Effectiveness of a nurse-led alcohol liaison service in a secondary care medical unit

Alcohol-related liver disease mortality and missed opportunities in secondary care: A United Kingdom retrospective observational study

Introduction

Alcohol‐related liver disease (ARLD) is a preventable cause of mortality. Historical epidemiological studies on ARLD often lack a detailed linked assessment of health‐related contacts prior to death which limits understanding of opportunities for intervention. We aimed to analyse retrospective population‐based data of all adult residents of Nottinghamshire dying from ARLD to determine the factors associated with delayed diagnosis of ARLD and the potential missed opportunities for interventions.

Methods

We linked the Office for National Statistics and Hospital Episode Statistics databases to identify adult (≥18 years) residents of Nottinghamshire, who died of ARLD over the 5‐year period (1 January 2012 to 31 December 2017). Death was used as the primary outcome, and logistic regression analysis was conducted to test the association between key variables and mortality due to ARLD.

Results

Over 5 years, 799 ARLD deaths were identified. More than half had no diagnosis or a diagnosis of ARLD less than 6 months before death. Emergency presentation at first ARLD diagnosis and White ethnicity were significantly associated with a delay in diagnosis. Overall, the cohort had a median of five hospital admissions, four accident and emergency attendances and 16 outpatient appointments in the 5 years before death. Treatment was provided by a range of specialities, with general medicine the most common. Alcohol was associated with most admissions.

Discussion and Conclusions

This study identified deficiencies in ARLD secondary care and provides us with a powerful methodology that can be used to evaluate and improve how alcohol issues are managed and where action can be best targeted.

The impact of disinvestment on alcohol and drug treatment delivery and outcomes: a systematic review

BACKGROUND

In the context of substantial financial disinvestment from alcohol and drug treatment services in England, our aim was to review the existing evidence of how such disinvestments have impacted service delivery, uptake, outcomes and broader health and social implications.

METHODS

We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42020187295), searching bibliographic databases and grey literature. Given that an initial scoping search highlighted a scarcity of evidence specific to substance use treatment, evidence of disinvestment from publicly funded sexual health and smoking cessation services was also included. Data on disinvestment, political contexts and impacts were extracted, analysed, and synthesized thematically.

RESULTS

We found 20 eligible papers varying in design and quality including 10 related to alcohol and drugs services, and 10 to broader public health services. The literature provides evidence of sustained disinvestment from alcohol and drug treatment in several countries and a concurrent decline in the quantity and quality of treatment provision, but there was a lack of methodologically rigorous studies investigating the impact of disinvestment.

CONCLUSIONS

This review identified a paucity of scientific evidence quantifying the impacts of disinvestment on alcohol and drug treatment service delivery and outcomes. As the global economy faces new challenges, a stronger evidence base would enable informed policy decisions that consider the likely public health impacts of continued disinvestment.

Patient experiences of alcohol specialist nurse interventions in a general hospital, and onwards care pathways

AIMS

To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B).

DESIGN

A longitudinal qualitative study.

METHODS

A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N = 12 in each pathway; purposive selection) 1-4 weeks post-detoxification and at 3 and 6 months, to identify patient experiences of these interventions.

RESULTS

Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems.

CONCLUSION

Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery.

IMPACT

Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

The suburban-city divide: an evaluation of emergency department mental health presentations across two centres

OBJECTIVE

To evaluate the characteristics of mental health presentations to the emergency department in two different hospital settings.

METHODS

This was a retrospective cross-sectional study examining ED referrals to psychiatry in an inner-city and suburban centre. The authors collected data on gender, age, employment, housing, clinical presentation, time of assessment and admissions, over a 1-month period.

RESULTS

The total number referred was 213: inner-city n = 109 and suburban n = 104. The inner-city saw a younger population; 47/109 (43%) were aged between 20 and 29 years, compared with 28/104 (27%) of suburban presenters (P value 0.0134). A higher number of presenters were aged over 60 in the suburban centre n = 13/104 (12.5%) versus the inner-city centre 3/109 (2.8%) (P value 0.0084). In the inner-city, the proportion of homeless presenters was significantly higher at 30/109 (28%) versus 5/104 (4.8%) in the suburban setting (P < 0.0001). Presentations related to substances were highest, a total of 73 (34.3%) across both centres, with no significant difference in clinical presentations across the two centres. The majority were seen in the on-call period, 74/109 (67.9%) in the inner-city centre and 66/104 (63.5%) in the suburban centre. The psychiatric admission rate was significantly different between the two centres, with 33/109 (30.3%) patients admitted in the inner-city centre and 13/104 (12.5%) patients admitted in the suburban centre (P value 0.002).

