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Alcohol-Related Hospitalizations -- Indian Health Service and Tribal Hospitals, United States, May 1992

Alcohol use is directly responsible for hospitalizations resulting from chronic conditions, such as alcoholic liver disease and alcoholic psychoses; in addition, alcohol use can be a contributing factor in other conditions, such as infectious diseases and injuries, that require hospital admission. Based on discharge data from Indian Health Service (IHS) facilities and CDC's National Hospital Discharge Survey (1), the proportion of alcohol-related hospitalizations (ARHs) among American Indians/Alaskan Natives has been reported as 2.5 times that for the total U.S. population. However, these estimates rely on a limited set of alcohol-defined diagnoses that are primarily associated with chronic alcoholism. To characterize more accurately the relation of alcohol use to inpatient admissions to IHS and tribally operated hospitals in the United States, IHS conducted a 1-day survey of ARHs in these facilities on Monday, May 18, 1992. This report summarizes preliminary results from the survey.

A survey instrument was mailed to the clinical director (CD) of each of the 50 IHS and tribally operated hospitals, and each CD was contacted by phone during the week before the survey date to confirm receipt of the letter and to designate a person to respond to a telephone survey. The survey requested aggregate information about the number of adult and pediatric (aged less than or equal to 15 years) patients (by sex) who were hospital inpatients on that date and the number of patients (by age group and sex) whose hospitalization was related to alcohol use. A list of broad diagnostic categories of potentially alcohol-defined (e.g., alcoholic psychoses, alcohol dependence syndrome, nondependent alcohol abuse, and alcoholic liver disease) or alcohol-related (e.g., gastrointestinal bleeding or unintentional injury) diagnoses was included on the survey instrument (Table 1); ARHs also included persons whose reason for admission was, in the judgment of the attending physician, related to past or current alcohol use, even if the patient was not the person using alcohol (e.g., an injury sustained in a motor-vehicle crash caused by a drunk driver even if the injured patient was not drinking). ARHs were ascertained based on interviews with the attending physician and review of medical records by the hospital's CD, quality assurance coordinator, or another physician designated by the CD.

Of the 50 hospitals, 49 completed the survey. Two hospitals (accounting for 13 adult and four pediatric patients) were deleted from the analyses because the surveys were completed incorrectly. Of 899 hospital inpatients (753 adults and 146 children) on the day of the survey, 161 (17.9%) had alcohol-related diagnoses. Among adult patients, 156 (20.7%) hospitalizations were alcohol-related. When women hospitalized for obstetric conditions were excluded, 155 (25.2%) of 616 hospitalizations were alcohol-related. The proportion of ARHs for men (34.5%) was nearly three times that for women (11.7%) (prevalence ratio [PR]=3.0; 95% confidence interval [CI]=2.2-4.0) and almost twice that for women when obstetric patients were excluded (16.4%) (PR=2.1; 95% CI=1.6-2.8).

The proportion of ARHs was greatest in smaller hospitals: in facilities with 25 beds or fewer, 34.9% of hospitalizations were alcohol-related, compared with 11.2% of hospitalizations in facilities with more than 50 beds (PR=3.0; 95% CI=2.2-4.1). Less than half (46.8%) of the ARHs were associated with alcohol-defined diagnoses (Table 1). Infectious diseases and injury (excluding suicide attempt) each accounted for approximately 15% of cases. Five pediatric hospitalizations were alcohol-related, including unintentional injury (two), child neglect (one), intoxication (one), and fetal alcohol syndrome (one).

The mean time required at each hospital for data collection was 40 minutes (range: 10-210 minutes). All responding hospitals received the study results within 3 weeks of the survey.

Reported by: JR Sugarman, MD, Epidemiology Program; EM Smith, MD, Alcoholism and Substance Abuse Program Br, Indian Health Svc.

