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. Author manuscript; available in PMC: 2011 Jul 1.
Published in final edited form as: Alcohol Clin Exp Res. 2010 May 4;34(7):1257–1265. doi: 10.1111/j.1530-0277.2010.01203.x

Physical Health and Drinking among Medical Inpatients with Unhealthy Alcohol Use: A Prospective Study

Emily C Williams ¥,§, Tibor Palfai α,*, Debbie M Cheng †,*, Jeffrey H Samet ©,*, Katharine A Bradley ¥,§,χ, Thomas D Koepsell §,σ, Thomas M Wickizer §, Patrick J Heagerty ∑, Richard Saitz *,∞
PMCID: PMC2911969  NIHMSID: NIHMS221166  PMID: 20477765

Abstract

Objective

Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a “teachable moment” that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.

Methods

Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n=341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.

Results

Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were non-dependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03 – 0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13 – 0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.

Conclusions

Among medical inpatients with non-dependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.

INTRODUCTION

Medical illness and poor physical health status are common among patients with unhealthy alcohol use (Blow et al., 2000; Bridevaux et al., 2004; Chou et al., 1996; Green et al., 2004; Rehm et al., 2003; Room et al., 2005; Saitz et al., 2006; Solberg et al., 2008; Stein, 1999; Williams et al., In press), a term which is used to describe a spectrum from drinking amounts that risk health consequences (e.g. above recommended limits), to drinking amounts associated with consequences but not yet meeting criteria for a disorder, to meeting diagnostic criteria for alcohol abuse or dependence (Saitz, 2005). Approximately 25% of all persons admitted to general hospitals have alcohol use disorders or are being treated for the consequences of their drinking, making hospitalization a potentially opportune time for interventions to reduce unhealthy alcohol use (Smothers et al., 2003). However, the evidence in support of brief counseling interventions in hospital settings is mixed, often showing lack of efficacy (Chick et al., 1985; Elvy et al., 1988; Emmen et al., 2004; Freyer-Adam et al., 2008; Heather et al., 1996; Holloway et al., 2007; Persson J and Magnusson P, 1989; Saitz et al., 2009; Saitz et al., 2007). This lack of efficacy may be due in part to the high prevalence of dependence among patients with unhealthy alcohol use in hospitals (Saitz et al., 2006), although studies that excluded dependent patients have also had mixed results (McQueen et al., 2009). Improvements in opportunistic counseling interventions for hospitalized patients identified with unhealthy use, including dependence, are sorely needed.

Qualitative studies have identified factors responsible for catalyzing change in patients with unhealthy alcohol use (Orford and Hawker, 1974; Orford et al., 2006; Orford et al., 2008), which include “awareness of accumulating harms” and “triggering occurrences”(Orford et al., 2006). As such, poor physical health may serve as a catalyst of change. Further, in the context of a hospitalization, which has been hypothesized to provide a “teachable moment,” patients with unhealthy alcohol use may recognize the link between their drinking and health and be particularly amenable to making changes in their drinking (Figlie et al., 2005; Stewart and Connors, 2007), with or without intervention. As such, patients with the physical health consequences from alcohol use would be more likely to change than those without such consequences.

Factors that may catalyze change among patients with unhealthy alcohol use may operate differently for patients based on both the severity of dependence symptoms and their readiness for or commitment to change. Specifically, patients with alcohol dependence, who typically exhibit impaired control over their drinking, or those who are not ready to change may be less likely to decrease drinking after a catalyst than those without dependence or those with greater readiness to change (DiMartini et al., 2002; Kelly et al., 2006; Moos and Moos, 2006; Orford et al., 2008; Saitz et al., 2009; Vielva and Iraurgi, 2001; Walton et al., 2003).

Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could help to inform further refinement of hospital-based brief interventions by identifying whether they should specifically focus on physical health. This study sought, in a secondary analysis of data collected prospectively, to evaluate whether, independent of an intervention, 5 different measures of physical health were associated with two drinking outcomes 3 months after hospitalization and to explore whether associations between physical health and drinking vary by alcohol dependence or readiness to change.

