostic tools.

Conclusions

Analysis of the higher order correlations and trends between relevant clinical measurements using the InSight algorithm leads to more accurate detection and prediction of septic shock, even in cases where diagnosis may be confounded by AUD.

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At 93% sensitivity, InSight reduces false alarms by >80% over other detection tools.

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InSight's diagnostic odds ratio is >30X those of MEWS, SAPS II, SIRS for detection.

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InSight outperforms comparable methods for septic shock prediction hours before onset.

Childhood Abuse Is Associated With Worse Survival Following Lung Transplantation

CONTEXT

Psychosocial factors can impact lung transplant outcomes. However, it is currently unknown whether abuse survivorship influences lung transplant survival.

OBJECTIVE

To characterize the abuse history of adult lung transplant patients and determine whether such history is associated with mortality.

PATIENTS AND OTHER PARTICIPANTS

Adult lung transplant recipients evaluated from 2000 to 2004.

MAIN OUTCOME MEASURES

The main outcome was post-lung transplantation survival. The secondary outcomes included demographic, transplantation, or psychological assessment differences between those with a history of abuse survivorship and those without.

RESULTS

Thirty-three lung transplant recipients (35.5% male, median age: 55 years) were included. A history of abuse survivorship was common (24.2%) and was associated with decreased survival following lung transplantation (P = .003). There was no difference in sex, marital status, or smoking history between abuse survivors and those who denied being the victim of abuse. Abuse survivors had a higher Personality Assessment Screener total score, a measure of maladaptive personality traits (P = .02).

CONCLUSION

Abuse survivorship is common in lung transplant patients and associated with increased posttransplant mortality and increased maladaptive personality traits. This preliminary evidence suggests that lung transplant patients should be screened for abuse history and provided with appropriate treatment of survivorship issues to potentially improve their health outcomes from transplantation.

See One, Do One, Order One: a study protocol for cluster randomized controlled trial testing three strategies for implementing motivational interviewing on medical inpatient units

Background

General medical hospitals provide care for a disproportionate share of patients who abuse or are dependent upon substances. This group is among the most costly to treat and has the poorest medical and addiction recovery outcomes. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance use problems in that patients are accessible, have time for an intervention, and are often admitted for complications related to substance use that renders hospitalization a “teachable moment.”

Methods/Design

This randomized controlled trial will examine the effectiveness of three different strategies for integrating motivational interviewing (MI) into the practice of providers working within a general medical inpatient hospitalist service: (1) a continuing medical education workshop that provides background and “shows” providers how to conduct MI (See One); (2) an apprenticeship model involving workshop training plus live supervision of bedside practice (Do One); and (3) ordering MI from the psychiatry consultation-liaison (CL) service after learning about it in a workshop (Order One). Thirty providers (physicians, physician assistants, nurses) will be randomized to conditions and then assessed for their provision of MI to 40 study-eligible inpatients. The primary aims of the study are to assess (1) the utilization of MI in each condition; (2) the integrity of MI when providers use it on the medical units; and (3) the relative costs and cost-effectiveness of the three different implementation strategies.

Discussion

If implementation of Do One and Order One is successful, the field will have two alternative strategies for supporting medical providers’ proficient use of brief behavioral interventions, such as MI, for medical inpatients who use substances problematically.

Trial registration

Clinical Trials.gov (NCT01825057)

Screening and brief interventions for hazardous and harmful alcohol use among hospital outpatients in South Africa: results from a randomized controlled trial

Background

High prevalence rates of hazardous and harmful alcohol use have been found in a hospital outpatient setting in South Africa. Hospital settings are a particularly valuable point of contact for the delivery of brief interventions because of the large access to patient populations each year. With this in mind, the primary purpose of this randomized controlled trial is to provide screening for alcohol misuse and to test the effectiveness of brief interventions in reducing alcohol intake among hospital outpatients in South Africa.

Methods

The study design for this effectiveness study is a randomized controlled trial with 6- and 12-month follow-ups to examine the effects of a brief alcohol intervention to reduce alcohol use by hazardous or harmful drinkers in a hospital setting. Outpatients were screened for alcohol problems, and those identified as hazardous or harmful drinkers were randomized into an experimental or control group. The experimental group received one brief counselling session on alcohol risk reduction, while the control group received a health education leaflet.

