Baseline audit of alcohol related assessment and management across Wessex acute trusts

Baseline audit of alcohol related
assessment and management across
Wessex acute trusts
Dr Samantha Taplin
Speciality Registrar in Public Health
(Samantha.Taplin@nhs.net)
1st February 2018
Reducing Harm From Alcohol: Creating Lasting Solutions 2018

2
Context
- Alcohol is a major health problem in the UK with over 300,000 potential
years of life lost due to alcohol in 2016 (PHE LAPE 2017)
- Alcohol is the leading cause of death among 15 to 49 year olds (PHE
alcohol evidence review)
- Alcohol related mortality strongly related to deprivation
- Liver disease is the 3rd most common cause of premature death in the UK;
alcohol related liver disease accounts for over 75% of these
- NCEPOD Measuring the Unit’s Report 2013 found a failure to screen
adequately for high risk drinking, and even when this was identified,
patients were not referred for support

3
Context
The Audit
- Completed as part of a Wessex Academic Health Science Network
(WAHSN) quality improvement programme around alcohol
- CQUIN to start on 1st April 2018

4
Aims and Objectives
Aims of secondary analysis
• To further describe the patterns in hospital activity around alcohol
use assessment and interventions and liver disease in acute trusts
in Wessex
• To provide meaningful data for decision making around the
development of services

5
Research Questions
• What is the documented evidence for assessment of alcohol use
and appropriate interventions instigated in Acute Trusts in Wessex
in patients with a liver disease diagnosis?
• How closely does care across Trusts in Wessex follow the pathway
for best practice for alcohol screening and interventions?
• Is there a difference in the documented management of alcohol and
liver disease patients between Acute Trusts?
• Is there any evidence that differences in management impact
outcomes for patients? E.g. death, length of stay, number of hospital
admissions?
• Is there any evidence for potential causes of any disparity in
management based on the data collected?

6
Design
• Retrospective audit data
• All acute trusts in the Wessex region were invited to participate
- 7 out of 8 acute trusts returned audit data
- Salisbury NHS Foundation Trust
- Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
- Portsmouth Hospitals NHS Trust
- University Hospital Southampton NHS Foundation Trust
- Hampshire Hospitals NHS Foundation Trust
- Isle of Wight NHS Trust
- Dorset County Hospitals NHS Foundation Trust

7
Selection of cases for audit
The search criteria used to identify individuals for inclusion in the
dataset were:
• All admissions between 1st January 2015 and 31st March 2015
• With any of the diagnosis codes:
• Alcohol related liver disease (ARLD) (K70 codes)
• Alcohol misuse (F10 codes)
• Other Liver Disease (non-K70 and F10 liver disease coded)
• With age: >18yrs
• With length of stay: > 24hrs (i.e. inpatients only)

8
Data Collected:
1. Pseudo patient identifier (e.g. “patient 1”)
2. Diagnosis code (does patient have a K70, F10 or other Liver disease diagnostic code)
3. Demographics (age and sex)
4. Documented alcohol use and screening (AUDIT C, AUDIT, Quantifiable alcohol use, evidence of
harmful drinking)
5. Evidence of documented alcohol history taken
6. Documented evidence of alcohol consumption
7. Documented intervention (brief advice given, referral to hospital alcohol team, review by alcohol
team, use of prescribed treatment, CIWA monitoring used)
8. Documented support offered on discharge from Hospital (alcohol related support offered, referral
to alcohol community services, GP informed on discharge summary)
9. Patient outcomes (number of attendances at hospital in 3 years prior to event, number of
admissions 3 years prior to event, death and date of death if applicable)
10. Presenting complaint on admission
• Non-identifiable patient data only recorded

9
Analysis
• Ethical approval gained for secondary analysis of data set
• Data transferred and processed on SPSS
• Data cleaning
• Assessment and management pathway mapping
• Proportionate uptake at each stage of the assessment and management
pathway calculated by disease category and aggregated
• Proportionate uptake filtered by pathway
• Statistical tests used to identify confidence intervals for difference in
proportions at key points in the pathway
• Binary logistic regression and Chi-Squared test used to identify potential
associations at key points in pathway

All patients
Asked about their alcohol use?
AUDIT C completed?
AUDIT C score
Lower risk
Increasing risk
Higher risk
Possible dependence
Referral to Hospital Alcohol Team?
Reviewed by Hospital Alcohol Team
Pabrinex/Thiamine/other treatment
prescribed?
CIWA used to monitor withdrawal
symptoms
Evidence of discharge alcohol related
support offered
Mention to GP of harmful drinking in
discharge summary
Referral to alcohol community
services
Evidence of harmful drinking?
Review not
required/
declined
Inpatient treatment/
detox required
Outpatient treatment/
detox/support required
Adequate alcohol history
Conflicting history
Brief advice
The Pathway