METHODS

Study Design

We studied a prospective cohort of adult medical inpatients with unhealthy alcohol use who were first identified by screening in the hospital and then enrolled in a randomized trial of brief alcohol counseling. Although the intervention was not associated with decreased drinking or receipt of alcohol-related treatment in this trial (Saitz et al., 2007), some subgroups, including patients without alcohol dependence, appeared to benefit from the brief intervention (Saitz et al., 2009). The study represents a secondary analysis of data collected during this trial and was approved by the institutional review boards of Boston Medical Center and the University of Washington. Subjects provided informed consent to participate in the trial and were compensated for each completed interview. A Federal government Certificate of Confidentiality was obtained to protect participant privacy.

Participants

Participants included 341 adult medical inpatients who reported drinking risky amounts in the past month defined as >14 standard drinks per week or ≥5 drinks per occasion for men (>11 and ≥4, respectively, for both women and people ≥66 years (i.e., screened positive for unhealthy alcohol use) based on the screening strategy recommended by the National Institute on Alcohol Abuse and Alcoholism (National Institute on Alcohol Abuse and Alcoholism et al., 2007). Participants also were fluent in English or Spanish, provided names of 2 contacts to assist with follow-up, had no plans to move away from the study area in the following year, scored 21 or more points on the Mini-Mental State Examination (Smith et al., 2006), and consented to participate in the trial (Saitz et al., 2007).

Assessments

Participants were assessed via in-person interviews by trained research associates at enrollment and a 3-month follow-up visit. Also at enrollment, a physician-researcher reviewed each participant's medical record to determine medical diagnoses, including the principal reason for admission (principal admitting diagnosis).

Measures

Drinking Outcomes

Alcohol use in the 30 days before each interview was assessed using the validated Timeline Follow-Back calendar method (Sobell et al., 1988), which identifies the number of standard drinks consumed on each of the past 30 days. Two drinking measures derived from the Timeline Follow-Back were used as study outcomes: 1) 30-day abstinence and 2) number of heavy drinking days (HDDs) reported in the 30 days prior to the 3-month assessment. HDDs were defined as drinking ≥5 drinks per day for men and ≥4 per day for women.

Independent Variables

Five measures of different dimensions of physical health, the independent variables for the study, were derived from interview and structured record review at the time of enrollment: 1) recent medical comorbidity, 2) lifetime medical comorbidity, 3) self-reported physical health status, 4) any alcohol-attributable medical diagnosis, and 5) alcohol-attributable principal admitting diagnosis. Medical comorbidities were assessed using a questionnaire validated by Katz, et al., which is similar to the Charlson Comorbidity Index (Charlson et al., 1994) but is based on patient report instead of administrative data and assesses the presence of medical illnesses including kidney disease, diabetes, heart disease, chronic obstructive pulmonary disease, AIDS, and others using both recent (past 3 months) and lifetime timeframes (Katz et al., 1996). We categorized the number of recent and lifetime comorbidities (0, 1, or ≥ 2). The physical component summary (PCS) score from the 12-item Short Form Health Survey (Ware et al., 1996) measured physical health status. The PCS score ranges from 1–100 and is standardized to the U.S. population mean with 1 representing poor and 100 representing perfect physical health status (Ware et al., 1996). To avoid an assumption of linearity, PCS scores were categorized into quintiles with the highest quintile (best health) used as the referent category. Finally, a physician-researcher reviewed each patient's medical record at enrollment for any medical diagnoses that are 100% alcohol-attributable, and for whether any of these were the principal admitting diagnosis. Diagnoses included alcohol intoxication, alcoholic pellagra, alcoholic polyneuropathy, alcoholic gastritis, alcohol cardiomyopathy, alcoholic liver damage, acute alcoholic cirrhosis of the liver, alcoholic hepatitis, alcoholic fatty liver, alcoholic amnestic syndrome, other alcoholic dementia, alcohol withdrawal, alcohol withdrawal hallucinosis, alcohol withdrawal delirium, other alcoholic psychosis, alcohol withdrawal convulsion, or alcoholic pancreatitis (Adams et al., 1993).

