Healthcare interactions prior to first hospital admission with alcohol-related liver disease.
Lewis, H., Parker, R., Ul-Haq, Z., et al. Liver International. 2024;44(9), 2095-2506
This observational retrospective cohort study aimed to examine the healthcare contacts of patients in the year before an index hospital admission with alcohol-related liver disease (ArLD). The authors wanted to identify opportunities for earlier identification of alcohol use disorders (AUD) and ArLD, and possible intervention. Using a database of NHS organisations across North West London (344 GP practices, 4 acute hospital trusts and 2 mental health and community health trusts), patients with an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured. There were 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD:
- 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts;
- 80% (n = 1199/1494) attended ED;
- 68% attended an outpatient clinic;
- 42% (n = 628/1494) had at least one inpatient admission;
- Only 9% of the ArLD cohort (137/1494) had formal testing for AUD, and;
- Abnormal bilirubin and platelets were more common in the ArLD than the control cohort; 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784).
The authors concluded that prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.
Commentary:
This paper is a timely reminder that we sometimes miss the opportunity to identify substance use disorders and provide appropriate interventions. I recently encountered several patients in hospital with a new diagnosis of decompensated ArLD, and was struck by how their liver disease managed to fly under the radar for so long. Of course, stigma and shame may factor into someone’s decision to disclose problematic alcohol use to a healthcare professional, and sometimes an individual may not think their alcohol use is problematic, but often clinicians simply do not have the relevant skills to identify AUDs. One of the biggest reasons for this is a lack of appropriate undergraduate addictions education for doctors and nurses.
We owe it to patients, however, to ask the uncomfortable questions so we can identify problems and provide appropriate harm reduction advice and treatment recommendations. A skilled clinician can identify and diagnose AUD with an unstructured assessment, but we should also be embedding standardised, structured AUD screening tools, which are relatively user-friendly, into practice. Given the long-term benefits of reducing preventable morbidity and mortality (and associated healthcare costs), the importance of consistent and standardised screening for AUD in high-traffic healthcare settings (EDs and GP practices) cannot be over-emphasised. Only 506 patients (34%) had some form of alcohol assessment in the ArLD cohort, and it is unclear if this took place before their ArLD diagnosis. This is not good enough. But, of course, there must be more investment for GPs and EDs to incorporate AUD screening into already-busy workloads. Perhaps technology (for patients with access) could be utilised to facilitate screening, and to provide brief interventions, education, and referral to alcohol services. Scanning a QR code and completing the Alcohol Use Disorders Identification Test (AUDIT) on a smartphone may be less daunting for some than being asked questions about their alcohol use by their GP, though this should not be a substitute for clinical assessment when it is indicated.
The patients in this study with ArLD had high rates of comorbidity, specifically depression, anxiety, hypertension, diabetes, obesity, and chronic obstructive pulmonary disease (COPD). Anyone with one of these conditions should be told about the bi-directional relationship between their diagnosis and alcohol, which may help to open up a wider conversation about their alcohol use. The authors point out that these comorbidities may also result in more frequent health service interactions and more opportunities for opportunistic screening of AUD. Finally, patients in the ArLD cohort were more likely to have liver function blood tests in the year prior to admission. The presence of elevated bilirubin and low platelets, which were far more common than in the control group, should direct the clinician to screen and test for AUD and ArLD.
Written by Tom Jones, Master of Advanced Nursing Practice
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