Abstract
Alcohol-related health harm is a major public health problem associated with millions of preventable hospital admissions worldwide each year. In the United Kingdom (UK) the cost of alcohol to the National Health Service (NHS) is estimated to be £3.5 billion per year, 80% of which is attributable to inpatient hospital care. In 2018/19, there were approximately 1.3 million alcohol-related hospital admissions in England alone. This number has increased year-on-year over the previous decade alongside simultaneous year-on-year reductions in the number of people accessing specialist treatment for problematic use of alcohol. Consequently, recent government reports have identified an urgent need to estimate the impact of specialist alcohol treatment on both acute care resource usage and alcohol-related health harm.This thesis aims to examine the utility of inpatient hospital admission and specialist alcohol treatment data in the evaluation of alcohol-related health harm and to determine the relationship between inpatient hospital admission and the provision of specialist alcohol treatment in England. Findings are incorporated from six new published studies which utilise a range of qualitative and quantitative methods. The first incorporated study, published in Alcohol and Alcoholism, reports an ecological analysis which aims to determine the feasibility and utility of using administrative inpatient hospital admission data to establish estimates of alcohol-related health harm at the level of countries in Europe. This demonstrates that national alcohol dependence prevalence estimates generated using inpatient hospital admission rates could be useful to compare relative trends over time, particularly if limited other sources of information are available.
The second incorporated study, published in Addiction, reports a systematic review, meta-analysis and meta-regression which aims to determine pooled prevalence estimates for conditions caused by alcohol in the UK hospital setting. This demonstrates that approximately one in five hospital inpatients in the UK uses alcohol harmfully (19.8% 95%CI 15.6 - 24.3) and one in ten is alcohol dependent
(10.3% 95%CI 7.1 - 14.0). Type of inpatient setting significantly impacts upon the variation in prevalence, with estimates differing substantially in accident and emergency departments and mental health inpatient units compared to other hospital settings.
The third incorporated study, published in the British Journal of Psychiatry, reports an ecological analysis which aims to determine any association between alcohol-related inpatient hospital admission and specialist alcohol treatment provision at the level of local authority areas in England. This demonstrates an association between the mean annual reduction in net expenditure for specialist alcohol treatment and the mean annual increase in alcohol-related inpatient hospital admission. The fourth incorporated study, published in the British Journal of Psychiatry Open, reports a qualitative study which aims to explore the views of service users, service providers and service commissioners in England regarding alcohol-related inpatient hospital admissions, and the number and type of people attending specialist alcohol treatment. This demonstrates a perceived reduction in the number of people attending specialist alcohol treatment with features of severe alcohol dependence, a lack of partnership between specialist alcohol services and their mental health service counterparts and, where those services exist, a lack of integration and communication with inpatient hospital services.
The fifth incorporated study, published in the British Medical Journal Open, reports the design, creation and evaluation of a novel unique national English record linkage between specialist alcohol treatment data (The National Drug Treatment Monitoring System (NDTMS)) and inpatient hospital admission data (Hospital Episode Statistics Admitted Patient Care (HES APC)). This demonstrates that it was possible to develop a deterministic algorithm to facilitate the creation of a national record linkage and that linkage error does not appear to substantially impact studied outcomes.
The sixth and final incorporated study, published in Lancet Regional Health - Europe, utilises the linked dataset generated above to report a retrospective cohort study which aims to characterise the lifetime hospitalisation patterns of people attending specialist alcohol treatment. This demonstrates that when compared to the general population of people being admitted to hospital, people attending specialist alcohol services have a significantly higher overall inpatient hospital admission rate, and a higher proportion of admissions from men, younger people, people from more deprived areas, people without a residential address and people of white ethnicities. Additionally, people with primary hospital admission diagnoses predominantly relating to mental and behavioural disorders and injuries or poisonings have a significantly elevated rate of inpatient hospital admission, an elevated odds of death during specialist alcohol treatment, and a reduced odds of successful completion of treatment for problematic alcohol use.
The thesis findings present an opportunity to reconsider the alcohol treatment landscape in England. They argue for the need for in-hospital screening for harmful use of alcohol and the development of Alcohol Care Teams (ACTs) in hospitals across the country, coupled with improvements in central reporting and legislative reform. Within people attending specialist alcohol treatment, it may be possible to identify ‘high-need, high-cost’ cohorts based on their primary reason for hospital admission and further research should build on this thesis to aid the identification and risk stratification of these individuals.
The work of this thesis ultimately aims to provide insights which could help further understanding and reduce the burden of alcohol-related health harm on the healthcare system; a phenomenon that unfortunately continues to be stigmatised, costly, and underfunded.
| Date of Award | 1 Jul 2021 |
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| Original language | English |
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| Supervisor | Colin Drummond (Supervisor) & Matthew Hotopf (Supervisor) |