Results

Of the 1419 screened for alcohol misuse who agreed to participate in the trial 392 (27.6%) screened positive for hazardous or harmful use on the Alcohol Use Disorder Identification Test (AUDIT) (score 7/8-19) and 51 (3.6%) had an AUDIT score of 20 or more. Among the 282 (72%) hospital outpatients who also attended the 12-month follow-up session, the time effects on the AUDIT scores were significant [F (1,195 = 7.72), P < 0.01] but the intervention effect on the AUDIT score was statistically not significant [F (1,194 = 0.06), P < 0.804].

Conclusion

Given the lack of difference in outcome between control and intervention group, alcohol screening and the provision of an alcohol health education leaflet may in itself cause reduction in drinking.

Trial registration

PACTR201110000319392

A descriptive comparison of alcohol-related presentations at a large urban hospital center from 1902 to 2009

Although alcohol use has long been a significant cause of hospital presentations, little is published regarding the long-term demographic changes that have occurred at a single hospital site. To address this deficit, we prospectively studied all acute alcohol-related presentations to Bellevue Hospital Center (New York, NY) and compared this contemporary data set with one from the same institution from 1902 to 1935. We prospectively identified all patients presenting to the emergency department because of acute alcohol use over an 8-week period in 2009. We described the basic attributes of patients presenting currently because of alcohol and compared these data to those previously described between 1902 and 1935. We also compared our census data with contemporaneous data from all patients presenting to this hospital site. During the study period, 560 patients presented because of acute alcohol use which extrapolated to an estimated 3,800 patients over the calendar year. This compares to 7,600 presentations recorded annually early in the twentieth century. Twelve percent of patients in 2009 were female as compared to 18 % of patients between 1934 and 1935. Patients with alcohol-related presentations in 2009 were more likely to be admitted than contemporaneous patients without an alcohol-related presentation (30 vs. 19 % admitted; p < 0.001). Since first measured 110 years ago at one large New York City hospital, alcohol-related presentations remain common representing 5 % of all emergency department visits. This demonstrates alcoholism's continuing toll on society's limited medical resources and on public health as a whole.

Randomized controlled trial of a brief intervention for unhealthy alcohol use in hospitalized Taiwanese men

AIMS

To evaluate the effectiveness of a brief intervention in hospitalized Taiwanese men to reduce unhealthy alcohol consumption.

DESIGN

Randomized controlled trial.

SETTING

Medical/surgical wards of a medical centre in Taipei, Taiwan.

PARTICIPANTS

Of 3669 consecutive adult male in-patients, 616 were identified as unhealthy alcohol users (>14 drinks/week) and assigned randomly to either usual care (n = 308) or a brief intervention (n = 308).

MEASUREMENTS

Primary outcomes were changes in alcohol consumption at 4, 9 and 12 months, including self-reported weekly alcohol consumption, drinking days and heavy drinking episodes assessed by 7-day time-line follow-back. Secondary outcomes were (i) self-reported alcohol problems, (ii) health-care utilization (hospital days and emergency department visits), (iii) self-reported seeking of speciality treatment for alcohol problems and (iv) 3-month Quick Drinking Screen.

FINDINGS

Based on intention-to-treat analyses, the intervention group consumed significantly less alcohol than the control group among both unhealthy drinkers and the subgroup of alcohol-dependent participants over 12 months, on both 7-day and 3-month assessments. Adjunctive analyses of only those who completed all assessments found that total drinks consumed did not remain significant. Significantly more participants with alcohol use disorders in the intervention than in the control group (8.3%, 19 of 230 versus 2.1%, four of 189) consulted specialists by 12 months (P = 0.01). However, alcohol-related problems and health-care utilization did not differ significantly in the two groups during follow-up.

CONCLUSIONS

Data from Taiwan confirm that brief in-hospital intervention can result in a reduction in alcohol intake by men who drink heavily or are diagnosed with an alcohol use disorder.

Prevalence and routine assessment of unhealthy alcohol use in hospitalized patients

OBJECTIVES

To determine the prevalence of alcohol misuse among medical inpatients and the methods used by medical staff to evaluate alcohol consumption.