Potential Effect Modifiers

DSM IV diagnosis of current alcohol dependence (American Psychiatric Association, 1994) was made at enrollment based on the Composite International Diagnostic Interview (CIDI) Alcohol Module (Robins et al., 1988). Readiness to change drinking was assessed via interview with the validated Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), which was developed to assess readiness among individuals presenting for specialty alcohol treatment (Miller and Tonigan, 1996). Two SOCRATES components (Problem Perception and Taking Action) were used rather than the 3 factors originally described based on results from a previous factor analysis in this patient population (Bertholet et al., 2009b), because it is consistent with another prior study (Maisto et al., 1999) and because these factors more aptly describe change readiness among patients not actively seeking or receiving specialty alcohol treatment. The two components yield continuous scores (range: 10–50 for Problem Perception, 6–30 for Taking Action) with higher scores representing more readiness. The readiness scores have been previously modeled using quartiles of the distribution due to non-linear associations with drinking outcomes (Bertholet et al., 2009b). For this study, each score was dichotomized based on the observed associations with the outcomes of interest for this study and for ease of interpretation. Based on results of preliminary analyses categorizing readiness scores using quartiles of the distribution, Problem Perception was dichotomized at the 50th and Taking Action at the 75th percentile; residual plots and likelihood ratio tests evaluating goodness-of-fit suggested adequate fit.

Covariates

Covariates representing potential confounders were selected based on known associations between medical illness or health status and alcohol use and included: demographic characteristics (age in years, female gender, and race including Hispanic, Black, White, and other); smoking status [never, current, and past (Fagerstrom Tolerance Test), and quantity/frequency questions] (Pomerleau et al., 1994), and alcohol use reported at enrollment. Number of drinks per day (continuous variable) was included in models with abstinence as the outcome, and the number of heavy drinking days in the 30 days prior to baseline (categories: 0–1, 2–14, and ≥ 15 heavy drinking days) was included in models with number of heavy drinking days as the outcome. For evaluating the association between measures of physical health and abstinence, alcohol dependence was considered a potential confounder (in addition to a potential effect modifier) due to its strong associations with both medical illness and abstinence (Dawson et al., 2005). Despite the negative main trial results, randomization group was also included as a covariate because we sought to identify associations independent of intervention, subgroup analyses suggested some intervention effect, and the intervention may have resulted in differences in drinking or readiness to change between groups (Saitz et al., 2009).

Analyses

Subjects lost to follow-up were compared with those assessed at 3 months on all patient demographic and drinking characteristics using chi-square statistics, two-sample t-tests, and non-parametric (two-sample Wilcoxon rank-sum or Mann-Whitney) tests as appropriate. Separate logistic regression models were fit to evaluate the association between each of the 5 independent variables and 30-day abstinence. Negative binomial regression was used to model the association between each of the independent variables and the number of heavy drinking days reported at 3 months, because days are counts with a skewed distribution (large numbers of zeros from abstinent subjects, and some extreme numbers of days). Negative binomial regression generates estimates of the incidence rate ratio (IRR), which is interpreted as a multiplicative increase or decrease in the number of days for each 1-unit difference in the predictor variable (similar to a relative risk). A robust variance correction was used to allow for over-dispersion. Preliminary unadjusted models were fit first and then adjusted models controlling for all covariates were used as the primary analysis. Multiplicative first-order interactions between each measure of physical health and potential effect modifiers (dependence status and readiness to change) were tested in both unadjusted and adjusted models. Stratified analyses were conducted when interactions were significant (p<0.05). We did not formally adjust for multiple comparisons because this secondary analysis was exploratory and intended to assess whether a single concept—physical health—was associated with drinking 3 months after hospitalization. All analyses were performed using Stata Version 10.1 (StataCorp., 2007).

