SGEM#313: Here Comes A Regular to the ED

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Date: December 18th, 2020

Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020

Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in Toronto and a lecturer at the University of Toronto. He holds a Masters in Public Administration from the Harvard Kennedy School of Government.

Hasan was on an SGEM Xtra last year discussing the Canadian Association of Emergency Physician’s (CAEP) position statement on Dental care in Canada.

“The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care.”

CAEP has put out other position statements. The most recent is on sick notes for minor illness. For a list of other positions statements from CAEP click on this LINK.

Case: A 45-year-old male with no fixed address is found by a bystander with decreased level of consciousness (LOC) on the street. Emergency Medical Services (EMS) is called, and the patient is brought to the emergency department (ED). An empty bottle of vodka is found on the patient, and the decreased LOC is suspected to be due to alcohol intoxication. It is the patient’s fifth visit to the ED in the last two weeks with a similar presentation. The patient is observed over many hours, their LOC improves, and they are discharged after demonstrating that they can ambulate safely.

Background: A leading driver of morbidity and mortality worldwide is alcohol (1). Alcohol consumption is attributed to approximately 5% of all global deaths. This works out to an estimated 3 million deaths due to alcohol (2).

Alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years according to the 2016 Global Burden of Disease Study (3). There are more hospital admissions in Canada for alcohol-attributable conditions than for myocardial infarction (4).

There is a cost associated with alcohol related harms. In Canada, that number is around $14.6 billion a year with $3.3 billion in health care costs (5). Alcohol related ED visits has also increased more than four times greater than the overall rate of ED visits (6).

This trend of increasing alcohol related ED visits is not unique to Canada. It has also been reported in England, Australia and the US (7-9).

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Clinical Question: What is the one-year overall mortality rate for adults with frequent visits to the ED for alcohol related reasons?

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Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020

• Population: Adults aged 16-105 years of age who made frequent ED visits for alcohol related reasons (two or more ED visits in a year).
  • Excluded: Data inconsistencies, not Ontario residents, Age < 16 or > 105 or death at discharge
• Exposure: Patients with ED visits for alcohol-related mental and behavioural disorders, using the ICD-10-CA code of F10. This includes simple intoxication and withdrawal
• Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons, including those that visited the ED twice in a year, 3-4 times in a year, and greater than four times in a year
• Outcome:
  • Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of co-morbidities
  • Secondary Outcomes: Mental and behavioural disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (e.g., accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, assault) with frequency >5%. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide.

Authors’ Conclusions: “We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.”

Quality Checklist for Observational Study:

1. Did the study address a clearly focused issue? Yes
2. Did the authors use an appropriate method to answer their question? Yes
3. Was the cohort recruited in an acceptable way? Yes
4. Was the exposure accurately measured to minimize bias? Unsure
5. Was the outcome accurately measured to minimize bias? Yes
6. Have the authors identified all-important confounding factors? Unsure
7. Was the follow up of subjects complete enough? Yes
8. How precise are the results? Fairly precise
9. Do you believe the results? Yes
10. Can the results be applied to the local population? Unsure
11. Do the results of this study fit with other available evidence? Yes

Key Results: They identified 160,170 alcohol-related ED visits that had at least one more alcohol-related visit in the 1-year time frame. This represented a cohort of 25,813 patients. The median age was 45 years, two-thirds male, 88% urban, 59% arrived by ambulance and 13% were admitted to hospital on their index case.

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Increasing ED visits was associated with an increased all-cause mortality

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The all-cause one-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common.

The data could also be represented in years of potential life lost (YPLL). This showed the all-cause one-year mortality was 121 YPLL overall, ranging from 97 YPLL among patients with two visits to 231 YPLL among those with five or more visits.

Listen to the podcast to hear Hasan answer my five nerdy questions.

1) Associations: The most obvious limitation to this study is the retrospective observational nature of the study. The multiple visits for alcohol use may be a surrogate marker for something else that is causing the increase observed in mortality. You did adjust for age, sex, income, rural residence, presence of comorbidities. However, there could be other unmeasured confounders responsible for the observed associated increase in all-cause mortality.

2) Validation: The use of ICD-10-CA code F10 to ascertain alcohol use disorders among patients presenting to the emergency department has not been validated. This does not mean it is not valid but should be interpreted with extra caution. 

3) Interventions: It is mentioned in the conclusions that effective interventions have the potential to prevent premature mortality and reduce hospital use. In the introduction you state a systematic review suggests that screening and brief intervention for alcohol-related problems in the ED is a promising approach for reducing problematic alcohol consumption. This was a publication from 2002 (D’Onofrio and Degutis AEM). Is there high-quality evidence for effective interventions that prevent mortality in these high-risk individuals.

4) Rural Areas: More than 10% of the cohort was from rural areas. This will make access to Rapid Access Addiction Medicine clinics more difficult. Does identifying these high-risk individuals make a difference if they cannot obtain the services?

5) Comparison: This data set was not compared to other chronic conditions (diabetes, COPD, CHF, etc.) that present frequently do the ED. It would have been interesting to know if the mortality rate is higher, lower or the same for people who present multiple times to the ED in one-year due to alcohol related reasons.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

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SGEM Bottom Line: Be aware that patients presenting frequently to the ED with alcohol related issues have an associated high risk of mortality in the next year.

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Case Resolution: You approach the patient with concerns over his multiple alcohol related ED visits and offer support in the department and at discharge.

• Offer referral/support to low-barrier addiction medicine services ex. RAAM clinic
• Offer anti-craving medications: naltrexone if no contraindications (especially no opiate use in the last 10 days) – start at 50 mg po daily x 1 week
• Consider additional anti-craving medications: gabapentin 300-600 mg po three-times a day x 1 week to help with cravings/reduce withdrawal symptoms
• Hope to engage people in care by taking this approach

Clinical Application: Have a high index of suspicion for this population. Ensure alcohol withdrawal is adequately treated in the ED. Get comfortable with anti-craving medications, including naltrexone and gabapentin. Familiarize yourself with the resources in your community, especially Rapid Access Addiction Medicine clinics.

What Do I Tell My Patient? I see that you have had multiple visits over the last year. We are worried about you and want to get you the care you need and deserve. I can offer you some medications that could help. Would you also be interested in knowing more about our special Rapid Access Addiction Medicine clinics?

Keener Kontest: Last weeks’ winner was Joshua McGough. Josh is a 3rd year medical student. He knew the word influenza comes from the Latin “Influentia” which translates to “Influence”.  It refers to the idea that the disease was attributed to the influence of the stars!

Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

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Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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Additional Resources:

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