METHODS

Multicenter, prospective, observational, cross-sectional study performed at 21 hospitals in Spain. All adult patients hospitalized in internal medicine wards on 12 March 2008 were eligible for study. Alcohol consumption was evaluated with the Alcohol Use Disorders Identification Test (AUDIT-C and AUDIT) and the Systematic Inventory of Alcohol Consumption questionnaire. Drinking patterns were determined according to clinical evaluation using ICD-10 criteria. Medical records were reviewed to gather information on the recording of alcohol use.

RESULTS

We assessed 1039 inpatients, of whom 123 (12%) had unhealthy alcohol drinking patterns. Alcohol misuse was more frequent among males (odds ratio 5.20), younger patients (odds ratio, 14.17), median age patients (odds ratio, 2.99), and South Region (odds ratio, 1.77). Alcohol use during hospitalization was recorded in 603 inpatients (59%); quantitative records were performed in 28% of hazardous and harmful drinkers and in 41% of dependent patients. Lack of alcohol use recording was more frequent among females (odds ratio 1.73), median and older age groups (odds ratios 1.44 and 1.73, respectively), Northwest Regions (odds ratios 3.46). Patients from the East Region (odds ratio 0.47) had more frequently assessed the question in their medical records.

CONCLUSIONS

Prevalence of alcohol misuse was higher in hospitalized patients than in the general population. Adequate quantitative recording was infrequent. We stress the need to implement measures to increase and improve the detection and recording of alcohol use.

Documentation of Alcohol Use in Hospital Records of Newly Diagnosed Cancer Patients: A Population-Based Study

Alcohol use has been associated with increased risk and poorer prognosis of various types of cancer, but the extent of actual screening for alcohol use in hospitalized cancer patients has received limited attention. In a random sample of 618 Connecticut patients diagnosed in 2002 with invasive cancer at age 20 + years, ascertained from a population-based registry, some information on usual frequency of drinking was found in hospital records for 478 (77.3%), but 143 (57.2%) of the 250 current drinkers were poorly described (e.g., "social," "occasional"). Alcohol use disorders were rarely mentioned. Gamma glutamyl transpeptidase was found for only 21 (3.4%). Mean corpuscular volume (MCV) was found for 434 (70.2%) and was associated with heavier drinking, independent of other predictors of MCV. Better screening is needed for all hospitalized cancer patients, to plan for interventions and conduct follow-up studies of prognosis.

Pre-operative screening for excessive alcohol consumption among patients scheduled for elective surgery

Pre-operative intervention for excessive alcohol consumption among patients scheduled for elective surgery has been shown to reduce complications of surgery. However, successful intervention depends upon an effective and practical screening procedure. This study examines current screening practices for excessive alcohol consumption amongst patients scheduled for elective surgery in general hospitals. It also examines the appropriateness of potential sites and staff for pre-operative screening. Forms used routinely to assess alcohol consumption in the pre-admission clinics (PAC) of eight Sydney hospitals were examined. In addition, the appropriateness of six staff categories (surgeons, surgeons' secretaries, junior medical officer, anaesthetists, nurses and a research assistant) and of two sites (surgeons' office and PAC) in conducting additional screening was assessed at two hospitals. Outcomes included observed advantages and disadvantages of sites and personnel, and number of cases with excessive drinking identified. There was duplication in information collected routinely on alcohol use in the PACs in eight Sydney Hospitals. Questions on alcohol consumption in patient self-completion forms were not validated. The PAC provided for efficient screening but time to surgery was typically too short for successful intervention in many cases. A validated tool and efficient screening procedure is required to detect excessive drinking before elective surgery. Patients often present to the PAC too close to the time of surgery for any change in drinking to reverse alcohol's effects. The role of the referring general practitioner and of printed advice from the surgeon in preparing patients for surgery needs further investigation.

Prevalence and record of alcoholism among emergency department patients

OBJECTIVES

The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team.

METHODS

The study population consisted of all patients admitted to the emergency room at Hospital São Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test.

RESULTS

We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively.