RESULTS

Participants had a mean age of 44 years and were racially diverse (45% Black, 39% White, and 9% Hispanic) (Table 1). Only 14% of participants reported never smoking; 75% reported current smoking. At baseline, patients reported consuming a median of 3.6 drinks per day, 38% of patients reported 15 or more heavy drinking days, 4% met diagnostic criteria for current alcohol abuse, and 77% met criteria for current alcohol dependence. Patients generally reported high levels of recognition of unhealthy drinking and efforts to change. Mean problem perception score was 35 (SD 11, range 10–50), and mean Taking Action score was 21 (SD 6, range 6–30). Participants had poor average physical health status [Physical Component Summary score of 38 (SD 9)]; 22% reported 2 or more recent medical comorbidities, and 33% reported 2 or more lifetime comorbidities. Forty-six percent of participants had any alcohol-attributable medical diagnosis in their medical record, while 15% had an alcohol-attributable principal admitting diagnosis.

Table 1.

Participant Characteristics at Baseline (n=341)

Mean (SD)
Age 44 (11)
N (%)
Female 99 (29)
Race
Hispanic 30 (9)
Black 155 (45)
White 133 (39)
Other 23 (7)
Smoking Status
Never 48 (14)
Current 257 (75)
Past 36 (11)
Heavy Drinking Days (in the prior 30 days)
0–1 59 (17)
2–14 152 (45)
≥15 130 (38)
Median Drinks/day 3.6
Alcohol Dependent 261 (77)
Alcohol Abuse 15 (4)
Mean (SD)
Problem Perception (Range 10–50) 35 (11)
Low, score ≤38 (n=172) 26 (9)
High, score >38 (n=166) 44 (4)
Taking Action (Range 6–30) 21 (6)
Low, score ≤25 (n=255) 19 (5)
High, score >25 (n=85) 28 (2)
Mean (SD)
Physical Health Status (PCS score; Range 17.8–61.9) 38 (9)
(Worst Health) Quintile 1 (17.8 – 30.3) 26 (3)
Quintile 2 (30.4 – 34.5) 33 (1)
Quintile 3 (34.6 – 39.4) 37 (1)
Quintile 4 (39.5 – 36.0) 43 (2)
(Best Health) Quintile 5 (46.2 – 61.9) 52 (4)
N (%)
Recent # Medical Comorbidities
0 148 (48)
1 96 (31)
≥2 67 (22)
Lifetime # Medical Comorbidities
0 107 (34)
1 102 (33)
≥2 104 (33)
Any Alcohol-attributable Medical Diagnosis 156 (46)
Alcohol-attributable Principal Admitting Diagnosis 51 (15)
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Overall, 272 patients were interviewed 3 months after hospitalization (80% follow-up). No statistically significant differences (at p<0.05) in demographic or drinking characteristics were identified between those with and without follow-up. However, a non-significantly greater proportion of patients with follow-up, compared to those without, met diagnostic criteria for alcohol dependence (79% vs. 68%, p=0.06). There were no significant differences in measures of physical health between those who did and did not complete follow-up.

At 3 months, 60 participants (22% of those with follow-up) were abstinent, and the median number of heavy drinking days was 5 (range 0 to 30). Most measures of physical health were not significantly associated with either abstinence or the number of heavy drinking days reported at 3 months in both unadjusted and adjusted regression models (Table 2). However, in unadjusted models, patients in the lowest quintile of self-reported physical health status (worst health) had significantly greater odds of abstinence at 3 months compared to those in the highest quintile (OR 3.35, 95% CI 1.25 – 8.96). The significance of the association was attenuated after adjustment (Table 2).

Table 2.

