Alcohol‐related injury and the emergency department: research and policy questions for the next decade
Year: 2006
Type: editorial
Abstract: This editorial focuses on issues related to the burden of alcohol-related injuries, screening, brief intervention and referral to treatment (SBIRT), and research and policy recommendations in the emergency department (ED). Specific issues discussed include the limitation of attributable fraction estimates and the importance of ED studies as a data source, the utility of observational assessment of alcohol intoxication in the ED as an alternative to blood alcohol measurement, legal considerations in identifying patients who have been drinking and practitioner attitudes and barriers to SBIRT. Research and policy recommendations highlight the need for continued investigation of country and cultural differences in alcohol-related injury in the ED with special attention to aggregate-level socio-cultural variables, policies for ongoing surveillance and monitoring of alcohol-related injury in the ED, research to evaluate alternatives to blood alcohol testing among ED patients and research on the feasibility and utility of initiating a brief intervention in this setting. We know that, world-wide, injuries account for a substantial proportion of the disability attributable to alcohol: 28% of the disability-adjusted life years (DALYs) for unintentional injuries and 12% for intentional injuries [1]. However, the proportion of injuries that can be accounted for by alcohol has been based largely on non-representative samples, with insufficient numbers for gender- and age-specific estimates. Attributable fraction estimates have also assumed that injury risk related to alcohol is similar across all countries and cultures. The emergency department (ED) has been used as a site for epidemiological studies of alcohol and injury in a number of countries, and is an important data source which has been relatively untapped for informing these estimates. More recent estimates have taken into account aggregate-level patterns of drinking [2] and this most probably will result in a better approximation of attributable fraction across countries with respect to different drinking cultures. However, other socio-cultural influences are also likely to contribute to differences in attributable fraction estimates, and these contextual variables are important to consider in future alcohol and injury research in the ED. Relatedly, individual-level estimates of alcohol and injury and those made at the aggregate level generally have not shown a high concordance, and data from ED studies would be useful in examining this discrepancy and possible resolution as well. While a high prevalence of heavy, problem and dependent drinking among patients seeking treatment in the ED is well documented, and those intoxicated at the time of ED admission are substantially more likely to be readmitted subsequently than those not intoxicated [3], neither monitoring nor surveillance of alcohol-involved admissions or identification of problem drinkers is carried out routinely in the ED in the United States or in other countries. Most trauma centers in the United States that obtain blood alcohol concentration (BAC) do so based on clinical suspicion, which has been found to be highly subjective and inaccurate. BAC testing may not always be possible in the ED, and one alternative is observational assessment of intoxication. The International Classification of Diseases, 10th revision (ICD-10) [4], provides two separate coding schemes, one for recording BAC (Y90 codes), and when this is not possible a separate coding scheme recording the level of apparent intoxication (Y91 codes). Y91 codes have received little attention, however, and have not generally been implemented in the ED setting. An observational assessment of level of intoxication also raises the obvious question of its validity and agreement with BAC measurement, and this would be expected to vary by several factors including skill in assessment, cross-cultural variations in intoxicated behavior, patient tolerance, whether BAC is on the ascending or descending curve and the proximity of assessment to BAC estimate. Given the potential of observational assessment of alcohol intoxication in the ED, the World Health Organization undertook a study of the validity of clinical observation using Y91 codes. The concordance of Y90 and Y91 codes was only moderate, however, and was poorer among those reporting drinking prior to injury [5], the group presumably one would hope to identify. National surveys in the United States have found repeatedly that almost half the trauma centers do not routinely obtain admitting blood alcohol on patients [6], and concerns with legal issues and reimbursement from health insurance have been cited as major reasons [7]. A heretofore relatively little-known law in the United States, the Uniform Accident and Sickness Policy Provision Law (UPPL), permits third-party payers to deny reimbursement for medical services for patients who are alcohol-positive at the time of injury. This law, which has been in effect since 1947, was repealed by the National Association of Insurance Commissioners; however, it is still on the