CONCLUSION

Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

Validation and comparison of alcohol-screening instruments for identifying hazardous drinking in hospitalized patients in Taiwan

AIM

The aim of this study was to validate the Mandarin Chinese version of different screening instruments and compare their performances for identifying hazardous drinkers in Taiwan.

METHODS

We compared the performance of the Mandarin Chinese versions of AUDIT, AUDIT-C (AUDIT items 1, 2 and 3), AUDIT-4 (AUDIT items 1, 2, 3 and 10), AUDIT-3 (AUDIT item 3), TWEAK, SMAST and CAGE to detect hazardous drinking in hospitalized patients in Taiwan. The results of the test instruments were blindly compared with the reference standard Schedule for Clinical Assessments in Neuropsychiatry (SCAN).

RESULTS

Of 404 patients evaluated, 100 were identified as having a hazardous drinking pattern. All screening instruments showed acceptable sensitivities (ranging from 85 to 93%) and specificities (ranging from 72 to 92%), but AUDIT and its short forms performed consistently better than the other instruments.

CONCLUSIONS

The Mandarin Chinese versions of AUDIT and its derivatives perform well in screening hospitalized Taiwanese patients for hazardous drinking.

A historical look at alcohol abuse trends in army and civilian populations, 1980-1995

OBJECTIVES

The purpose of this study was to compare civilian and Army alcohol-related hospitalization trends and to plot temporal changes in rates relative to alcohol-related legislation and social policies.

METHOD

We compared population-based civilian and Army annual hospitalization rates for overall alcohol-related diagnoses and for alcohol-related diagnostic subgroups (1980-1995) and plotted them against civilian and military substance abuse regulations. Civilian data were adjusted to Army age, gender, and race.

RESULTS

Although overall civilian and Army alcohol hospitalization rates were similar, alcohol subgroup rates varied. Simultaneous drug and alcohol abuse (polyabuse) rates were higher among civilians (16.6 per 10,000) than Army soldiers (5.1 per 10,000). Army rates for dependent alcohol-related disorders were higher and increased. Army nondependent alcohol disorders tracked with alcohol-related regulations as rates fell 69% between 1985 and 1995.

CONCLUSION

Army and civilian alcohol abuse trends vary by abuse type. Without longitudinal, diagnosis-specific subgroup analyses, these trends would not have emerged. Army policies and screening may explain divergent nondependent alcohol abuse and lower polyabuse rates.

Perceived health status, alcohol-related problems, and readiness to change among medically hospitalized, alcohol-dependent patients

OBJECTIVE

Alcohol dependence is prevalent among medically hospitalized patients, and acute illness has the potential to increase motivation to change and provide a therapeutic window for treatment of alcohol dependence. This study evaluated the correlations of readiness to change drinking behavior with perceived physical and mental health status and specific alcohol-related consequences of medical inpatients.

DESIGN AND MEASUREMENTS

The study was a cross-sectional survey of 50 clinically recognized and subsequently confirmed alcohol-dependent patients admitted to general internal medicine teaching services with no evidence of chronic cognitive functional deficits. We estimated correlations of process-of-change variables (problem recognition, ambivalence about change, and taking steps to change drinking) with measures of patient perception of general physical and mental health status and self-reported alcohol-related consequences.

RESULTS

Problem recognition (r = -0.31, P = .028) and ambivalence about change (r = -0.41, P = .003), but not taking steps to change drinking (r = -0.26, P = .072) were significantly associated with perceived physical health. Perceived mental health was not associated with these variables, but greater alcohol-specific consequences were typically associated with greater recognition, ambivalence, and intent to change.

CONCLUSIONS

Among alcohol-dependent patients with acute medical illness requiring hospitalization, poorer perceived health status was associated with increased recognition of drinking problems and thoughts about changing drinking behavior. Future research should evaluate if problem recognition and ambivalence modify treatment involvement and outcomes following hospitalization and if hospital-based interventions designed to link medical conditions and their treatment to alcohol dependence enhance recognition and ambivalence.

