Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study |
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Authors: | Jennifer Hulme Hasan Sheikh Edward Xie Evgenia Gatov Chenthila Nagamuthu Paul Kurdyak |
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Affiliation: | University Health Network (Hulme, Sheikh, Xie); Department of Family and Community Medicine (Hulme, Sheikh, Xie), University of Toronto; ICES (Gatov, Nagamuthu, Kurdyak); Institute for Mental Health Policy Research (Kurdyak), Centre for Addiction and Mental Health, Toronto, Ont. |
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Abstract: | BACKGROUND:Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada.METHODS:We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16–105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL).RESULTS:Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45–64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19–1.59). Among 25 298 people aged 16–74 years, this represented 30 607 YPLL.INTERPRETATION:We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.Alcohol is a leading driver of morbidity and mortality worldwide.1 An estimated 3 million deaths in 2016 — 5% of all global deaths — were attributable to alcohol consumption.2 The 2016 Global Burden of Disease Study showed that alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years.3 In Canada, hospital admissions for alcohol-attributable conditions out-number those for myocardial infarction.4 Alcohol-related harms cost Canadians about $14.6 billion annually, with $3.3 billion in health care costs.5In addition to the societal impact of mental and behavioural disorders due to alcohol (henceforth referred to as alcohol-related) — mainly acute intoxication and withdrawal — these disorders are common reasons for emergency department visits.6,7 Data from the United States and Canada, furthermore, suggest that alcohol-related emergency department visits have increased in recent years.8,9 For example, a study in Ontario showed that, between 2003 and 2016, the age-standardized rates of alcohol-attributable emergency department visits increased by 86.5% in women and 53.2% in men.8 People who visit emergency departments frequently for alcohol-related reasons have high levels of comorbidity and social disadvantage,10,11 and represent a readily identifiable patient population for whom interventions to address unmet social and health care needs could be developed.12–14 A systematic review suggested that screening and brief intervention for alcohol-related problems in the emergency department is a promising approach for reducing problematic alcohol consumption.13Despite this, little is known about the risk of death, a key outcome for health system performance, among people who use emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. To address this gap, our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, the most populous Canadian province.15 |
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