CONCLUSIONS

A large proportion of ED referrals to psychiatry constitute patients with unmet social and addiction needs, who are seen out of hours. This prompts consideration of expanding both ED and community services to comprise a more multidisciplinary-resourced, 24/7 care model.

Course and outcome of patients with alcohol use disorders following an alcohol intervention during hospital attendance: mixed method study

BACKGROUND

Alcohol-related presentations to acute hospitals in the UK are increasing, but little is known of the clinical characteristics or natural history of this patient group.

AIMS

To describe the clinical characteristics, drinking profile and trajectory of a cohort of patients with alcohol use disorder (AUD) attending hospital, and explore participant perspectives of the impact of hospital attendance on their relationship with alcohol.

METHOD

We conducted a mixed method, prospective, observational cohort study of patients with AUD seen in an acute hospital. Participants were interviewed with a range of questionnaires at baseline and followed up on at 6 months. A subsample also completed in-depth qualitative interviews.

RESULTS

We recruited 141 patients; 132 (93.6%) were followed up at 6 months and 26 completed qualitative interviews. Of the 141 patients, 60 (42.6%) stated the index hospital episode included the first discussion of their alcohol use in a secondary care setting. Most rated discussion of their alcohol use in hospital as 'very positive' or 'positive' (102/141, 72.3%), but lack of coordinated care with community services undermined efforts to sustain change. At 6 months, 11 (7.8%) patients had died, but in those who survived and completed assessment (n = 121), significant and clinically meaningful improvements were seen across a range of outcomes, with 55 patients (45.5%) showing a favourable drinking outcome at 6 months.

CONCLUSIONS

Patients with AUD have high levels of morbidity and mortality, yet many made substantial changes following intervention in hospital for their alcohol use. Prospective trials need to identify the effect of alcohol care teams in optimising this 'teachable moment' for patients.

Alcohol care teams: where are we now?

Alcohol consumption affects the risks of approximately 230 three-digit disease and injury codes in the International Statistical Classification of Diseases and Related Health Problems-10th Revision. The United Nations Sustainable Development Goals comprise 17 challenging goals with 169 targets, which the 193 Member States aim to achieve by 2030. Action to reduce the harmful use of alcohol, especially addressing global health inequalities, will contribute to achieving many of the health-related goals and targets. Alcohol care teams, mainly developed in acute UK hospitals, reduce acute hospital admissions, readmissions and mortality, improve the quality and efficiency of alcohol care, and have 11 key evidence-based, cost-effective and aspirational components. A clinician-led, multidisciplinary team, with integrated alcohol treatment pathways across primary, secondary and community care, coordinated alcohol policies for emergency departments and acute medical units, a 7-day alcohol specialist nurse service, addiction and liaison psychiatry services, an alcohol assertive outreach team, and consultant hepatologists and gastroenterologists with liver disease expertise facilitate collaborative, multidisciplinary, person-centred care. Quality metrics, national indicators, audit, workforce planning, training and accreditation support research and education of the public and healthcare professionals. Hospitals should collaborate with local authorities, public health, clinical commissioning groups, patients and key stakeholders to develop and disseminate cost-effective prevention and treatment strategies. Globally, alcohol care teams can support the achievement of the United Nations Sustainable Development Goals, and should be advocated and implemented through the WHO global alcohol strategy. This requires collaborative care planning by key stakeholders, a skilled workforce, targeted financial resources and dedicated political commitment.

Treating alcohol-related liver disease from a public health perspective

Herein, we describe the evolving landscape of alcohol-related liver disease (ALD) including the current global burden of disease and cost to working-aged people in terms of death and disability, in addition to the larger spectrum of alcohol-related heath complications and its wider impact on society. We further review the most effective and cost-effective public health policies at both a population and individual level. Currently, abstinence is the only effective treatment for ALD, and yet because the majority of ALD remains undetected in the community abstinence is initiated too late to prevent premature death in the majority of cases. We therefore hope that this review will help inform clinicians of the "public health treatment options" for ALD to encourage engagement with policy makers and promote community-based hepatology as a speciality, expanding our patient cohort to allow early detection, and thereby a reduction in the enormous morbidity and mortality associated with this disease.

