The Case 

A 53-year-old male known to have a substance use disorder presents to the emergency department. EMS reports finding an empty bottle of vodka at the scene, the patient had a decreased level of consciousness, and alcohol intoxication is suspected. This is the patient’s third visit to the emergency department in a week with a similar presentation. He is observed for six hours while his mental status improves and is discharged after demonstrating clinical sobriety and that he can ambulate safely.

Clinical Question

What is the association between visits to the emergency department for alcohol-related issues and one-year all-cause mortality?

Background

Alcohol consumption is known to be a major contributor to morbidity and mortality.¹ It is estimated that around 3 million deaths globally can be ascribed to the consumption of alcohol, representing 5 percent of all deaths.² In the United States, close to 100,000 people per year die from alcohol-related causes.³ This makes alcohol-related illnesses the third leading preventable cause of death. The single greatest risk factor for ill health worldwide among people ages 15 to 49 years, according to the 2016 Global Burden of Disease Study, is alcohol.⁴ 

Alcohol-related ED visits have increased more than the overall rate of ED visits in the United States.⁵ This trend of increasing alcohol-related ED visits has been reported in Canada, England, and Australia.^6–8

Reference: Hulme J, Sheikh H, Xie E, et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ. 2020;192(47):E1522-E1531.

Population: Adults ages 16 to 105 years who made two or more ED visits for alcohol-related reasons in a year.

Excluded: Data inconsistencies, not Ontario residents, age <16 or >105, or death at discharge.

Exposure: Patients with ED visits for alcohol-related mental and behavioral disorders, using the Canadian ICD-10 (ICD-10-CA) code of F10. 

Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons. Frequent use was categorized into either two visits per year, three or four visits per year, or more than four visits per year. 

Outcome:

Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of comorbidities.

Secondary Outcomes: Mental and behavioral disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (eg, accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, and assault) with frequency greater than 5 percent. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide.

Table 1: Patients with Multiple Alcohol-Related ED Visits

Authors’ Conclusions

“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.”