References to alcohol consumption and alcoholism in medical records of a general hospital of Porto Alegre, Brazil--a comparison between samples with a 20 year gap

Two samples of inpatients (493 and 158 subjects, respectively) of a large teaching hospital, collected using the same methodology and with a 20-year time frame, were analyzed aiming at finding information about alcohol consumption, abuse or dependence in the subjects' medical charts. Items reviewed were: the list of medical problems; hospital intake form; daily nursing review; medical anamnesis; pre-surgery records, and discharge forms. Only 54% and 50% of each sample, respectively, had some type of reference to alcohol consumption; when references were present, they were in most part incomplete, possibly reflecting distortions in the process of gathering information about alcohol consumption that involves the client and the health professionals. The authors discuss potential reasons for this, suggesting that lack of training of medical personnel in the identification of alcoholism, as well as prejudice towards its recovery, may be some of the underlying causes.

Interest in pharmacotherapy and primary care alcoholism treatment among medically hospitalized, alcohol dependent patients

This study assessed medically hospitalized alcoholics attitudes about pharmacotherapy and interest in primary care-based treatment. The survey included 50 medical inpatients with current alcohol dependence. Participants were asked to indicate their agreement with the following statements: (1) I need to stop drinking, (2) Some medications can help prevent drinking, (3) If a medication did help prevent drinking, I would like to receive this from a doctor, and (4) I would like a primary care doctor to treat or help treat my drinking problems. Eighty-four percent agreed they needed to stop drinking, 50% agreed that medications help prevent drinking, 66% agreed they would like to receive an effective medication to help prevent drinking, and 32% were interested in primary care treatment. Medically hospitalized patients with alcohol dependence were interested in effective medication for relapse prevention, but primary care follow-up alone may not adequately address patients' perceived treatment needs.

Validation of the revised Self-Administered Alcohol Screening Test (SAAST-R)

This study examined the sensitivity and specificity of the revised Self-Administered Alcohol Screening Test (SAAST-R)1 among adult outpatients evaluated at community addictions and psychiatry and psychology clinics. A total of 417 adults (mean +/- SD age of 41.4 +/- 15.0 years, 52% female, 91% Caucasian) completed the 36-item SAAST-R prior to their evaluation. Based on the clinician's documentation of the patient's alcohol use, two criterion groups were established: one composed of subjects classified as having no alcohol problems (n = 214), and one with alcohol problems (n = 203). The SAAST-R was found to have high internal consistency reliability (Cronbach's alpha = 0.96), sensitivity (90%), and specificity (82%) for differentiating outpatients with and without alcohol problems, respectively, using a cut point of >or=4 to indicate risk for alcohol-related problems. The SAAST-R was found to have good sensitivity and specificity among both males and females.

From data to evidence, to action: findings from a systematic review of hospital screening studies for high risk alcohol consumption

OBJECTIVE

To conduct a systematic review of hospital alcohol screening studies to identify effective and efficient evidence-based strategies.

METHOD

Sixty-five studies (N=100,980) of alcohol problem prevalence amongst hospital patients were reviewed.

RESULTS

Prevalence of positive alcohol screens varied according to hospital location, screening tool and patient characteristics. BAC measures (26%) were nearly twice as likely (OR=1.92, p<.001) to reveal positive screens in the ED than self-reports (16%). No difference was found in prevalence of self-report positive screens between ED (16%) and ward settings (17%). Males were two to four times more likely than females to screen positive (BAC: OR=2.37, p<.001, ED self-report: OR=3.07, p<.001, ward self-report: OR=4.30, p<.001). ED patients aged 20-40 years and ward patients aged 30-50 years had the highest prevalence of positive screens.

CONCLUSIONS

Prevalence of risky or problematic drinking among hospital patients is high and warrants systematic screening and intervention. Many hospitals lack sufficient resources to undertake widespread screening programs. For optimum return on resources, it is recommended to screen males in the ED using BAC measures. Established protocols applying priority criteria and staff training can increase screening accuracy and effectiveness.

Are Commonly Ordered Lab Tests Useful Screens for Alcohol Disorders in Older Male Veterans Receiving Primary Care?

