Opportunities in UK primary and secondary healthcare settings to prevent alcohol misuse

Background Alcohol-related deaths and hospital admissions have risen steeply in the United Kingdom and little is known about whether there are opportunities for preventive interventions or opportunities for the earlier detection of alcohol misuse. The purpose of this research was to investigate and describe patterns of healthcare utilisation in the pre-diagnosis period of alcoholic cirrhosis and alcoholic psychosis, two alcohol-related disorders which contribute significantly to alcohol related morbidity and mortality. This information is important as it could greatly facilitate a better understanding of opportunities for the earlier detection of alcohol misuse, and could also potentially encourage and assist practitioners in the timely identification of those who are at high risk of developing significant alcohol-related illnesses. Specific research objectives 1)To estimate rates of primary and secondary healthcare contacts before the diagnosis of alcoholic cirrhosis/psychosis and assess whether this differs from rates in the general population 2)To characterise the healthcare contacts and establish whether such consultations were for other conditions known to be related to alcohol. 3)As a secondary objective, to establish whether prior healthcare contacts led to recognition of alcohol problems and consequent interventions. Methods UK general practice and hospital admissions data were used for this research. A population of patients diagnosed with alcoholic cirrhosis and subsequently, a population of patients with alcoholic psychosis were identified. For each case, 10 patients without the disease who were of similar age and from the same general practice were selected as controls. For each disease group, a case-control study design was used to compare rates of primary care contacts and hospital admissions in cases to that of the control population. Further, the reasons for primary care visits and hospital admissions were assessed to describe the frequency of other alcohol-attributable morbidities in cases and controls, and to assess whether there were any morbidities which were strongly associated with the later development of alcoholic cirrhosis and psychosis. Finally, the proportions of patients who had a record of their alcohol use status or a record of an offer of brief alcohol intervention/referral were estimated. Results Alcoholic cirrhosis 2,479 patients with alcoholic cirrhosis and 24,790 controls matched on age and GP practice were available for analysis. Assessment of healthcare utilisation showed that people with alcoholic cirrhosis had 50% higher rate of GP visits and twice as many hospital admissions compared to the control population. This excess healthcare use was apparent as far as 10 years pre-diagnosis of alcoholic cirrhosis, but greater excesses were seen within 5 years of diagnosis. Cases of alcoholic cirrhosis did have a higher frequency of other conditions that are partly alcohol-attributable, especially diabetes, epileptic seizures, hypertensive diseases, injuries and digestive diseases. Of all these conditions, injuries, seizures and digestive diseases had the strongest association with the development of alcoholic cirrhosis. Overall, a high proportion of patients with alcoholic cirrhosis (84%) had their alcohol use documented on an average of 4 years before diagnosis and 58% of these records indicated harmful/hazardous drinking. However, only 1 in 5 patients (22%) had any record of a brief alcohol intervention or an alcohol referral. Alcoholic psychosis 1,731 patients with alcoholic psychosis and 17,310 matched controls were included in the study. As with alcoholic cirrhosis, there was a substantially higher rate of primary and secondary care use in cases which was apparent up to 10 years prior to disease diagnosis. Cases of alcoholic psychosis also had a higher frequency of partly alcohol attributable morbidities. However, the strongest associations were seen for intentional and unintentional injuries and seizures. 78% of cases of alcoholic psychosis did have their alcohol use recorded, 50% had a harmful/hazardous drinking record but only 1 in 5 (19%) had any intervention record. Conclusion and Implications: This research has shown that patients who misuse alcohol make frequent contacts with both primary and secondary care, suggesting that there are high number of opportunities within these healthcare settings to improve the early identification and treatment of alcohol use. Relatively few patients were identified to have received brief alcohol interventions/referral despite the large proportion of people with documented drinking problems, suggesting potential inadequacy in the treatment of alcohol problems. However, this may also partly be an artefact of recording biases. Considering that alcohol is one of the leading preventable causes of morbidity and mortality in the UK, these findings should encourage healthcare professionals to, at the very least, screen for alcohol misuse in patients presenting with any alcohol-attributable condition, and for policy makers to consider directing more effort towards integrating alcohol screening and brief intervention into routine clinical practice