Unadjusted and Adjusted Associations between Measures of Physical Health and 3-month Drinking Outcomes

30 Day Abstinence*^ Number of Heavy Drinking Days**^
Unadjusted Models Adjusted Models Unadjusted Models Adjusted Models
OR 95% CI OR 95% CI IRR 95% CI IRR 95% CI
Recent # of Medical Comorbidities
0 --- --- --- --- --- --- --- ---
1 1.60 0.78 –3.29 1.69 0.80 – 3.59 1.04 0.75 – 1.43 0.93 0.66 – 1.31
≥2 1.51 0.67 – 3.39 1.44 0.62 – 3.34 1.34 0.90 – 1.98 1.18 0.78 – 1.79
Lifetime # of Medical Comorbidities
0 --- --- --- --- --- --- --- ---
1 1.04 0.48 – 2.25 1.13 0.51 – 2.51 1.03 0.75 – 1.40 0.95 0.68 – 1.32
≥2 1.26 0.59 – 2.70 1.15 0.51 – 2.58 1.22 0.84 – 1.77 1.10 0.73 – 1.64
Physical Health Status
Quintile 1 3.35 1.25 – 8.96 2.81 0.98 – 8.00 1.07 0.66 – 1.71 0.96 0.60 – 1.54
Quintile 2 1.34 0.47 – 3.82 1.00 0.32 – 3.03 1.24 0.81 – 1.89 1.18 0.78 – 1.80
Quintile 3 1.54 0.54 – 4.33 1.10 0.36 – 3.38 1.09 0.72 – 1.65 1.04 0.67 – 1.61
Quintile 4 1.95 0.71 – 5.37 1.74 0.61 – 4.95 1.00 0.66 – 1.52 0.96 0.63 – 1.45
Quintile 5 --- --- --- --- --- --- --- ---
Any Alcohol-Attributable Medical Diagnosis 1.26 0.71 – 2.23 1.13 0.60 – 2.10 0.90 0.66 – 1.22 0.83 0.60 – 1.14
Alcohol-Attributable Principal Admitting Diagnosis 1.81 0.87 – 3.76 1.87 0.85 – 4.11 0.97 0.65 – 1.44 0.88 0.58 – 1.33
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*

adjusted models included age, gender, race, smoking status, randomization group, alcohol dependence, and drinks/day at baseline

**

all models were adjusted for heaving drinking days at baseline; adjusted models also include age, gender, race, smoking status, randomization group, and alcohol dependence

^

p-values for all associations were all >0.05. P-values obtained for categorical independent variables were the result of tests of trend; p-values obtained for dichotomous independent variables were the results of Wald tests.

P-values for all tests of effect modification are presented in Table 3. Alcohol dependence significantly modified the association between having any alcohol-attributable medical diagnosis and abstinence and between having an alcohol-attributable principal admitting diagnosis and the number of heavy drinking days reported at 3 months but did not modify any other associations between measures of physical health and either drinking outcome. For the 58 participants without alcohol dependence, having an alcohol-attributable medical diagnosis (n=13) was significantly associated with increased abstinence in unadjusted analyses (OR 4.36; 95% CI: 1.12 – 17.0)3 but not after adjustment for potential confounders (OR 3.83; 95% CI 0.75 – 19.59). For those who were alcohol dependent (n=214), there was no significant association between having an alcohol-attributable diagnosis (n=114) and abstinence in unadjusted or adjusted analyses (ORs 0.90; 95% CI 0.47 – 1.70 and 0.78; 95% CI 0.41 – 1.62, respectively). For the 58 participants who were not alcohol dependent, having an alcohol-attributable principal admitting diagnosis (n=4) was significantly associated with fewer heavy drinking days in unadjusted and adjusted models (Table 4). For the 214 participants who were alcohol dependent, there was no significant association between having an alcohol-attributable principal admitting diagnosis (n=37) and number of heavy drinking days (Table 4).

Table 3.

Results of tests of effect modification: p-values for interactions between measures of physical health and alcohol dependence and readiness to change (significant results are bolded).