Although mean corpuscular volume (MCV), aspartate aminotransferase (AST), alanine aminotransferases (ALT), and the AST/ALT ratio are sometimes used as markers of alcohol disorders, their utility has not been established in older persons. We determined the tests' performance characteristics for (1) at-risk drinking, (2) CAGE positivity, (3) at-risk drinking and CAGE positivity, and (4) a clinician-recorded diagnosis of alcohol abuse/dependence in a study of older male veterans receiving primary care. Participants (n = 587) included patients who had MCV, AST, and/or ALT data collected as part of routine care no more than 12 weeks before or after enrollment. MCV, AST, and ALT test results were obtained from the VA's database. At enrollment, the Timeline Followback and Alcohol Use Disorders Identification Test (AUDIT) were used to identify at-risk drinkers (> or = 15 drinks per week or AUDIT score > or = 8), and the CAGE questionnaire was administered to identify participants with a history abuse/dependent drinking (CAGE score > or = 2). Participants' medical records were reviewed to identify subjects with a clinician-recorded diagnosis of alcohol abuse/dependence. The prevalence of abnormal test results for MCV (threshold value = > 98), AST (> 41), ALT (> 41), and the AST/ALT ratio (> 2) was 11%, 4%, 4%, and 5%, respectively. The occurrence of at-risk drinking, CAGE positivity, at-risk drinking and CAGE positivity, and a clinician-recorded diagnosis of alcohol abuse/dependence was 11%, 25%, 5%, and 9%, respectively. Test sensitivity ranged from 3.9% to 25.4% and specificity from 88.5% to 97.1%, whereas positive likelihood ratios varied from 0.72 to 4.01 and negative likelihood ratios from 0.82 to 1.04. Areas under the receiver operating characteristic curve were similar (range = 0.50-0.58) across tests. In conclusion, MCV, AST, ALT, and the AST/ALT ratio are not useful markers of alcohol disorders in older male veterans.

Prevalence and detection of alcohol use disorders among general hospital inpatients in eastern Taiwan

OBJECTIVE

To examine (1) the prevalence of alcohol use disorders (AUD) and its various correlates, and (2) the detection rate of AUD by nonpsychiatric physicians and its related factors associated with increased chances of detection among inpatients in a general hospital in rural eastern Taiwan.

METHODS

A well-trained psychiatrist interviewed all adult patients admitted during a 1-month period using the Alcohol Inventory and reviewed all medical records for alcohol-related diagnoses.

RESULTS

A total of 303 inpatients aged 18 to 93 years were evaluated, of whom 78 (25.7%) were diagnosed by the psychiatrist as having AUD within the past year. Males, aborigines, middle-aged, current smokers and betel quid chewers had a significantly higher odds ratio for AUD. Nonpsychiatric physicians detected only 14.1% patients with recent AUD. Internists identified AUD nearly four times as often as surgeons. Better detection was associated with higher level of alcohol intake.

CONCLUSIONS

This study demonstrates the high prevalence of AUD among hospitalized patients in eastern Taiwan and the frequent failure of physicians to identify the disorder. These findings suggest that more effort should be directed toward increasing medical professionals' awareness of AUD in general hospital settings, especially among high-risk groups.

Screening and Intervention for Alcohol and Illicit Drug Abuse

This study attempts to determine how internal medicine housestaff screen and intervene for problematic alcohol and illicit drug use, as well as identify factors correlating with favorable practices. A cross-sectional survey was administered to 93 medical housestaff. Of 64 (69%) respondents, 94% reported routinely screening new patients for alcohol or illicit drug use, while only 52% routinely quantified alcohol consumption and 28% routinely used a screening instrument. Housestaff were unfamiliar with national guidelines and felt unprepared to diagnose substance use disorders, particularly prescription drug abuse. Most routinely counseled patients with alcohol (89%) or illicit-drug problems (91%), although only a third of these patients were referred for formal treatment. More thorough screening practices were associated with greater treatment optimism, while favorable referral practices were associated with greater optimism about 12-step program benefit and difficulty with management. These findings suggest areas to be addressed in residency curricula on substance abuse.

Age- and sex-specific income gradients in alcohol-related hospitalization rates in an urban area

PURPOSE

This study examines the effects of age and sex on the relationship between neighborhood income and alcohol-related hospitalization rates in a large urban area.

METHODS

Adults in Toronto, Canada, who were hospitalized with an alcohol-related condition between 1995 and 1998 were identified using discharge diagnoses. Income quintiles were determined based on area of residence. Annual rates of hospitalization for alcohol-related conditions per 10,000 individuals were calculated.

