Title: Evaluating and improving inpatient interventions to reduce alcohol intake in patients with alcohol related cirrhosis.
Funder: Department of Health and Social Care

Abstract: Background: Alcohol-related cirrhosis (AC) is responsible for 84% of liver related death in the UK. The only treatment available for AC is alcohol abstinence and reduction. Despite there being a number of treatments for alcohol use disorder, most have not been evaluated specifically in patients with AC. Moreover, little is known about acceptability of these treatments in patients with AC. These barriers and others likely contribute to low uptake of interventions and poor outcomes for patients with AC. The inpatient admission provides a unique opportunity for patients to be engaged.Research Questions: What is the impact of inpatient interventions to reduce alcohol intake on clinical outcomes of patients with AC? In patients with AC, what is the experience of available interventions? What do healthcare professionals view as the barriers and facilitators to interventions for alcohol use disorder in patients with AC and what are their desired outcomes?Methods:Study 1: A systematic literature review of current interventions used to manage alcohol intake in inpatients with AC will be undertaken. The purpose will be to review the evidence for the effectiveness of these strategies, and to establish which outcome measures are used. Study 2: A retrospective cohort study of emergency admissions of patients with AC. This will allow measurement of the clinical effect of current inpatient interventions. This will assess the impact of current interventions to manage alcohol intake on the clinical endpoints of hospital admissions, liver disease scores and mortality. Study 3: Qualitative study. Semi-structured interviews with patients admitted to hospital with AC will be conducted. Interviewing patients admitted to hospital will allow those of most need to participate. A grounded theory approach and purposive sampling will be used to generate a rich and diverse qualitative dataset. We will explore experiences and views of interventions to reduce alcohol intake, barriers and facilitators of alcohol reduction and goals for treatment. Study 4: A consultation with stakeholders involved in the care of patients with AC will be carried out. This consultation will aim to take account of the whole system and will include patients, hepatologists, psychiatrists, psychologists, nursing staff, healthcare assistant, general practitioners, hospital managers and others. Initially a survey will be used to gather view on barriers and facilitators to provision of interventions in patients with AC. Survey questions will be informed by findings from the first three studies. Respondents will then be invited to participate in a consensus building exercise to identify the priorities for improving uptake of interventions and to determine desired outcomes of AUD interventions in AC. Impact:This research will provide insight into the clinical outcomes of interventions to reduce alcohol intake in patients with AC. Results from quantitative data and the views and experiences of patients and professionals will lead to recommendations on methods to improve the uptake of treatments. We will also be able to recommend preferred outcome measures for evaluating treatments to reduce alcohol intake in patients with AC.

Lay abstract: Why is this research needed?Deaths and harm from alcohol related liver disease have doubled in the last 20 years. Patients often die at a young age and liver disease has overtaken lung and breast cancer in causing years lost of working life. Patients who have alcohol related liver disease and continue to drink alcohol will progress to advanced liver disease called alcohol related cirrhosis and have a very poor outlook. Hospital admission provides an opportunity to engage patients about their alcohol use and help them to cut down or stop drinking alcohol completely. Unfortunately, many of the treatment options to help people cut down on alcohol use are untested in patients with cirrhosis. Available treatments are also grossly underused with only 1% of patients with cirrhosis receiving the preferred combination of medications and talking therapies to support them in reducing their alcohol intake.What will this research find out? This research aims to answer the following questions about treatments to reduce alcohol intake in patients admitted to hospital with alcohol related cirrhosis. What does existing literature tell us about what works? What are the effects of treatments in a real world setting? What is the patient's experience of treatments and how can this help us plan better treatments or better use the treatments we have available? What do health care professionals and feel is preventing patients from receiving treatments? How should we best measure the impact of treatments?What will this research involve?Study oneI will find and review all previous studies that examine treatments to help patients with alcohol related cirrhosis reduce their alcohol intake.Study twoI will review all admissions over a 5-year period to a large teaching hospital for patients with alcohol related cirrhosis. I will establish what treatments they were offered and the effect of those treatments on admissions to hospital, progression of their liver disease and survival.Study threeI will interview patients who have been admitted to hospital with alcohol related cirrhosis. I will ask them about their experiences of treatments, their attitudes towards reducing alcohol intake and their views on how treatments could be better.Study fourI will reach out to a wide range of professionals involved in the care of patients with alcohol related cirrhosis. I will explore their views on how to improve the uptake of current treatments and on how treatment success should be measured.How will patients or public help guide the research?The James Lind Alliance held a consultation with patients and researchers to determine priorities for research in alcohol related liver disease. They set the number one priority as 'What are the most effective ways to help people with alcohol related liver disease stop drinking?' Their fourth priority was 'What is the patients' experience of alcohol related liver disease?' This study seeks to address these two questions. The research engages patients directly to seek insights on these important questions. Discussions with patients in clinic, on the ward and through formal interviews have guided the design of this study. A group of patient representatives will continue to provide advice and support throughout the study.How will findings be shared?The findings will be published in research journals and presented at scientific meetings. I will disseminate the work by presenting it to the broadest range of healthcare teams involved in the care of patients with alcohol related cirrhosis. I will share findings with the patients who participate in the study. I will promote the findings through social media and other publicly accessible sources such as patient groups and newsletters.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: ORAL AND GASTROINTESTINAL