1. Improving the Discharge Process for Hospitalized Patients with Alcohol Use Disorders
John Stephens
March 22, 2016

2. Disclosures
No financial conflicts

3. Objective
Describe a quality improvement project within UNC Hospital Medicine to improve the discharge process for hospitalized patients with alcohol use disorders (AUDs), including the rationale and evidence for the project

4. Outline Background Description of implementation measures and metrics
Results to date

5. Background
Alcohol-related hospitalizations incurred $5.1 billion in costs in 2006
Approximately 17% of hospitalized patients have a history of unhealthy alcohol use
Am J Prev Med 2011;41(5):516–524
Drug Alcohol Depend. 2006;83:1–14.

6. Background
At UNC, we admit a significant number of patients with AUDs to Hospital Medicine
Previous work our group did centered on standardizing the evaluation of patients referred for detoxification
Statistics prior to that project:
18.9 admissions/month
30-day readmission rate 26.7%

7. Background Statistics after project: 15.9 admissions/month
30-day readmission rate 28.4%

9. Background
Several medications are approved for use as adjuncts to maintain sobriety

10. Background
The agents with the best evidence for efficacy are acamprosate and naltrexone
Naltrexone has been the most studied agent in the United States

12. Evidence Review
The majority of the naltrexone trials used 50 mg daily for 12 weeks
Outcome
Studies
Patients
Risk Difference
NNT
Any drinking 16
2347
-5% 20
Heavy drinking 19
2875
-9% 12

13. Background
Most studies enrolled patients after detoxification or 3 days of sobriety
The majority of trials included psychosocial interventions in addition to medication vs. placebo
The studies were largely performed in outpatient settings

14. Background
A recent study performed in the inpatient setting included starting naltrexone as part of a discharge bundle
JGIM. 2015, 30(3):

15. Background

16. Background
We had no standard processes for discharging patients with AUDs
The discharge process from UNC Hospital Medicine essentially never included counseling on medications to aid in maintenance of sobriety

18. Interventions 3 Steps: 1) Identifying patients to target
2) Counseling patients with AUDs on medications to aid in maintenance of sobriety and prescribing when appropriate
3) Providing appropriate follow up

19. Interventions Identifying patients
Targeted patients admitted for alcohol detox or withdrawal
Recommended grouping these admissions to one of our three medical services; the APP on this service, Kelly Stepanek, is part of the improvement team
Patients are identified prospectively and placed on EPIC list

20. Interventions Counseling
Britta Starke from UNC ASAP program created a suggested script, based on motivational interviewing techniques, to use in talking with patients about alcohol misuse and medications
She also gave a group noon conference on motivational interview techniques

21. Interventions Counseling/prescribing
For interested patients without contraindications, we start naltrexone 50 mg daily for 30 days with 2 refills (12 weeks) at discharge
Naltrexone contraindications
Concurrent opiate use
Cirrhosis
Acute hepatitis (AST/ALT >3x upper limit normal)

22. Interventions
EPIC Smart Phrases were created to aid counseling, prescribing and documentation
The patient was counseled on the need for alcohol cessation.  Patient has [AST/ALT >3x ULN/cirrhosis/concurrent opiate use/no contraindications to naltrexone].  Counseling included discussion of medications for maintenance of sobriety.  Patient [has contraindications to naltrexone/declined naltrexone/will be started on 50 mg naltrexone daily at discharge].

23. Interventions Appropriate follow up
If patient has PCP, we utilize him or her for follow-up
If no PCP, patient should qualify for the UNC Transitions Program and can be made an appointment through that process

24. Metrics Process measures Outcome measures
% of alcohol detox/withdrawal patients (DRG 896/897) counseled or discharged on naltrexone
Outcome measures
30-day readmission rate
30-day ED revisit rate

25. Pre-Intervention (n=165)
Results
Process measures
Study Outcome
Pre-Intervention (n=165)
Post-Intervention
(n=40)
p-value
% Counseled on Naltrexone
3.0%
72.5%
<.001
% Started on Naltrexone
40.0%

26. Results

27. Pre-Intervention (n=165)
Results
Outcome measures
Study Outcome
Pre-Intervention (n=165)
Post-Intervention
(n=38)
p-value
30-Day ED Revisit
27.9%
15.8%
0.124
30-Day
Re-hospitalization
13.9%
5.3%
0.142

28. Summary
There is evidence naltrexone helps patients with AUDs maintain sobriety and it has been started in inpatient setting after detox
We have successfully implemented a process for starting naltrexone on these patients at UNC Hospital Medicine
Implementation has correlated with trends towards decreased hospital utilization

29. Questions?