RESULTS

Rates of hospitalization with a primary diagnosis of an alcohol-related condition were similar among men age 20 to 39 in all incomes quintiles, but were inversely associated with income among men age 40 to 64 (28.8 and 13.3 per 10,000 in the lowest and highest income quintiles). Among women age 40 to 64, the lowest income quintile had the highest hospitalization rate (12.1 per 10,000), but women in all other income quintiles had relatively low hospitalization rates (5.9 to 7.7 per 10,000). As age increased above 65 years, rates of hospitalization with a primary diagnosis of an alcohol-related condition decreased or stabilized in both men and women.

CONCLUSIONS

The inverse association between income level and alcohol-related hospitalization rates becomes apparent after age 40. A gradient in hospitalization rates is seen in men across all income levels, but in women a prominent effect is seen only in those with the lowest income.

Revision of the Self-Administered Alcoholism Screening Test (SAAST-R): a pilot study

The original Self-Administered Alcoholism Screening Test (SAAST; Swenson and Morse, 1975) is a self-report alcoholism screening measure intended for use with adult medical patients. However, the SAAST does not indicate the recency of alcohol use-related problems, not all items use the appropriate verb tense for assessing lifetime experience of alcohol use-related problems, many of the items contain out-dated language, and the diagnostic criteria for alcohol dependence and alcohol abuse are not fully represented. The SAAST was revised to address these issues. This paper describes the rationale for revision and the process through which the SAAST was revised. Preliminary information about comparability of the original SAAST and the revised version (SAAST-R) was obtained. Data are presented from two intervention trials for smokers in which both the SAAST and SAAST-R were administered. One sample was comprised of participants in recovery from alcoholism (N = 60; 82% male) and the other sample consisted of participants not meeting criteria for alcohol abuse or dependence within the previous year (N = 98; 45% male). The results suggest that the SAAST-R is highly correlated with the original SAAST, has a similar factor structure, good internal consistency, and correctly identifies those in recovery from alcoholism. Areas for refinement in the format and items of the SAAST-R were identified and suggestions for further validation studies are presented.

Enfermedades relacionadas con el consumo de alcohol: seguimiento a los dos años de la hospitalización

BACKGROUND AND OBJECTIVE

Our objective was to study the outcome and compliance of both medical and alcoholism treatment in alcoholics discharged from a general hospital.

PATIENTS AND METHOD

This was a 2 years prospective follow up study of a cohort of 100 inpatients referred to the Alcohol Unit during the first semester of 1998.

RESULTS

After 2 years, 9 patients had died and 14 had been referred to other hospitals. 15% of patients refused medical treatment from the beginning and alcoholism treatment was initially refused by 31% of alcoholics. At 2 years of follow up, compliance rates were 46% for medical treatment and 10% for alcoholism treatment. All patients under treatment for alcoholism were also good compliers of medical treatment. Survival analysis for alcoholism treatment at 2 years was 19%, with higher rates in patients with psychosocial problems and previous alcohol consultations. The probability of being alive was 89%.

CONCLUSIONS

Few alcoholics are detected. Most of them display high levels of severity and poor prognosis, with high mortality rates. Compliance with follow up treatment is low. There is a clear correlation between compliance of alcoholism and medical treatment.

Implementing an effective intervention for problem drinkers on medical wards

Many medical inpatients have alcohol related problems but evidence of the feasibility of instituting a brief intervention is incomplete. An alcohol counsellor trained nurses on five general medical wards to screen patients routinely for alcohol problems. She counselled appropriate patients using one or two counselling sessions. Efficacy of the counselling was assessed at interview six months following the admission. We found that 19.6% of male and 4.8% of female medical patients were drinking more than 50 units (U) or 33 drinks per week (male) or 35 U or 23 drinks per week (female). Counselling, with one or two sessions led to a reduction from a median of 74 U (49 drinks) per week at admission to 26 U (17 drinks) per week at six months follow-up. A second counselling session after discharge showed no advantage over a single one administered while the patient was in the ward. The barriers to developing a successful alcohol screening and counselling service in medical wards can be overcome provided there is also adequate support and training of the ward nursing staff.