Full length articleUnhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge☆
Introduction
Efforts to improve the quality of hospital care often focus on readmissions within 30 days of hospital discharge because readmissions can reflect a poor outcome for patients and higher costs for the health care system (Jencks et al., 2009). Hospital readmissions are common among older adults and are an international hospital quality indicator (Blunt et al., 2015, Gerhardt et al., 2014, Jencks et al., 2009, Parker, 2005). In the U.S., the Centers for Medicare and Medicaid Services (CMS) recently implemented the hospital readmission reduction program (Centers for Medicare and Medicaid Services, 2014) and funded implementation of care coordination interventions (Brock et al., 2013, Voss et al., 2011), based on evidence that readmissions can be prevented with proper transitional support and discharge planning (Coleman et al., 2006, Leppin et al., 2014). Use of emergency departments (ED) could also indicate poor transitions following inpatient care (Baier et al., 2013, Kocher et al., 2013), but has received less attention from policy makers and is not currently monitored as a hospital quality metric. However, previous literature has highlighted many complex patient-level characteristics that may contribute to risk for readmissions and ED visits, such as patient age, gender, or socioeconomic status (Amarasingham et al., 2010, Arbaje et al., 2008), which may not be modifiable characteristics within the control of hospitals.
Unhealthy alcohol use is a potentially modifiable health behavior that may be a risk factor for readmissions in the elderly. While several studies have examined the association between unhealthy alcohol use and readmissions (Kartha et al., 2007, Rubinsky et al., 2012, Walley et al., 2012, Wei et al., 2015), no prior study has focused on older adults. Prior studies have also not utilized alcohol screening results documented in the electronic health record (EHR) as part of routine care, and have not examined the association between unhealthy alcohol use and ED visits in the 30 days after discharge. While unhealthy alcohol use is less common among older adults, nearly 9% drink at unhealthy levels based on self-reported consumption (Kirchner et al., 2007), although the exact prevalence is unknown. Older adults are particularly vulnerable to the adverse effects of alcohol (National Institute on Alcohol Abuse and Alcoholism, 2005), but are less likely than younger patients to have alcohol use assessed during clinical care (Burman et al., 2004, Duru et al., 2010).
Routine alcohol screening with the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) screening questionnaire was implemented in the U.S. Veterans Health Administration (VA) in 2004 (Bradley et al., 2006). The VA is the largest integrated health care system in the U.S. and provides care for over 5 million patients annually (Kizer and Dudley, 2009). VA patients generally have poorer health status and more comorbidities, including mental health conditions, than non-VA patients (Ajmera et al., 2011, Selim et al., 2010). The VA has emerged as a leader in implementation of alcohol screening and other health systems are increasingly implementing alcohol screening as well (Jonas et al., 2012). Yet, it is currently unknown whether available alcohol screening results, collected as part of routine care during outpatient visits, could be useful for identifying hospitalized older adults at increased risk for hospital readmissions and ED visits within 30 days of hospital discharge.
The present study's objectives were to examine whether unhealthy alcohol use, according to AUDIT-C scores documented in the VA's EHR, was associated with (1) increased risk for readmissions or (2) increased risk for ED visits, in the 30 days following a hospitalization for a medical or surgical condition in a national sample of older VA patients. If unhealthy alcohol use was associated with increased 30-day hospital readmissions or ED visits, it could indicate an opportunity for clinicians and health systems to deliver targeted alcohol-related interventions for hospitalized patients in an effort to reduce hospital readmissions or ED use.
Section snippets
Data sources and study sample
The VA's Corporate Data Warehouse (CDW) provided data for VA acute care hospitalizations, outpatient utilization, AUDIT-C scores, demographics, and date of birth and death. The VA Information Resource Center (VIReC) provided Medicare Inpatient, Outpatient, and Carrier standard analytic files for non-VA inpatient and outpatient utilization.
The study sample included all VA outpatients age 65 or older who were hospitalized for a medical or surgical condition at a VA or non-VA hospital
Results
Among 579,330 patients included in the study sample, most patients reported nondrinking (61.6%), based on AUDIT-C screening results, and smaller proportions reported low-risk drinking (27.1%), moderate-risk drinking (10.0%), or high-risk drinking (1.2%). Overall, the mean age was 77 (SD = 7.4) and most patients were white, male, married, and exempt from VA copayments. Table 1 shows descriptive analyses comparing patient demographic and clinical characteristics in the four alcohol risk groups.
Discussion
This study is the first to evaluate the association of unhealthy alcohol use and 30-day hospital readmissions or ED visits in older adults. In this large sample of older adults hospitalized for a medical or surgical condition, patients with routine alcohol screening results indicating high-risk drinking had approximately 1% greater risk of readmissions relative to low-risk drinkers, and this was not explained by demographics, comorbidities, or prior health care utilization. The increased risk
Role of funding source
Ms. Chavez's work on this study was supported by an Agency for Healthcare Research and Quality (AHRQ) Dissertation Grant (NIH 1R36HS022800-01). Dr. Bradley's and Ms. Rubinsky's time on this study was supported by the Center of Excellence for Substance Abuse Treatment and Education (CESATE) at VA Puget Sound. Dr. Bradley's NIAAA R21 (5R21AA020894-02) supported the collection of the data used in this study. Dr. Clark is supported by NIH grant K23 AA 021814.
Disclaimer
Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the United States Government, or any of the authors’ institutions.
Contributors
Ms. Chavez led the study design, conducted analyses, and drafted the manuscript. All co-authors gave input on statistical analyses, interpretation of results, and contributed to and approved the final manuscript.
Conflict of interest statement
No conflicts of interest.
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2020, AlcoholCitation Excerpt :In a study conducted among older adults in the Veterans Health Administration (VA), high-risk drinkers were at increased risk of readmissions compared to low-risk drinkers (Chavez et al., 2016). Patients were defined as low- or high-risk drinkers based on AUDIT-C scores of 1–3 and 8–12, respectively (Chavez et al., 2016). ( The AUDIT-C is an alcohol screen that identifies those who engage in hazardous drinking – i.e., drinking that places patients at risk for adverse health events – or those with active alcohol use disorders [Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998]).
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2020, General Hospital PsychiatryCitation Excerpt :Two patterns of alcohol use were derived from the AUDIT-C based on extensive prior research [50–57]. First, levels of alcohol consumption were measured categorically based on gender-specific AUDIT-C cut-points of the total score (0−12) of the three items—nondrinking: score 0; low-level: score 1–2 or 1–3 (women, men); moderate-level: score 3–7 or 4–7 (women, men), and high-level: score 8–12 (both women and men) [58]. Second, frequency of heavy drinking episodes was measured categorically based on responses to the third AUDIT-C question, which asks how often patients consume six or more drinks on one occasion, with response options: “never,” “less than monthly,” monthly,” “weekly,” and “daily or almost daily” [53,56].
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2019, Geriatric NursingCitation Excerpt :The Centers for Medicare & Medicaid Services use 30-day readmission rates as outcome measures for patients with acute myocardial infraction, heart failure, and pneumonia.18 Chavez and colleagues found pre-hospitalization high risk drinking in Veterans Affairs patients, age 65 years and older was modestly associated with risk for 30-day readmissions leading to increased health care utilization and costs.19 Because care for older adults is unique with complex medical considerations, screening for alcohol consumption to determine implications upon medical status for logical intervention should likely be regarded as a routine process during care in any setting.
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Supplementary material can be found by accessing the online version of this paper at http://dx.doi.org and by entering doi:10.1016/j.drugalcdep.2015.11.008.