Alcohol burden on Accident & Emergency Departments: Implications for policy and practice. Dr. Tom Phillips, PhD. The MCA Symposium 16 th November 2016

Transcription

1 Alcohol burden on Accident & Emergency Departments: Implications for policy and practice Dr. Tom Phillips, PhD The MCA Symposium 16 th November 2016 Background to AED 18.3million AED attendance 2012/13 Increasing demand of AED services (4% since 2011/12) 42.8% < 29years; with 3million aged 20-29yrs 59% of all attendances discharged to GP 21.2% of AED attendances admitted to hospital bed 35% of hospital admission episodes via AED 1million hospital admissions consequence of alcoholrelated diagnosis Relationship between alcohol and AED attendances unclear Source: HSCIC,

2 Background Previous studies have attempted to estimate burden: small studies, time period, coverage (Parkinson et al, 2015; Crawford et al, 2004; Drummond et al, 2003) Estimate the prevalence of alcohol problems in AED through screening instruments (Drummond et al, 2014; Patton, et al, 2004) Further analysis of data would help identify linked AED presentations and alcohol diagnosis that could be utilised to target condition and assess overall prevalence and burden Presentation aims Aims: Identify the needs and burden placed on AED by those who attend with alcohol related presentations Consider policy and practice implications for meeting gaps Method: Presentation of previous studies and analysis of National Hospital Episode Statistics related to AED attendances and Hospital Admissions following AED attendance 2

3 UK Alcohol Strategy (2012) Alcohol Liaison Nurses to provide: Medical management of patients with alcohol problems in the hospital; Liaison with community alcohol and other specialist services; Education and support for other healthcare workers in the hospital; and Delivery of IBA within the hospital with a focus on key groups, including pregnant New health-related objective for alcohol licensing related specifically to cumulative impact policies. Number of alcohol-related hospital admissions in England, by ICD-10 code for wholly attributable conditions 2003/ /14 (HSCIC, 2015) Intox. Harmful Depend All Other ALD Cirrhosis Toxic effect 3

4 Previous analysis of HES data (Currie et al 2015) In 6 years 2008/ /14, doubling of AED attendance rate due to alcohol poisoning Higher rates age groups; women Only accounted for small proportion of activity (0.5%) In 2013/14, approximately 1 in 20 emergency admissions in England were related to alcohol (primary or secondary diagnosis). Highest rates of emergency admission were found in year-old men Data not analysed at individual patient level and did not examine all AED presentation data Analysis of HES data at an individual patient level HES Inpatient Data 2009/10 N=6,563,447 Finished Consultant Episodes Retained individuals: N=2,430,979 ICD-10 code Wholly Alcohol Attributable Diagnosis (WAAD) HES AED Data 2009/10 N= 13,284,470 Attendances Retained individuals: N=7,810,689 AED Diagnostic code Merged HES Inpatient & AED Data 2009/10 Matched: N=2,154,158 FINAL DATASET Significant numbers of cases did not have any recorded AED conditions Final dataset: N=1,209,760 4

5 Description of sample No WAAD N=1,128,502 Acute WAAD N=27,798 Chronic WAAD N=53,460 Not having WAAD Intoxication, Toxic effects, etc Alcohol Use Disorder, Alcohol Liver Disease Mean Age: 59.2yrs Males: 46.1% White: 83.5% Mean Age: 38.0yrs Males: 59.8% White: 84.3% Mean Age: 49.5yrs Males: 71.4% White: 88.1% Associations between AED presentations and WAAD Acute WAAD (Intoxication) Chronic WAAD (Depend, ALD) 5

6 Hospital service utilisation No WAAD Acute WAAD (Intoxication) Chronic WAAD (Depend, ALD) Mean AED Attendances 2.06 (CI ) 2.78 (CI ) 4.33 (CI ) Mean Admissions 1.57 (CI ) 1.58 (CI ) 2.56 (CI ) Mean Total Bed Days 10.4 (CI ) 3.70 (CI ) 15.1 (CI ) Estimated cost using DH Reference Costs 2009/10 No WAAD Acute WAAD (Intoxication) Chronic WAAD (Depend, ALD) AED Mean Cost 257 (CI ) 334 (CI ) ATT: (CI ) ATT: 288 Overall Mean Cost 4,742 (CI 4,648-4,836) 2,488 (CI. 2,387-2,589) 7,270 (CI. 7,093-7,448) ATT: 2,324 Propensity Score Matching using age, gender and ethnicity to obtain Average Treatment effect on the Treated (ATT) 6

7 140 Analysis of 211,000 individuals admitted via AED with A-R Admissions (390k) 2009/ Number of Admissions x 1, Count Cum % ARFA_1 (63.1%) ARFA_2 (19.2%) ARFA_3 (8.0%) ARFA_4 (3.8%) ARFA_5 (2.1%) ARFA_6 (1.2%) ARFA_7+ (2.6%) 0 Insights into the frequent alcohol attender Qualitative study of 30 Alcohol frequent attenders to AED found (Parkman et al 2015): Severe and chronic alcohol alcohol misuse among a group with mean of 5 hospital admissions Substance misuse, self-harm, acute effects of substance misuse need for support drivers for help Lack of engagement in substance misuse services and healthcare services Little desire to address alcohol use more focused Pathways to support beyond AED limited 7

8 Summary HES Data presents a robust, but conservative estimate of alcohol burden on AED where 6.72% of individuals were identified with WAAD Alcohol places a disproportionate burden on AED Those with more severe and chronic alcohol use have the greatest burden on hospital utilisation and exert a cost of 1.47 times greater than similar individuals without WAAD Those presenting most frequently, and being admitted most often, have complex clinical presentations involving alcohol, chronic health problems and mental heath problems Clinical presentations to AED with alcohol, mental health and poisonings suggests there is a cohort of high-risk patients requiring services prioritising patient safety Call to arms! Senior clinicians have identified the need target those alcohol related diseases most burdensome and most in need (Mdege et al, 2014) Current hospital data (SUS) could be utilised to identify the frequently admitted alcohol related patients Consistent call for the development of Alcohol Care Teams in each District Hospital to meet the needs of complex patient groups (NHS Evidence, 2011) Expansion of Assertive Outreach Services beyond the 40% available via AED (Patton, 2016) Enhancing service provision through joint working, training, policies and procedures to prevent high risk patients not being followed up (NCI, 2016) Broaden screening approaches beyond the provision of IBA to identify care pathways for those with chronic and severe alcohol misuse Continued lobbying for the adoption of policies that are likely to have the greatest impact on reducing alcohol related attendances: price, taxation, reduction of license premise density, high quality services 8

9 Thanks you Any questions? 17 9