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

Gentilello Brief Motivational Alcohol Intervention in a Trauma Center; Annals of Surgery, % of injured trauma center patients age 18 and older screened positive for alcohol problems. Half (N=336) randomly allocated to receive 30 minute brief intervention to reduce risky drinking and offered links to alcohol treatment

Gentilello Brief 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

Monti Brief 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 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

Monti et al., 1999 Results at 6 months MISC 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= Comparable drinking declines in both groups

Longabaugh (2001) 539 Injured Emergency Department Patients Brief Intervention (BI) Brief Intervention and Booster (BIB) Standard Care (SC) R J. Studies on Alcohol. 62:

Longabaugh 2001 Brief Intervention 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)

Longabaugh 2001 Booster Session 7 days after Brief Intervention Discussed post discharge drinking and experiences

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

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 Oct 9;364(9442): 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 Sep;145(3): 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 Sep;5(3): 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 Apr 6;140(7): Review

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

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 N=34, 546 completed patient record forms

Results million ED visits 2.5 million alcohol related ED visits (2%) 39.4 million injury/poisoning visits 5% alcohol related N= 2 million

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

Results: 1 st Time Admissions 86% treated and discharged 2% alcohol related N= 1,712,598 <1% 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, % died (228,689) 6% alcohol related N= 14,802

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% (N=6,297) were referred for additional alcohol treatment Among ED alcohol related injury visits admitted to ICU/CCU none were referred to additional alcohol treatment

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

Discussion McDonald, Wang, Camarge. Archives of Internal Medicine. 1643: , 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

3 Groups of AAF’s % attributable to alcohol by alcohol dependence alcoholic cirrhosis 2. AAF <1 disease e.g. oral cancer 50% 3. AAF <1 injuries e.g. motor vehicle injuries 42%

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

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