ReviewFrom data to evidence, to action: Findings from a systematic review of hospital screening studies for high risk alcohol consumption
Introduction
Numerous studies have attempted to establish the prevalence of alcohol problems in individuals presenting to hospital. However, a defining feature of this research literature is the diversity in both prevalence rates identified (ranging from 1 to 45%) and definitions of problematic use (chronic versus acute). Such variable findings are further confounded by the different screening locations and methodologies used, making it difficult to synthesise and generalise from these findings. The purpose of this study was to conduct a systematic review of hospital screening studies in order to distil findings that could be used to inform hospital policies and to support resource efficient and clinically effective evidence-based screening strategies.
The prevalence of problematic alcohol use in most developed countries is high and the impact on health services substantial. The highest burden of disease in developed and developing regions is associated with alcohol, preceded only by tobacco (Rehm and Room, 2003). In Australia, for example, alcohol is second only to tobacco in drug-related deaths and hospitalisations (Miller and Draper, 2001), with up to one in five general hospital patients reported to have significant alcohol-related problems (Foy, 1999, Foy and Kay, 1995, Hanlin et al., 2000). In the U.K., it is estimated that one in four men and one in 10 women drink at hazardous or harmful levels, and that one to three million individuals attend EDs with an alcohol-related condition every year (Charalambous, 2002). In the U.S., 30–40% of trauma patients have been found to have positive blood alcohol readings (Fleming, 2002), and 24–31% of ED patients to have scored positively on the CAGE, a screening tool for dependence (Bernstein et al., 1996, Whiteman et al., 2000).
Screening is one method by which to detect individuals whose alcohol use puts them at risk for health and medical problems. It also provides opportunity to influence consumption, modify drinking habits and assist with the management of withdrawal (Brown et al., 1998, Conigliaro et al., 1998, Dinh-Zarr et al., 2004, Foy, 1999). Over the past 20 years, there has been increasing interest in screening proactively for alcohol problems in a range of settings (e.g., hospitals, general practice). Hospitals are particularly well suited to screening for problematic alcohol use. They often have large numbers of alcohol-related admissions (Cherpitel and Borges, 2002, Green et al., 1993, Thom et al., 1999, Waller et al., 1998) from both acute (e.g., accidents and injuries, violence, deliberate self harm, acute alcohol poisoning) and chronic drinking (e.g., cardiac arrhythmias, pancreatitis) (Charalambous, 2002). A wide range of presentations may be linked to risky alcohol consumption. Huntley et al. (2001) identified the top 10 conditions that patients present with to an Emergency Department which are most likely to be alcohol-related. These include: (1) fall, (2) collapse (including fit and blackout), (3) head injury (including facial injury), (4) assault (including domestic violence and “other”), (5) non-specific gastrointestinal problem, (6) “unwell”, (7) psychiatric (including depression, overdose and confusion), (8) cardiac (including chest pains and palpitations), (9) self-neglect and (10) repeat attendance. Hospital settings also provide an ideal opportunity for interventions such as advice and referral (Charalambous, 2002, D’Onforio and Degutis, 2002, Patton et al., 2004, Zarkin et al., 2003).
From a research perspective, the case for implementing hospital screening is self evident. Evidence supports the sensitivity and specificity of screening instruments for alcohol-related problems (Cherpitel, 1998, Dawe et al., 2002), the efficacy of brief interventions (Bien et al., 1993, Fleming et al., 1999, Fleming et al., 2002, Moyer et al., 2002) and their effective implementation in hospital settings (Barnett et al., 2003, Conigrave et al., 1991, Peters et al., 1998, Wright et al., 1998). Furthermore, there is evidence that a significant proportion of hazardous drinkers presenting to the ED will accept and act on advice presented by health professionals (Patton et al., 2004, Patton et al., 2003, Dinh-Zarr et al., 2004). However, it is also clear that in real world settings screening occurs at less than optimal levels.
From the practitioners’ perspective, the time and resource implications of routinely screening all patients can be prohibitive (Charalambous, 2002, Danielsson et al., 1999, Graham et al., 2000). Furthermore, the large and complex research literature provides little guidance regarding targeted screening systems that constitute clinically and cost efficient best practice. This dilemma is made somewhat more difficult in light of increasing concern for problems related to different types of drinking problems, from chronic to regular heavy drinking and infrequent heavy drinking. Each involves different health risks and requires different forms of screening tools and intervention techniques. Very recent work has highlighted the additional risk of injury to which the occasional heavy drinker is exposed (Gmel et al., 2005, Pidd et al., 2005). There has been a historical shift in focus from chronic to acute harms (Roche and Freeman, 2004), and this is reflected in changing methods and screening tools. Hence, the purpose of screening has changed considerably over the past 20 years.
Different screening systems have different purposes and intentions, some to detect dependence, others to detect regular risky patterns of consumption, and others yet again to determine if the patient has a current positive blood alcohol content (BAC). Each of these purposes for screening has different implications and requires different screening tools, approaches and mechanisms. Nonetheless, screening systems can be developed to incorporate all three different purposes. A systematic review of hospital screening studies was undertaken to identify the key characteristics of an effective and efficient hospital screening system likely to produce optimal outcomes for hospitals and patients. The review focused on three key issues of importance for practitioners and administrators: how to screen (i.e., BAC or self-report), who to screen (i.e., males, females; ward or ED patients) and where to screen (i.e., ward or ED).
Section snippets
Method
A systematic review of hospital screening studies was undertaken. Studies were included if published from 1990 onwards in English language journals. The databases searched were Medline, PsycINFO, ERIC, CINAHL, all EBM Reviews, AustHealth and ISI Web of Science. The search string used was: (“hospital” or “screening”) and “alcohol” and (“alcohol consumption” or “alcohol interventions” or “Emergency Department” or “injury” or “problem drinking” or “trauma”). Only studies which reported prevalence
Results
Sixty-five studies were identified as acceptable for inclusion in the review. All 65 studies identified in this systematic review are summarised in Table 1, Table 2, with studies located in the Emergency Departments (EDs) and wards presented separately. The 65 studies represent a total sample of 100,980 participants across 17 countries. A diverse range of research methodologies and screening systems were observed across the studies. The studies were examined according to: (1) screening tool
Discussion
This paper presents the results of a systematic review of research on screening for problematic alcohol use in hospital settings. The aim of the review was to synthesise a large and disparate research literature in order to develop practical and efficient recommendations for the design of hospital alcohol screening systems. We reviewed 65 studies representing a total sample size of 100,980 across 17 countries. Prevalence of positive alcohol screens was high, varying from 16–26%. The key finding
Acknowledgements
The authors wish to thank the Australian Government Department of Health and Ageing and the South Australian Department of Health for the financial support which made this study possible.
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