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Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024.

Date: March 27, 2024

Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals.

Case: It’s a Friday evening at the end of the academic year in the Paediatric Emergency Department (ED) and you are with the parents of a 15-year-old girl who has been brought in acutely intoxicated from an unofficial “School’s Out” party. Although your patient has recovered and is now fit for discharge, her parents are very worried that this may mean she is at more risk in the future.

Background: We know that alcohol is a major cause of mortality and morbidity across the world [1] and that ED attendance due to it is rising [2,3]. We also know that adults who attend ED with alcohol-related problems are at an increased risk of death in the following year [4]– in fact, we discussed exactly that in SGEM#313 where we agreed that increasing frequency of alcohol-associated ED visits was associated with increasing mortality.

However, we haven’t previously looked at the effect of alcohol in this specific vulnerable age group.

CLINICAL QUESTION: IS A FIRST ED PRESENTATION RELATED TO ALCOHOL ASSOCIATED WITH INCREASED MORTALITY IN ADOLESCENTS AND YOUNG ADULTS?

Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024.

  • Population: Patients aged 12-29 with ≥1 ED visit in Ontario 2009-15.
    • Excluded: Patients not resident in Ontario, those who were not eligible for OHIP 2 years before and 3 years after, and those with an alcohol-related ED visit in the 2 years before study commencement.
  • Intervention: Any visit related to alcohol
  • Comparison: No visits related to alcohol
  • Outcomes:
    • Primary Outcome(s): Mortality at 1 year
    • Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death.
  • Type of Study: Retrospective cohort study.

Dr. Daniel Myran

This is an SGEM HOP and we are pleased to have the lead author Dr. Daniel Myran on the show. Dr. Myran is the Canada Research Chair, Social Accountability, University of Ottawa Investigator, Assistant Professor, Department of Family Medicine, University of Ottawa, Associate Scientist, Ottawa Hospital Research Institute with a Cross Appointed School of Epidemiology and Public Health, University of Ottawa

Authors’ Conclusions: “Incident ED visits due to alcohol in adolescents and young adults are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation.”

Quality Checklist for Observational Cohort Studies:

  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? No
  7. Was the follow-up of subjects complete enough? Yes
  8. How precise are the results? The confidence intervals are well away from zero, so precise enough.
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Yes and unsure
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding? Canadian Institutes of Health Research, Ontario Ministry of Health, Ontario Ministry of Long-Term Care. One author received speaker fees from pharma for unrelated subjects.

Results: There were 71,778 alcohol-related attendances out of 2,340,097 total attendances in the study period. Of the alcohol-related attendances, 56% were male, 25% in the lowest income quintile, and 68% related to acute intoxication.

KEY RESULT: ED ATTENDANCE WITH AN ALCOHOL-RELATED ISSUE WAS ASSOCIATED WITH AN ODDS RATIO OF 3.07 FOR MORTALITY AT 1 YEAR.

  • Primary Outcome: 1-year mortality was 0.35% in the alcohol group versus 0.1% in the non-alcohol group for an adjusted odds ratio of 3.07 (95% confidence intervals 2.69-3.51). The odds ratio varied across demographics (see Table 2).

  • Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death.

Listen to the SGEM podcast to hear Daniel’s response to our five nerdy questions.

1. Retrospective Study: As a retrospective study, you could only explore covariates that were routinely recorded, so there is a risk of missing unknown confounders like chaotic lifestyle or neurodivergence. Do you have any insights into these based on your experience in the field?

2. Inclusion Criteria: You relied on ICD-10 coding to identify alcohol-related attendances. Although this is likely to be accurate for diagnoses like acute intoxication and alcoholic cirrhosis, do you think it risks under-identifying the involvement of alcohol in other situations like intimate partner violence or accidental injury?

3. The COVID-19 Effect: You deliberately truncated your cohort in 2015 to exclude the effect of COVID-19 on mortality. Your secondary outcome was mortality at 3 years (2018). This makes sense, but do you think it impacts the generalisability of your findings given that as you comment in the manuscript about the pandemic altered drinking patterns? Responds

4. Gender or Sex? You have used biological sex as a covariate, presumably because this is what is recorded in Ontario. Is it possible that your findings would be different in gender non-conforming patients? Responds

5. Intersectionality: You include a logistic regression analysis which identified being male, being aged 25-29, attending with harmful use or withdrawal rather than acute intoxication and having comorbid mental health or substance abuse diagnoses as risks for death. Did you have the opportunity to examine the interaction of these? So, is it disproportionately worse to be an alcohol-dependent 26-year-old man than an alcohol-dependent 18-year-old woman? Responds

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

SGEM BOTTOM LINE: A FIRST ED PRESENTATION RELATED TO ALCOHOL IS ASSOCIATED WITH INCREASED MORTALITY IN ADOLESCENTS AND YOUNG ADULTS.

Dr. Kirsty Challen

Case Resolution: You explain to the teenager and her parents that there is an increased risk associated with this alcohol-related presentation, but that their daughter’s age and gender reduce this risk. You also signpost them to the local alcohol harm reduction and family support services.

Clinical Application: You work with your ED education team to ensure that staff are aware of this risk and able to support patients in addressing their alcohol issues.

Keener Kontest: Last week’s winner Was Dr. Kay Dingwell. She knew a genetic disorder which raises the risk of pneumothorax and is associated with skin tumours and kidney cancer is Birt-Hogg-Dubé.

Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on the risks of alcohol for adolescents and young adults? Tweet your comments using #SGEMHOP.  What questions do you have for Daniel and his team, Ask them on the SGEM blog. The best social media feedback will be published in AEM.

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

 References:

  1. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2018; 392(10152): 1015-1035. doi:10.1016/S0140-6736(18)31310-2
  2. Myran DT, Hsu AT, Smith G, Tanuseputro P. Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study. Can Med Assoc J. 2019; 191(29): E804-E810. doi:10.1503/cmaj.181575
  3. White AM, Castle IJP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020; 44(1): 178-187. doi:10.1111/acer.14239
  4. Hulme J, Sheikh H, Xie E, Gatov E, Nagamuthu C, Kurdyak P. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. Can Med Assoc J. 2020; 192(47): E1522-E1531. doi:10.1503/cmaj.191730