11
Acute Trust Proportion (yes)
Bournemouth Dorchester HHFT IOW PHT UHS Salisbury All Trusts
Documented alcohol use? 79% 84% 88% 79% 56% 89% 78% 75.4
(n=480/637)
Alcohol use documented (yes)
Adequate alcohol history taken? 71% 75% 77% 54% 77% 84% 60% 73.5
(n=352/479)
Alcohol use documented (Yes) and Harmful
alcohol use (yes)
Documented brief advice given by non-
hospital alcohol team staff?
90% 33% 14% 56% 47% 44% 24% 45.5
(n=101/222)
Referral to hospital alcohol team? 45% 0% 28% 0% 76% 50% 71% 49.3
(n=111/225)
Alcohol use documented (Yes), harmful
alcohol use (yes) and reviewed by Hospital
alcohol team (yes)
Treatment prescribed:
Pabrinex/Thiamine/other treatment?
100% 0% 87% 0% 85% 96% 100% 90.1
(n=109/121)
CIWA used? 10% 0% 65% 0% 30% 9% 100% 28.1
(n=34/121)
Evidence of alcohol related discharge support
offered?
90% 0% 61% 0% 61% 74% 90% 68.6
(n=83/121)*
* 2.5% N/A
Statistically significantly below regional average
Not significantly different from regional average
Statistically significantly above regional average
Filtered analysis by questions specified in table
Results
Acute Trust- key points on pathway
Statistical significance for the difference in acute trust proportionate uptake, against trusts overall

12
Logistic Regression
Documented alcohol use &Harmful alcohol history
• Males twice as likely to have an alcohol history documented than
females (Documented alcohol use OR 2.12 p<0.001, harmful
alcohol history OR 2.15 p<0.001) even when adjusted for age
• Older groups were less likely to have a documented alcohol history
(p=0.004) or harmful alcohol use documented (p<0.001) when
compared to the those aged <50
• The “Other” LD diagnostic code group were 4 times less likely to
have an alcohol history documented than the ARLD group
(p<0.001), but were almost 20 times less likely to have a history of
harmful alcohol use than the ARLD group (p<0.001)

13
Logistic Regression
• Alternative explanations for observations seen in logistic regression
for example:
– Audit methodology, not a research study
– Observational design
– Cannot confer causality
– Identifies odds of association only
– Uncontrolled variables
- Co-morbidities
- Missing data
– Potential for impact by: age, sex

14
Treatment and reviews by the HospitalAlcohol
Team
(Available in full analysis for each Acute Trust individually)
- In total 239 (of 639) people were prescribed treatment
- Of those, 10 (4.18%) did not have an alcohol history documented
- Of those prescribed treatment, ¼ did not have harmful alcohol use
documented (24.3% n=58)
- Of all those prescribed treatment, just over ½ were not seen by the
Hospital alcohol team (130 people 54.4%)

15
Treatment and reviews by the HospitalAlcohol
Team
Is this difference statistically significant?
- % prescribed treatment seen by HAT (If alcohol use was documented)
- % prescribed treatment NOT seen by HAT (If alcohol use was documented)
- Pearson Chi-squared test p<0.001
 Yes!
If seen by the hospital alcohol team, patients were more likely to be
prescribed treatment for withdrawal

16
Recommendations for repeat audit
– Presenting complaint: consideration required for whether this is
needed, and what the purpose is
– The format of presenting complaint provided in this audit made
accurate analysis impossible due to subjectivity of interpretation
– Consider the use of code for end of hospital episode or team admitted
under as an alternative
– Missing data needs to be considered. It would be helpful to provide a
positive “no” or strict adherence to the audit protocol
– Consider the use of a control group for comparison e.g. inpatients with
a chronic illness other than liver related disease
– Use CQUIN for benchmarking future pathway adherence

17
Limitations
• Cross sectional design so not directly linked to outcomes
• Audit, not a research study
• Only able to identify what is documented in the patient’s notes
• It is not possible to assess whether the treatment prescribed or
actions during the pathway was clinically appropriate with the data
available
• Missing data numbers affects the proportions presented and
associations for confounding. This needs further consideration
before the next audit is completed
• No target uptake available for comparison

18
Summary and conclusions
• Each trust has varied uptake across the patient pathway
• Uptake comparisons can be used to identify areas for improvement
locally
• Comparisons are made against the regional average, rather than
against national targets. This can be remediated for the next audit
following the introduction of the CQUIN.
• Age and gender may impact how frequently alcohol use is
documented, and the odds of harmful alcohol use being
documented
• If seen by the hospital alcohol team this appears to influence the
proportion of patients prescribed detox treatment as an inpatient
• Systematic screening of all new admissions for alcohol use should
be performed using a validated tool

19
Acknowledgements
• Dr Julia Sinclair
• Dr Leoni Grellier
• Amelia Middlemiss
• Dr Simon Fraser
• Brian Yeun
• Academic Health Science Network

Baseline audit of alcohol related assessment and management across Wessex acute trusts

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Baseline audit of alcohol related assessment and management across Wessex acute trusts

Similar to Baseline audit of alcohol related assessment and management across Wessex acute trusts (20)

More from Health Innovation Wessex

More from Health Innovation Wessex (20)

Recently uploaded

Recently uploaded (20)

Baseline audit of alcohol related assessment and management across Wessex acute trusts