SMJ 2003 48(4): 114-116
Tom S. Waddell*, W. Stuart Hislop+
* Final year medical student, University of Glasgow
+ Department of Medicine, Royal Alexandra Hospital, Paisley
Key Words : admissions, alcohol, alcoholic liver disease (ALD), cardiology, gastroenterology, respiratory
A 4 week study of medical inpatients was performed to look at prevalence of alcohol- related problems in three different sub-specialties. Alcohol-related conditions accounted for 51% of gastroenterology inpatients, and 65% of these patients had alcoholic liver disease. In contrast, the cardiologists and respiratory physicians managed far less alcohol-related pathology, accounting for only 6% of inpatients in each specialty. Alcohol-related conditions were three times commoner in men. Patients admitted due to alcohol had longer lengths of stay, and experienced higher morbidity and mortality. These findings have important implications for health care planning and provision. They highlight a need for specialist training to be given to staff who deal with alcohol-related conditions on a daily basis. There is also a significant public health issue raised by these results regarding public attitudes in Scotland towards alcohol abuse and the increasing burden it is placing on the NHS.
INTRODUCTION
In recent years, there have been several reports about increasing number of patients admitted to general hospitals in Scotland with of alcohol-related illness (1,2,3). The purpose of this analysis was to provide information regarding the prevalence of alcohol-related conditions in the medical unit of the Royal Alexandra Hospital, Paisley. A previous study performed at the same hospital (4) demonstrated a wide range of alcohol-related conditions on the gastroenterology ward, and the acute medical receiving unit (AMRU), where a specialty triage system operates.(5) By comparing the amount of alcohol-related pathology on three different medical wards, it would be possible to establish the exposure of several individual specialties to these problems. It was therefore decided to collect information such as patient age, sex, presence of alcoholic liver disease (ALD), and length of patient stay to allow a more detailed analysis to be performed.
METHODS
Information was collected on data sheets regarding the reason for admission of each patient on the three wards (cardiology, gastroenterology or respiratory medicine). Patients were broadly classified as being either
(a) general medical (eg cellulitis, minor cerebrovascular events, frail elderly patients admitted for “social” reasons, deep vein thrombosis, alcohol related problems of a non-gastroenterological nature etc), or
(b) appropriate to the ward speciality.
Inappropriate triage was rare; patients were sometimes kept longer in AMRU until a suitable speciatlty bed became available. It was also recorded whether the admission was related to alcohol. (Sources of this information included medical and nursing staff, case-notes, hospital computer records, the patients themselves or their relatives). Also collected were the patient’s name, age, sex, hospital identification number, date of admission, and the consultant in charge. In addition, patients on the gastroenterology ward were classified according to the presence or absence of decompensated liver disease. The information was updated daily for all new admissions to the wards, and discharge dates were filled in for those patients who had left hospital. Patients transferred within the hospital were followed up at a later date to establish when they were discharged. Patients who had died whilst in hospital were recorded as such, along with the date of death.
A variety of different admissions were classified as having been directly related to alcohol. These included ALD, upper gastrointestinal bleeding related to alcohol abuse, acute alcohol poisoning, self –poisoning with drugs coexistent with alcohol abuse, self- neglect, malnutrition, or starvation due to alcoholism, alcohol-induced chest pain or dysrhythmias, respiratory or other infections due to alcoholic immunosuppression, alcoholic peripheral neuropathy, Korsakov psychosis or other type of chronic alcohol related brain damage, and withdrawl syndromes including delirium tremens, fits or Wernicke’s encephalopathy.
Statistical analysis where indicated used the students t test (6)
RESULTS
Over the 4 week period, data was collected on 390 patients across the three wards. (Table 1) The average age of the study population was 66.2 years (range 19 to 94). Alcohol was a significant factor in 51% (43/84) of total inpatients in the gastroenterology ward, and accounted for 65% (37/57) of all inpatients who had a gastrointestinal complaint. In contrast, alcohol only accounted for 6% (11/179) of cardiology inpatients, and was the cause of admission in only 7 out of 127 inpatients on the respiratory ward (6%). The results show that the bulk of alcohol-related admissions were seen by the gastroenterologists, with cardiologists and respiratory physicians dealing with less than one third of all alcohol-related admissions.
A comparison of the numbers of non-specialist patients on each ward revealed that only 9% (16/179) of cardiology inpatients had a non-cardiac complaint. In contrast, 24% (30/127) of the inpatients managed by the respiratory consultants were admitted for non-respiratory problems, and 32% (27/84) of patients looked after by the gastroenterologists had no gastrointestinal complaint. Of the 73 general medical patients, 11(15%) had conditions relating to alcohol misuse and 6(55%) of these patients were placed under the care of the gastroenterologists
Of the 43 gastroenterology inpatients with alcohol-related pathology, 65% (28/43) already had decompensated ALD (Table 2). Conversely, of the 34 patients on the ward with decompensated liver disease, 82% (28/34) were due to ALD. Men accounted for 77% (33/43) of all gastroenterology inpatients whose admissions were due to alcohol (m/f ratio of 3.3/1). This difference increased when looking only at those patients with ALD, with men accounting for 79% (22/28) of cases (m/f ratio of 3.7/1).
