Alcohol Care in NHS Hospitals: Needs better integration ...
Transcript of Alcohol Care in NHS Hospitals: Needs better integration ...
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Alcohol Care in NHS Hospitals:Needs better integration with the
wider care system
Professor Colin DrummondNational Addiction Centre
Institute of Psychiatry, Psychology and NeuroscienceKing’s College London
Danish National Conference on Alcohol, Jan 2020
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Alcohol related hospital admissions England 2003-2017
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400.000
600.000
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1.200.000
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WhollyPartly
Drivers:-Baby boomers-Increasinginequalities
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• 26 wholly alcohol attributable conditions• 124 studies; 1.7m patients• Harmful alcohol use = 20%• Alcohol dependence = 10%• 10x higher than general population• 20-30x higher than NHS (HES) estimate
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Proportion of smokers and excessive drinkers offered SBI by PHC last year
(Alcohol Toolkit Survey – Brown et al., 2016, BJGP)(n=15,252)
• 20% smokers (n=3,043)
• 62% visited GP last yr• 52% of smokers
received BI for smoking• (30% of all smokers)• Older, female, less
education, disability,higher dependence,more quit attempts
• 12.4% excessive drinkers(n=1,894)
• 59% visited GP last yr• 6.8% of XSD received BI
for alcohol• (4% of all XSD)• Older, smokers, higher
dependence, male
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26 25
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80 80
2,66
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0
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Problem gambling Alcohol dependence Drug dependence Psychosis Psychosis withdependence
Prevalence and treatment for dependence and comorbidity
Prevalence % x 100 Treatment for MH % Treatment for SM %
1.2%(600K)
0.8%(380K)
0.5%(240K)
0.15%(72K)
0.7%(340K)
(Drummond et al, APMS 2014)
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http://www.clahrc-southlondon.nihr.ac.uk/files/Alcohol%20care%20in%20NHS%20hospitals%20–%20Full%20report.pdf
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Alcohol CQUIN –Identification and brief advice
≥ 80% brief
advice
Adult inpatient
≥ 50% Screened
Dependent
Low-risk or non-drinker
≥ 80% Referral
offerReferred
Does not accept referral
IDENTIFY ADVISE ACT
Increasing or high-
risk
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Alcohol CQUIN – expected impact
~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.
Smoking
Even if only half of patients get screened.
~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.
The NHS could save >£20M per year from reductions in ill-health caused by drinking.
Alcohol
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ALCOHOL RELATED FREQUENT HOSPITAL ATTENDERS
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www.slam.nhs.uk
What problem did we address?
• Alcohol-related frequent hospital attenders (ARFA):– 3+ alcohol-related admissions per year– Multiple unmet physical, mental and social care
needs– Rarely access community addiction services– Feel stigmatized and socially excluded– Represent 9% of people with alcohol dependence
but 59% of alcohol admissions– 1.4 million bed days per year = £848 million– Identified 324 ARFA patients in Lambeth and
Southwark, with £5m annual cost15
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68
22,9
45,4 40,7
9,1
54,6 59,3
0%
10%
20%
30%
40%
50%
60%
70%
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100%
Prevalence Spells OBDs
%
Distribution of alcohol admissions in people with alcohol dependence
3+ admissions
1-2 admissions
No admissions
54,369
136,015
404,616 303,313
365,359 1,402,600
962,718
£848 Million
£704 Million
Total = £1.6 BillionTotal = 2.4 Million
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Total = 600,000
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Alcohol Frequent attenders per 100,000 and Index of Multiple Deprivation x10 South London
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ARFA rateARFA rateLineær (ARFA rate)
IMD
ARFA
LEWGRE
SOULAM
CROWAN
BEXSUTBRO
KINRIC
MER
r = 0.74
Health inequalities and the alcohol harm paradox
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Alcohol Assertive Outreach Team Colin Drummond, Emily Finch, Barney Hyndman
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www.slam.nhs.uk
What is Alcohol Assertive Outreach Treatment?
• Minimum weekly contact for 12 months• Small keyworker caseloads ≤15• Persistent, assertive engagement• Home-based or community setting• Working across traditional professional boundaries• Patient-led agenda• Engagement with families, carers and professionals• Supporting patients to attend addiction and health
services• Volunteers provided practical help and support
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www.slam.nhs.uk
What we did
• Worked with patients and clinicians to adapt anAssertive Outreach Treatment model used in severemental illness training manual
• AAOT much more intensive and prolonged thanstandard alcohol care
• AAOT clinical team for Lambeth and Southwark• Created partnerships with hospital and community
teams• Identified ARFA patients through hospital e-records• Recruited 174 ARFA patients into a trial of AAOT versus
Care as Usual, 87 per treatment group
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Value in reduced healthcare costsMean inpatient nights pre-post intervention
0,27 0,21
26,8
10,5
0,07 0,191,15
5,2
0,27 0,21
26,8
10,5
0,05 0,18
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14,6
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SIPS PHC AESOPS ACTAD AAOT
Intervention Baseline Intervention 6 months Control baseline Control 6 months 21
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www.slam.nhs.uk
Change in alcohol admissions via Emergency Department in King’s College Hospital
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-20
-15
-10
-5
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F10 admissions % change
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Introduction of AAOT
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BMJ Mental Health Team of the Year 2019
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Extrapolation from AAOT trial to national ARFA data
• England 54,369 ARFAs• OBDs 1,402,600• Cost £848M• Saving AOT compared to CAU = £13,819/case = £751M• AOT treatment cost = £2,979/case = £161M• Net saving = £10,840/case = £590M• For every £1 spent, net cost saved = £3.66• So potential cost saving overall = £590M in England
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Alcohol CQUIN – expected impact
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~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.
Smoking
Even if only half of patients get screened.
~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.
The NHS could save >£20M per year from reductions in ill-health caused by drinking.
Alcohol
Cost of implementation: BA £10 per case (SIPS ED) = £10 x 900,000 = £9MNet saving = £11M
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900
5411
590
0100200300400500600700800900
1000
IBA AOT
Numbers of patients and cost savings for IBA and AOT
Number of patients (1000s) Net cost saving (£M)
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£12 per patient
£11,000 per patient
Value for healthcare costs
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Figure 2. Differential changes in liver morbidity risk related to changes in alcohol consumption in dependent and hazardous/harmful drinkers following intervention
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Dependence (ACTAD)Reduction 238 units/dayRisk reduction 4188.2x= -410
Hazardous/Harmful (Cochrane)Reduction 4.44 units/dayRisk reduction 2.92.6x= -0.3
-15 U/day
-410x risk
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Conclusions• Alcohol care in acute hospitals is enjoying growth• But focus is on SBI rather than complex needs• Community addiction services shrinking and cater for more
motivated, less complex people• Hazardous/harmful drinkers more numerous but morbidity
and costs relatively small and natural remission high compared to dependence
• Although intervention costs 150 times more for AOT than SBI, risk reductions and cost savings exponentially greater
• Focus needs to shift to High Need High Cost patients with multimorbidity and complex needs
• Need for Integrated Care Pathways between hospital and community
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