Examining an alcohol health worker service's patient coverage

Alcohol health workers (AHWs) have been found to be effective at reducing alcohol-related hospital admissions, but there is still a paucity of evidence in keys areas. This was the first study to investigate what percentage of patients referred to an AHW service by alcohol screening tools are actually seen by the AHWs. The study-based in a large teaching hospital in the north of England-also investigated the impact of social deprivation on service usage. Research data came from a patient database and semi-structured interviews with AHWs. Further research is required to better understand the 'harm paradox' of patients' differential susceptibility to alcohol-related harm and how this might impact AHW service patient flow.

A mixed-method outcome evaluation of a specialist Alcohol Hospital Liaison Team

AIMS

To evaluate the effectiveness of an Alcohol Hospital Liaison Team at reducing alcohol-specific hospital attendances and admissions.

METHODS

In a mixed-method evaluation, 96 patients who accessed the team were monitored using data for alcohol-specific hospital attendances and Accident and Emergency (A&E) admissions before, during, and after engaging with the team. A feedback survey was sent to patients and a focus group was held with staff from the team to identify barriers and facilitators to the successful delivery of this service.

RESULTS

No differences were observed when looking at alcohol admissions or A&E attendances before patients engaged with the service to those after discharge. While hospital admissions decreased slightly and A&E attendances increased slightly, these differences were not significant. Hospital admissions and A&E attendances increased significantly during engagement with the service. The focus group identified confusion over who should be delivering brief interventions and that the team was holding onto patients for too long.

CONCLUSION

The results of this evaluation demonstrated that this team was not effective at reducing alcohol attendances or admissions due to a number of factors. Policy makers should make note of the barriers to effectiveness highlighted in this article, before commissioning alcohol care teams in the future.

The impact of alcohol care teams on emergency secondary care use following a diagnosis of alcoholic liver disease - a national cohort study

Background

The increasing mortality rates from alcohol-related liver disease (ARLD) are a public health concern. To address this, alcohol care teams (ACT) case-find and lead management of alcohol issues for these patients. Local assessments of ACTs have shown reductions in emergency admissions and emergency department attendances. We examine the impact of ACTs on emergency hospital activity following a diagnosis of ARLD.

Methods

Administrative Hospital Episode Statistics (HES) data were extracted. Information on ACT provision at English NHS hospital trusts and sites in 2009/10 was taken from a survey by Public Health England. We undertook a difference-in-difference analysis to compare emergency hospital activity for a cohort of individuals diagnosed with ARLD who presented to hospitals either with or without an ACT in the one year before and after a first ARLD diagnosis during 2009/10.

Results

Over the study period, 9,165 individuals eligible for inclusion in our study had a first diagnosis of ARLD. 4,768 presented to one of 41 hospital trusts with an ACT (59 sites) and 4,397 presented to one of 50 non-ACT hospital trusts (65 sites). Whilst age and sex demographics were similar between the two cohorts, the ACT hospital cohort had a higher proportion of individuals in the most deprived quintile (41.6 % v 28.5 % p < .0001). In the difference-in-difference analysis, the presence of an ACT at a hospital trust was not associated with a change in all-cause emergency admissions (0.020 (95 % CI −0.070, 0.111), p = 0.656), alcohol-related emergency admissions (−0.025 (95 % CI −0.104, 0.054), p = 0.536) or all-cause emergency department attendances (0.042 (95 % CI −0.087, 0.171), p = 0.521). Sensitivity analyses by sex and hospital site did not affect the study findings.

Conclusions

In this study, the presence of an ACT at the NHS hospital trust where individuals have their first recorded diagnosis of ARLD does not appear to be associated with subsequent emergency hospital activity within these populations. Further analysis focussing on the components and specific effects of ACT interventions on individuals and systems both pre- and post-diagnosis of ARLD may reveal important avenues to improve care.