The average age of the patients varied across the three wards, being significantly younger at 62.5 (SD = 15.6) in gastroenterology than in cardiology {66.6 (SD=13.8; p<0.05)}, or in respiratory {68.1(SD=15.3; p<0.01)}. The average age of patients whose admissions were due to alcohol were even lower at 55.0 (SD=9.9) in gastroenterology, compared to 60.9 (SD=12.2) in cardiology, and 58.4 (SD=15.9) in respiratory, but these differences between wards did not reach statistical significance. Compared to the overall figures (Table 2), alcohol-related illness is prevalent in significantly younger gastroenterology inpatients; 55 (SD=9.9) for all alcohol-related gastroenteroloy problems, and 52.6 (SD=9.7) in ALD (p<0.01, for both groups). In contrast there were no significant differences between the average age of inpatients with alcohol-related problems, and those inpatients without, in either the cardiology or respiratory wards.
Analysis
of the age distribution on the gastroenterology ward (Fig.
1) showed that 68% (29/43) of all patients with alcohol-related admissions
were in the age range 40-59 years, and in ALD the proportion in the same age
range was slightly higher at 72% (20/28).
Length of stay in gastroenterology was 22.2 (SD=26.3) days; significantly longer than either respiratory (14.3 days; SD=18.7; p<0.05), or cardiology (10.4 days; SD=20.4; p<0.001). Amongst the gastroenterology patients with alcohol-related complaints the average admission lasted for 22.7 days, and this increased to 25.8 days in those with ALD. Although these numbers did not reach statistical significance, they suggest a trend of increased morbidity in patients with ALD of whom 14% (4/28) died in hospital. In gastroenterology as a whole the mortality rate was 12% (10/84); higher than the mortality rates seen in either respiratory or cardiology .{10% (13/127) and 7% (13/179) respectively}.
DISCUSSION
The current study completes a survey of the current pattern of specialty inpatient work in relation to alcohol related illness in the Royal Alexandra Hospital since 1999. This study again demonstrates the burden being placed on the specialty of gastroenterology as a result of increasing numbers of inpatients with alcohol-related illness; which, during the study period accounted for nearly two thirds of all gastroenterology inpatients (4). However, the gastroenterology ward was also found to have significantly more patients with general medical complaints than either cardiology or respiratory. This may be explained by the tendency for patients with other alcohol problems, but without gastrointestinal complaints, to end up under the care of the gastroenterologists, perhaps because of the expertise built up by their nursing staff in dealing with these kind of cases.
Morbidity associated with alcohol abuse has been shown to be closely related to the amount consumed, with a significantly worse prognosis in those drinking more than 22 units a week (7). However, this study found that 65% of gastroenterology inpatients admitted to hospital with an alcohol-related illness already had decompensated ALD. This highlights a need for early intervention to reduce alcohol consumption to a safe level before irreversible damage has taken place, as put forward in the recent National Alcohol Plan for Scotland (8). However, there is also a need for resources now to tackle the very serious problem of the cost of treating the current levels of decompensated ALD presenting to our hospitals. These inpatients not only have average lengths of stay of over 3 weeks, but also have many complications such as ascites, bleeding varices, and septicaemia that are expensive to treat.(9)
The results of this study also stress the increased prevalence of alcohol-related disease in males. Men were more than three times as likely to have an alcohol-related illness, and were nearly four times more likely to have ALD. Recent data suggests that males with cirrhotic liver disease have a marked survival disadvantage compared to females, and prognosis worsens with increasing age (10)
Perhaps more worrying was the age distribution of alcohol problems, especially that nearly three quarters of all patients with ALD being in the 40-59 year age group. This supports other data which suggests that drinking patterns have changed across the general population (3), with problem drinking occurring at an progressively younger age. In addition, the length of stay and mortality data suggest that these patients have insreased morbidity, and higher death rate than other inpatients. Alcohol misuse seems therefore to be causing both significant morbidity in middle-aged patients, (who might otherwise expect fewer health problems), and also an accompanying reduction in life expectancy, and should thus be a major public health priority. However, the complex aetiology of alcohol abuse, which includes socio-economic factors such as poverty, social class, and alcohol availability, make it a particularly difficult problem (11)
The high prevalence of alcohol-related problems among their inpatients emphasises the need for specific training to be given to trainee gastroenterologists in all aspects of alcohol-related disease. In addition, there may be an indication for specialist nursing staff to be trained to deal with the particular problems faced in the management of the physical consequences of alcohol abuse. This might increase the efficacy of patient management and relieve the burden these patients place on other medical or surgical specialties (12).
The findings of this study make it clear that continuing research is required into the field of alcohol abuse and the reasons behind its increasing prevalence. Only by developing a better understanding of the factors leading to alcoholism, and the current problems faced in its management can new treatment strategies, and effective preventive measures be introduced.
While current political attention is focused correctly on strategies to prevent problem drinking , (particularly among the young), there is an equal need for increased resource allocation for the current burden of care, which should be targeted to those areas of the acute sector most under pressure from the current record levels of alcohol related illness.
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