books in the majority of states [8]. The rationale for brief intervention in the ED and referral for specialized treatment is compelling. Patients with an alcohol-related ED visit and/or those intoxicated at the time may be more accepting of treatment for problem drinking and an injury event, specifically, may provide a special opportunity for intervention [9]. An intervention that can successfully link alcohol consumption to the event, possibly in combination with other hazardous behaviors (e.g. risk-taking), may be sufficient to effect a change in drinking and future alcohol-related consequences [10,11]. The ED visit may also provide a window of opportunity for changing drinking behavior for those who are alcohol negative at the time of the ED visit and/or are presenting to the ED with conditions unrelated to alcohol consumption, but who have a history of hazardous, harmful or dependent drinking. Given this seemingly opportune time to initiate screening, brief intervention and referral to treatment (SBIRT), the questions remains: 'Why doesn't this happen?' A number of factors have been offered that contribute to the low levels of SBIRT by ED practitioners, including an insufficient knowledge base in addiction and screening tools, lack of skill in motivational interviewing and lack of familiarity with referral resources. Would SBIRT happen if these barriers no longer existed? A study that developed methods to effectively implement a model of SBIRT into ED practice and overcome these barriers was conducted recently at 14 academic-based EDs in the United States [12]. This is the first multi-site collaborative study of brief intervention in the ED, and included development of a SBIRT curriculum and training of ED practitioners [13]. Practitioners undergoing training (n = 401) were administered pre- and post-training questionnaires which found significant but only modest changes at 12 months compared to baseline: a 5% increase in believing it is their responsibility to screen and intervene, a 3% increase in believing that barriers to SBIRT were less troublesome and that SBIRT would make a difference, an 8% increase in confidence in their ability to perform SBIRT and a 11% increase in actually providing SBIRT. Unfortunately, despite what could be considered a successful study, these figures do not seem overly encouraging. The ED provides an important arena for future research on alcohol-related injury and resulting policy recommendations. The recent International Conference on Alcohol and Injury: New Knowledge from Emergency Room Studies (http://www.arg.org/ER-conference.html) highlighted areas in need of continued research, including investigating cultural and country differences in alcohol- related injury and the utility of these data for informing policy development. To move the field forward, research over the next decade should focus on a better understanding of the global alcohol–injury nexus, with particular attention to aggregate-level socio-cultural variables affecting this relationship in ED studies, as well as the feasibility and utility of initiating brief intervention in this setting. We know that alcohol places a substantial burden on the ED and policies need to be in place for international ongoing surveillance and monitoring of alcohol-related injury. Additional research is also needed to evaluate alternatives to BAC testing, which is not always feasible in the ED setting. The US Department of Health and Human Services has targeted adoption of SBIRT in the ED by emergency service providers as one of the objectives of the Healthy People 2010 initiative, and SBIRT has also been mandated recently by the American College of Surgeons Committee on Trauma, to commence in 2007. Findings from studies of screening and brief intervention in the ED have been mixed, however, and all the evidence regarding the efficacy of SBIRT in the ED has not yet been gathered. Is it premature, therefore, to recommend (mandate or legislate) SBIRT given laws are in place that could potentially result in serious consequences for the patient, a continued reluctance remains on the part of ED practitioners to provide SBIRT, and to date, data are limited on the efficacy of brief intervention in the ED setting? Have we, then, 'put the cart before the horse', so to speak? While official recognition and support for SBIRT is important, and SBIRT training in effecting provider change has been demonstrated to some degree, the likelihood of routinely implementing SBIRT in US EDs seems highly unlikely, given the prevailing attitude among emergency service practitioners and their reticence in identifying problem drinking patients due to potential legal barriers and reimbursement constraints. If practitioners are to be motivated to provide SBIRT in the ED, they will be motivated most probably by economic incentives, and this would require that SBIRT becomes a reimbursable procedure. Although this dilemma is uniquely relevant to the US situation at present, it may be germane for other countries where routine implementation of SBIRT in the ED is being considered.
Source: Addiction
Author: CHERYL J. CHERPITEL
Institution: Alcohol Research Group
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1481315414