A national study of acute hospital based alcohol health workers

Alcohol health workers (AHWs) have been identified as an effective means of tackling alcohol-related hospital admissions. However, there is no understanding of the national coverage, or the extent and diversity of the services provided by hospital-based AHWs. Using a cross-sectional questionnaire, this is the first study to explore the current provision and remit of AHWs in acute hospitals across England.The data was analysed using SPSS. Significant differences were found with regards to the extent and diversity of AHW provision across England. This research provides a point of comparison for current and future hospital-based AHW provision.Further research is necessary to examine different 'service types', establish effective ways of working, and determine whether sources of funding could and should more accurately reflect the remit of hospital-based AHW roles.

Current treatment options for alcohol-related liver disease

PURPOSE OF REVIEW

The burden of alcohol on global health is increasing, and there is a strong relationship between population alcohol consumption and liver-related deaths. As alcohol-related liver disease (ArLD) often develops with no signs or symptoms, the prevention of liver disease relies on the recognition of harmful drinking and screening of those patients at risk for early markers of liver disease.

RECENT FINDINGS

A robust method of screening patients at risk of ArLD is essential. Once a patient develops ArLD, abstinence and early recognition of its complications are keys to improving outcomes. Corticosteroids remain the mainstay treatment in alcoholic hepatitis pending the results from large multicentre trials. More recently, there has been an increased interest in the use of rifaximin and albumin in various settings of ArLD.

SUMMARY

Advances in the treatment of ArLD and its complications, such as alcoholic hepatitis, will allow a greater proportion of patients chance for their liver to recover. However, new strategies to detect and intervene in those patients at higher risk of ArLD are likely to have the greatest overall impact.

Alcohol misuse: the need to take a preventative approach

Consuming alcohol within moderate and recommended amounts can have its benefits. These include: social inclusion, socialising, positive impacts it can have on providing employment and to the economy. However, not all people drink in moderation. Alcohol misuse (AM) is increasingly becoming a cause for concern in public health, medical reports and criminal justice systems. Reports and strategies continue to highlight the risks and dangers that AM poses for those who engage in harmful drinking. Alongside the risks to the individual, other costs include discord within families and society and further financial pressure on healthcare systems. However, often AM does not come to the attention of health practitioners until it is in its advanced stages, yet it is preventable and is an issue that impacts all age groups from children to older people. Community nurses can play a pivotal, proactive and preventative role in detecting and offering information and brief advice for those in their care. Though this may be challenging and requires innovative thinking in identifying the most suitable approaches to best match the needs of their patients, it is an issue that can be prevented and have untold benefits for individuals, families and societies.

A randomised controlled trial of extended brief intervention for alcohol dependent patients in an acute hospital setting (ADPAC)

Background

Alcohol dependence affects approximately 3% of the English population, and accounts for significant medical and psychiatric morbidity. Only 5.6% of alcohol-dependent individuals ever access specialist treatment and only a small percentage ever seek treatment. As people who are alcohol dependent are more likely to have experienced health problems leading to frequent attendance at acute hospitals it would seem both sensible and practical to ensure that this setting is utilised as a major access point for treatment, and to test the effectiveness of these treatments.

Methods/Design

This is a randomised controlled trial with a primary hypothesis that extended brief interventions (EBI) delivered to alcohol-dependent patients in a hospital setting by an Alcohol Specialist Nurse (ASN) will be effective when compared to usual care in reducing overall alcohol consumption and improving on the standard measures of alcohol dependence. Consecutive patients will be screened for alcohol misuse in the Emergency Department (ED) of a district general hospital. On identification of an alcohol-related problem, following informed written consent, we aim to randomize 130 patients per group. The ASN will discharge to usual clinical care all control group patients, and plan a programme of EBI for treatment group patients. Follow-up interview will be undertaken by a researcher blinded to the intervention at 12 and 24 weeks. The primary outcome measure is level of alcohol dependence as determined by the Severity of Alcohol Dependence Questionnaire (SADQ) score. Secondary outcome measures include; Alcohol Use Disorders Identification Test (AUDIT) score, quantity and frequency of alcohol consumption, health-related quality of life measures, service utilisation, and patient experience. The trial will also allow an assessment of the cost-effectiveness of EBI in an acute hospital setting. In addition, patient experience will be assessed using qualitative methods.

Discussion

This paper presents a protocol for a RCT of EBI delivered to alcohol dependent patients by an ASN within an ED. Importantly; the trial will also seek to understand patients' perceptions and experiences of being part of a RCT and of receiving this form of intervention.

Trial registration number

ISRCTN: ISRCTN78062794