Clinical

Chronic management

Alcohol Dependancy

Background

  • Mortality from liver disease in young and middle aged people in the UK has increased 6 fold in the past 30 years.
  • The key driver is alcoholic liver disease which accounts for 84% of liver deaths.
  • There is a direct relationship between deaths from liver disease and overall alcohol consumption within the population.
  • Alcohol also acts as a co- factor in other liver diseases such as HCV and NAFLD.
  • Alcohol has multiple impacts beyond liver disease and contributes to more than 60 medical conditions
  • At present more than 2 (9%) million men are drinking at a hazardous level and 1 million (4%) women.
  • In 2008, in England, 9,031 deaths were recorded as directly related to alcohol. Most were due to liver disease . (See http://www.statistics.gov.uk/pdfdir/ghs.0110.pdf).
  • These figures are probably a gross underestimate, because of under-reporting and under-detection, with alcohol misuse contributing to possibly as many as 40,000 deaths annually.
  • NHS expenditure on alcohol services is estimated to be £2.7 billion (2008 figures) with over 78% of costs incurred from hospital-based care.
  • Reducing mortality attributable to liver disease is a key objective of the government’s outcomes framework
  • Patients with alcohol problems are major contributors to hospital readmission, reduction of which is also a key government objective

Patient View

  • The views of patients with alcohol dependence are not generally sought in a systematic and constructive way. Surveying the service should be part of the management of this group of patients.
  • Patients are often depressed and this is often unrecognised and/or not treated promptly enough.
  • Many patients are more susceptible to brief advice and for more formal psychiatric intervention during a brief period of time (the teachable moment). This has relevance to service delivery.

Current Practice

  • Approximately 35% of all A&E attendances are alcohol-related. This increases to 70-80% at weekends. One audit observed that 21.4% of general medical admissions via A&E were alcohol-related
  • Most care for alcoholic liver disease is hospital based, but often reactive, wasteful and futile. Patients are admitted acutely for lack of an alternative and are a major contributor to readmission rates.
  • Only a minority of patients admitted with alcohol dependence or alcoholic liver disease are seen by a consultant with specialist training in hepatology and even fewer by a multidisciplinary team.
  • Active early detection in primary care and the Accident & Emergency Department and intervention with brief advice is important but variably employed

Recommended Practice and Opportunities for Integrated Working

  • Our principal recommendation is that Care for patients with alcohol dependence should be commissioned by the establishment of multidisciplinary Alcohol Care teams as recommended by QIPP (http://arms.evidence.nhs.uk/resources/qipp/29420/attachment), NICE (http://www.nice.org.uk/guidance/qualitystandards/alcoholdependence/home.jsp) and in the Joint BSG/BASL/AHA Position Paper (http://www.bsg.org.uk/clinical/publications/alcohol-related-disease-2010.html) which gives details of the proposed care model.
  • The Alcohol Care Team should have a substantial specialist nurse component with cross-cutting complementary skills (principally hepatology and psychiatry) and an identified leader with dedicated sessions, who would collaborate with Public Health bodies, Primary Care Trusts, patient groups and key stakeholders, to develop and implement a district alcohol strategy, based on the above recommendations and quality standards.
  • Responsibilities would include establishment of:
    • Effective detection of alcohol dependence in primary care and in A&E
    • Pathways for rapid access to specialist care, (within the “teachable moment”).
    • Community detoxification programmes
    • Assertive Outreach Alcohol Services, with the task of developing and harnessing community care (including community detoxification) to reduce (eg by 50%) bed occupancy by patients with alcoholic liver disease

Opportunities for Savings

  • In 2006/7, alcohol misuse cost the UK economy £25 billion. Of this, the NHS expenditure was £2.7 billion. In 2008, over 78% of the costs were in hospital based care.
  • The ideal service described above is one where divisions between Primary and Secondary Care are broken down and all working is essentially integrated (including co-planning with Public Health for social policy).
  • Important measures: Support for multidisciplinary Alcohol Care Teams across secondary, primary and community care that provide secondary prevention for people with alcohol problems.
  • Brief intervention targeted at acute services ie A&E and acute services for individuals with alcohol problems.
  • There is evidence that for every 8 people who are given simple advice on alcohol, one will reduce their drinking to lower risk levels.
  • A 5% reduction in alcohol related hospital admissions has potential cost savings to a DGH and its locality of £1.6M annually. This would equate to an annual saving for the overall UK economy of £393M.
  • Prevention of progression to end stage disease and reduced complications of liver disease, reduced hospitalisation, reduced incidence of HCC and reduced requirement liver transplantation

Quality Indicators (Outcomes)

Alcohol Care Teams should be judged according to NICE quality standards. The team should work with commissioners to set and monitor goals for improvement in important areas such as

  • Detection of alcohol dependence in primary care and in A&E
  • Availability of rapid brief interventions and advice, in hospital and in primary care
  • Rapidity and effectiveness (% attending) of access to Mental Health teams
  • Proportion of patients undergoing community detoxification
  • Rates of acute admission for alcohol related disorders
  • % of 30 day hospital readmission rates

Many NICE standards are process measures and we think that additional outcome measures should be evaluated, in line with the priorities of the NHS Outcomes Framework and specifically the Improvement Area 1.3 “(Reducing) under 75 mortality from liver disease”: by setting clear objectives and policies to reduce:

  • Local alcohol related death rates (eg by 6% per annum over at least 3 years)
  • The prevalence of cirrhosis in the community
  • The incidence of alcoholic hepatitis
  • Measurable health hazards (eg injury to self or others, domestic abuse) through social measures in collaboration with Public Health departments.
  • BSG and partners have formed AlcoTOLL (Alcohol Total of Lives Lost) to monitor and comment upon alcohol related disease at a national level and are ready to co-ordinate data in support of local initiatives.

Commissioners should also consider additional quality indicators based on the wide range of Areas for Improvement in the NHS Outcomes Framework in order to encourage the patient-centred approach that we consider important in relation to an addiction that arguably represents the biggest health problem facing society today. These areas (numbered according to Outcomes framework) include

  • 2.1 Proportion of people feeling supported to manage their condition
  • 2.2 Employment of people with long-term conditions
  • 2.4 Health related quality of life for carers
  • 2.5 Employment of people with mental illness
  • 4.1 Patient experience of Primary Care
  • 4.2 Patient experience of hospital care
  • 4.3 Patient experience of A&E services
  • 4.7 Patient experience of community mental health services

Social Policy & Understanding

  • The BSG supports selective financial measures to reduce excessive drinking (principally minimum unit pricing) and restrictions on advertising (particularly to children and teenagers), as well as educational initiatives. Where possible offers of cheap booze as a loss leader by supermarkets should be vigorously discouraged or prohibited (eg by minimum pricing). At a local level, Councils/Public Health bodies should take robust steps to ensure that publicans are supported in not serving alcohol to individuals who are drunk.
  • In 2009 alcohol-related deaths fell by 6% in response to reduced consumption, probably as a result of the economic pressures of the recession. Given the scale of alcohol’s impact on society, we think that a continuing annual reduction of 6% pa should be set as a target outcome both nationally and at a local level.
  • Patients with alcohol related disorders suffer difficulties and discrimination both socially and in the workplace. A holistic non-judgemental approach that involves patients in identifying service need and ensuring delivery should be supported.
  • Employers should be encouraged to promote alcohol health awareness
  • Healthcare service costs – including costs to primary care services and hospital services (A & E, medical and surgical inpatient services, paediatric services, psychiatric services and outpatient departments) of alcohol-related morbidity and mortality

Reference