title: Opportunities for intervention: Characteristics of alcohol related visits to United States emergency departments, 2003 - 2007
Creators: name: LaValley, Jonathon
Publisher: name: University of Nevada, Las Vegas
Year: 2010

description: The cycle of alcohol intoxicated patients passing through United States (US) emergency departments (ED) and repeated inpatient detoxification for alcohol inebriates is costly, as these patients are continually exposed to injury and other health and legal consequences of their continued at risk alcohol use. The high proportion of ED resources used by these alcohol intoxicated patients has contributed to increased patient wait times, increased ambulance diversions, forced closures of US EDs, increased numbers of patients leaving without being seen, and an overall reduction in the quality of medical services provided in the ED. In order to contribute to efforts towards reducing the proportion of ED visits which involve hazardous alcohol consumption, this project used a national probabilistic sample of emergency department patient visits to demonstrate and quantify: 1) the burden that alcohol use and abuse places on EDs in the US; 2) the particular service needs of patients presenting for alcohol intoxication; 3) the degree to which ED clinicians refer patients with alcohol related diagnoses to treatment geared towards at risk alcohol consumption; and 4) trends in rates of hospitalizations for alcohol related visits over the study period. 
Alcohol related and non-alcohol related visits were compared using national ED data to measure the impact of alcohol related visits on the emergency medical service delivery system. Using cross-sectional data from the 2003 - 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS), patients were assigned to alcohol related and non-alcohol related categories using physician diagnoses. These diagnoses, present in the NHAMCS data are coded using the International Classification of Disease Ninth Revision - Clinical Modification (ICD9-CM). Once identified, patients seen for alcohol related visits were compared to patients seen for non-alcohol related visits. Weighted visit characteristics were compared with odds ratios (OR), t-tests and 95% confidence intervals (CI). 
Of 575 million weighted ED visits, 1.62% were for alcohol related conditions. This translated to an average annual rate of 1,619.6 alcohol related visits per 100,000 ED admissions. No temporal trends in the rate of visits per 100,000 ED admissions were observed during the study period. Alcohol related visits took longer (1,254.2 min vs. 892.6 min; p<0.0001), were triaged with a higher level of acuity, and received more diagnostic tests (5.5 vs. 4.4; p<0.0001). Patients seen for alcohol related conditions were more apt to have been seen in the last 72 hours and had more visits to the same ED within the last year (2.6 visits vs. 1.5 visits, p=0.0028). Alcohol related patients more frequently arrived at the ED via ambulance (51.6% vs. 16.3%; OR 5.2, 95% CI 4.7-5.5) or via public services (9.4% vs. 1.5%, OR 7.0, 95% CI 5.6-8.8). Alcohol related patients were more often male (71% vs. 46%; OR 3.0, 95% CI 1.9-2.3), aged 25-44 years (44.6% vs. 28.7%; OR 2.0, 95% CI 1.8-2.2), and homeless (13.5% vs. 0.5%; OR 5.7, 95% CI 3.9-8.3). The primary payer source was self-pay (31.6% vs. 15.1%; OR 2.6, 95% CI 2.4-2.9). Alcohol related patients were more apt to be injured (97.2% vs. 34.7%; OR 64.5, 95% CI 45.61-91.4). Alcohol related patients were more likely to become injured due to assault (6.9% vs. 4.4%, OR 1.6, 95% CI 1.3-1.9) and unintentional injury (51.7% vs. 26.7%, OR 1.6, 95% CI 1.5-1.9) than patients without alcohol diagnoses. Alcohol related patients were more often admitted to a hospital (7.9% vs. 12.8%; OR1.4, 95% CI 1.2-1.6) or to leave the ED against medical advice (3.2% vs. 1.1%; OR 3.1, 95% CI 2.3-4.2). Patients discharged from the ED were referred to alcohol treatment only 18.5% of the time. Patients presenting with alcohol related conditions were more frequently referred to social services (7.4% vs. 0.7%, OR 12.1, 95% CI 9.0-16.4). Only 47.8% of all alcohol related visits required medical treatment beyond alcohol detoxification. 
Patients presenting to the ED with alcohol related medical conditions use more resources, have longer ED visits, and infrequently receive referral to substance abuse treatment. High priority should be placed on methods to identify patients who could safely be managed in sobering facilities. Indicated interventions with measured levels of success in reducing the frequency of alcohol related visits to the ED such as the Screening and Brief Intervention with Referral to Treatment (SBIRT) program must be employed. SBIRT has performed well in clinical evaluation for reducing alcohol related visits to US EDs.