Hospital contacts with alcohol problems prior to liver cirrhosis or pancreatitis diagnosis

ARTICLE HIGHLIGHTS

Research background

Alcoholic liver cirrhosis and alcoholic pancreatitis develop over many years prior to diagnosis, which offers a window of opportunity in which preventive interventions could be implemented. Hospital contacts with alcohol problems in the period before disease may constitute opportunities for offering alcohol treatment. Earlier studies found that 33%-58% of liver cirrhosis patients had prior hospital contacts indicated by disorders that are sometimes, though not always, associated with alcohol problems such as injuries, non-variceal upper gastrointestinal bleeding, and epilepsy. Hospital contacts with a specific set of alcohol problems (alcohol intoxication, harmful alcohol use, and alcohol dependence) might represent a more feasible opportunity to offer alcohol treatment than disorders associated with alcohol problems. No prior studies evaluated hospital contacts with alcohol problems in patients with alcoholic pancreatitis.

Research motivation

In Denmark, as in many other countries, formalised hospital-based alcohol treatment is not available. Hospitalization with alcohol problems prior to alcoholic liver cirrhosis or pancreatitis diagnosis may represent an opportunity to offer preventive interventions. In a nationwide study, we evaluated previous hospital contacts with alcohol problems in patients with incident alcoholic liver cirrhosis and alcoholic pancreatitis diagnosis.

Research objectives

The objective was to conduct a nationwide study of all patients diagnosed with alcoholic liver cirrhosis and alcoholic pancreatitis 2008 to 2012 in Denmark. In these patients, the extent of prior hospital contacts with alcohol problems in the 10 years prior to their diagnosis of alcoholic liver cirrhosis or alcoholic pancreatitis were evaluated.

Research methods

This was a nationwide, register-based study of all patients diagnosed with alcoholic liver cirrhosis or pancreatitis during 2008-2012 in Denmark. Hospital contacts with alcohol problems (intoxication, harmful use, or dependence) in the 10-year period preceding the diagnosis of alcoholic liver cirrhosis or pancreatitis were identified. Data was obtained from nationwide registries on hospital contacts and causes of death. This is the first study to evaluate prior hospital contacts with alcohol problems in a nationwide design. Furthermore, no prior studies included psychiatric hospital contacts with alcohol problems. Hospital contacts with alcohol problems occurring in the three months prior to diagnosis of alcoholic liver cirrhosis and pancreatitis were excluded to avoid including hospital contacts that might have been precipitated by symptoms of liver or pancreatic disease that were not immediately recognised. Alcohol diagnoses (alcohol intoxication, harmful alcohol use, and alcohol dependence) were assessed as an indicator of the severity of alcohol problems among patients with alcoholic liver cirrhosis and alcoholic pancreatitis. We also estimated the type of hospital care of the prior hospital contacts with alcohol problems (somatic, psychiatric, inpatient, emergency room, or outpatient clinic). Finally, we estimated the time in years that had passed from the initial hospital contact with alcohol problems to alcoholic liver cirrhosis or pancreatitis diagnosis.

Research results

In the 10 years prior to diagnosis, 40% of the 7719 alcoholic liver cirrhosis patients and 40% of the 1811 alcoholic pancreatitis patients had at least one prior hospital contact with alcohol problems. Every sixth patient (15%-16%) had more than five contacts. The 7719 patients with alcoholic liver cirrhosis had a total of 38227 hospital contacts with alcohol problems in the prior 10-years (mean of 5.0 contacts). The median number (5^th-95^th percentiles) of prior contacts was 0 (0-19). The 1811 patients with alcoholic pancreatitis had 8997 prior hospital contacts with alcohol problems in the prior 10 years (mean of 5.0 contacts). The median number (5^th-95^th percentiles) of prior contacts was also 0 (0-19) in these patients. A similar pattern of prior hospital contacts was observed for alcoholic liver cirrhosis and pancreatitis. Around 30% were diagnosed with alcohol dependence and 10% with less severe alcohol diagnoses. For the majority, admission to somatic wards was the most common type of hospital care with alcohol problems. Most had their first contact with alcohol problems more than five years prior to diagnosis.

Research conclusions

In the present study, 40% of all Danish patients with alcoholic liver cirrhosis and alcoholic pancreatitis diagnosed from 2008 to 2012 had at least one hospital contact with alcohol problems in the prior 10 years before diagnosis. Every sixth patient (15%-16%) had more than five contacts. The pattern of prior hospital contacts with alcohol problems was similar for patients diagnosed with alcoholic liver cirrhosis and alcoholic pancreatitis. Roughly 30% had been given a prior diagnosis of alcohol dependence and 10% had less severe alcohol diagnoses (harmful use and intoxication). Inpatient admission to a somatic ward was the type of hospital care most patients have had with prior alcohol problems. More than half of cases with a prior hospital contact in the preceding 10 years had had their initial alcohol-related contact five or more years prior to diagnosis.The implication of our study is that there are opportunities to reach around half of patients who later develop alcoholic liver cirrhosis or alcoholic pancreatitis with preventive interventions in the hospital setting. Suggested preventive interventions for liver disease involve implementation of hospital-based alcohol care teams which was shown to reduce alcohol-related admissions. It may also involve non-invasive assessment of liver disease. Hospital patients with alcohol problems and somatic disease or injury are in particular motivated for alcohol treatment.

Research perspectives

Future studies should assess contacts with obvious alcohol problems in primary care in addition to hospital contacts to compare where patients are most frequently seen with alcohol problems prior to diagnosis of alcoholic liver cirrhosis or alcoholic pancreatitis. In particular, randomized controlled trials are needed to evaluate if alcohol treatment in the hospital setting can decrease the incidence of alcoholic liver cirrhosis and alcoholic pancreatitis.