Elsevier

Drug and Alcohol Dependence

Volume 158, 1 January 2016, Pages 94-101
Drug and Alcohol Dependence

Full length article
Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge

https://doi.org/10.1016/j.drugalcdep.2015.11.008Get rights and content

Highlights

  • Evaluated the association of unhealthy drinking with 30-day readmissions.

  • Unhealthy drinking identified through routine outpatient alcohol screening.

  • High-risk drinking associated with 1% greater absolute risk for 30-day readmissions.

  • Other social risk factors appeared to account for this elevated risk.

Abstract

Background

Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits.

Methods

Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009–10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization.

Results

Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n = 7,167) and nondrinking (n = 357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0–14.6%; and 14.2%, 95% CI 14.1–14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7–13.0%). Only nondrinkers had increased risk for ED visits.

Conclusions

Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits.

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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