Editorial Note

Editorial Note: When surveillance of alcohol-related morbidity among hospital inpatients is restricted to a limited set of alcohol-defined diagnoses typically associated with chronic alcoholism, the contribution of alcohol use to overall morbidity may be substantially underestimated. A previous report indicated that a more comprehensive assessment of alcohol-related mortality can be attained by assigning alcohol-attributable fractions (AAFs) to a spectrum of disease and injury diagnoses that are causally linked to alcohol use and applying these fractions to diagnoses on death certificates (2); however, estimated AAFs are imprecise and do not permit adequate morbidity analyses. The approach used by the IHS in this report not only relies on a defined set of alcohol-related diagnoses and statistical algorithms but also incorporates patient-specific clinical impressions of treating physicians to assess the role of alcohol use for each hospital admission.

The methods used in this survey are not comparable to those used in other studies (3,4), so the overall proportion of ARHs can not be directly compared to published data. Because the ascertainment of ARHs in the IHS study was based on the clinical impressions of health-care providers, it is possible that a higher proportion of alcohol-related problems would have been identified if all patients were screened for alcohol abuse.

After its reliability (reproducibility) and validity have been established, the 1-day "snapshot" survey method described in this report may be used as a rapid and efficient surveillance method to provide information on ARHs. However, this method has several potential limitations. First, seasonal and day-of-week variation in ARHs would be undetected; however, the proportion of ARHs in this survey was almost identical to that described in a similar IHS survey conducted in September 1987 (5). This survey was conducted on a Monday, while the survey in 1987 was conducted on a Thursday, by which time some patients with ARHs associated with the previous weekend should have been discharged. Second, in the absence of systematic screening of all patients for alcohol use, the proportion of ARHs is likely to have been underestimated -- even though some admissions may have been considered to have been alcohol-related only on the basis of clinical impressions, in the absence of a true causal relation between alcohol use and the disease or injury.

Despite potential limitations, this survey underscores the impact of alcohol use on hospitalization among American Indians/Alaskan Natives. Because rates of alcohol use are high among American Indian/Alaskan Native youth, often beginning at early ages, primary prevention of alcohol abuse should be a high priority (6-8). In addition, secondary prevention efforts among established alcoholics by rehabilitation to establish sobriety are necessary. Although the specific infectious diseases resulting in hospitalization in this population were not determined, heavy alcohol use is a risk factor for pneumococcal infections and tuberculosis (9,10). Prevention of alcohol-related infectious diseases by appropriate use of pneumococcal vaccine and chemoprophylaxis of alcohol abusers with positive tuberculosis skin tests should be a high priority among those providing health care for American Indian/Alaskan Native patients. The IHS Alcoholism and Substance Abuse Program Branch will use these survey results as part of a surveillance system to direct interventions to reduce ARHs in locations with a high proportion of ARHs and to evaluate those interventions.

References

  1. Indian Health Service. Alcohol-related discharges from Indian Health Service and contract general hospitals: fiscal year 1984. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Indian Health Service, 1985; report no. 2862K (0159K).

  2. CDC. Alcohol-related mortality and years of potential life lost- -United States, 1987. MMWR 1990;39:173-8.

  3. Umbricht-Schneiter A, Santora P, Moore RD. Alcohol abuse: comparison of two methods for assessing its prevalence and associated morbidity in hospitalized patients. Am J Med 1991;91:110-8.

  4. Moore RD, Bone LR, Geller G, et al. Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA 1989;261:403-7.

  5. Marfin AA, Helgerson SD. Surveillance of alcohol-related conditions in IHS direct and tribally-operated hospitals: a one-day snapshot, 1987. Tucson, Arizona: US Department of Health and Human Services, Public Health Service, Indian Health Service, Office of Health Program Development, 1987.

  6. Bachman JG, Wallace JM, O'Malley PM, et al. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors. Am J Public Health 1991;81:372-7.

  7. Beauvais F, Oetting ER, Wolf W, Edwards RW. American Indian youth and drugs, 1976-1987: a continuing problem. Am J Public Health 1989;79:634-6.

  8. Beauvais F. An integrated model for prevention and treatment of drug abuse among American Indian youth. Journal of Addictive Diseases 1992;11:63-80.

  9. CDC. Update on adult immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-12).

  10. CDC. Screening for tuberculosis and tuberculous infection in high-risk populations and the use of preventive therapy for tuberculous infection in the United States: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1990:39 (no. RR-8).

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