Independent Variables^ 30-Day Abstinence* # Heavy Drinking Days**
Dependent Problem Perception Taking Action Dependent Problem Perception Taking Action
Recent # of Medical Comorbidities
Unadjusted 0.67 0.73 0.56 0.76 0.52 0.16
Adjusted 0.71 0.74 0.66 0.60 0.62 0.12
Lifetime # of Medical Comorbidities
Unadjusted 0.19 0.90 0.90 0.09 0.75 0.95
Adjusted 0.25 0.85 0.80 0.08 0.72 0.98
Physical Health Status
Unadjusted 0.83 0.27 0.12 0.28 0.02 0.87
Adjusted 0.87 0.21 0.09 0.21 0.01 0.85
Any Alcohol-Attributable Medical Diagnosis
Unadjusted 0.04 0.80 0.18 0.12 0.17 0.75
Adjusted 0.05 0.83 0.08 0.12 0.22 0.91
Alcohol-Attributable Principal Admission
Unadjusted 0.94 0.70 0.18 0.04 0.07 0.13
Adjusted 0.92 0.70 0.06 0.02 0.04 0.03
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^

Medical comorbidities (both recent and lifetime) modeled categorically (0,1, ≥ 2) with 0 the referent; Physical Health Status modeled categorically in Quintiles (Quintile 5 referent); Alcohol-Attributable diagnoses (both any and principal admission) modeled dichotomously.

*

adjusted models included age, gender, race, smoking status, randomization group, alcohol dependence, and drinks/day at baseline

**

all models were adjusted for heaving drinking days at baseline; adjusted models also include age, gender, race, smoking status, randomization group, and alcohol dependence

Table 4.

Associations between Alcohol-Attributable Principal Admitting Diagnosis and number of heavy drinking days stratified by Alcohol Dependence and Problem Perception (significant results are bolded)

Non Dependent (N=58) Dependent (N=214) Low Problem Perception (N=132) High Problem Perception (N=137)
N (%) N (%) N (%) N (%)
Alcohol-Attributable Principal Admitting Diagnosis 4 (7) 37 (17) 9 (7) 30 (22)
IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI)
Unadjusted* 0.15 (0.04 – 0.56) 1.04 (0.71 – 1.53) 0.46 (0.21 – 1.00) 1.10 (0.83 – 1.67)
Adjusted** 0.10 (0.03 – 0.32) 0.94 (0.62 – 1.42) 0.36 (0.13 – 0.99) 1.02 (0.61 – 1.71)
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*

adjusted for heaving drinking days at baseline

**

adjusted for age, gender, race, smoking status, randomization group, heaving drinking days at baseline, and alcohol dependence

Neither measure of readiness to change modified any of the associations between measures of physical health and abstinence in unadjusted or adjusted analyses (Table 3). In contrast, both measures of readiness to change modified associations between having an alcohol-attributable principal admitting diagnosis and the number of heavy drinking days at 3 months (Table 3). Associations in unadjusted and adjusted analyses stratified by levels of Taking Action were not significant. However, among subjects with low Problem Perception (n=132), those with an alcohol-attributable principal admitting diagnosis (n=9) had 0.36 times the number of heavy drinking days compared to those without such a diagnosis (95% CI 0.13 – 0.99) (Table 4). No association was detected between having an alcohol-attributable principal admitting diagnosis (n=30) and heavy drinking days among participants with high Problem Perception (n=137). Problem Perception also modified the association between self-reported physical health status and heavy drinking days (Table 3). Among the 132 patients with low Problem Perception, those in the 2nd Quintile of health status (n=20) had 2.06 times the number of heavy drinking days (95% CI 1.17 – 3.62) compared to those in the referent group with the highest health status [5th Quintile (n=33)] in unadjusted analyses. However, associations in stratified adjusted analyses were all not significant. No other significant interactions were found between readiness to change and the independent variables in models of heavy drinking days at 3 months (Table 3).

DISCUSSION

In this study of medical inpatients with unhealthy alcohol use, most participants had alcohol dependence and reported substantial medical comorbidity. Among all participants, there were no significant associations between measures of physical health and either abstinence or heavy drinking days 3 months after hospitalization, though we did observe a borderline-significant association between worse physical health status and abstinence. However, among participants with non-dependent unhealthy alcohol use and those who were less aware of their drinking as a problem regardless of dependence status, having an alcohol-attributable principal admitting diagnosis was associated with less heavy episodic drinking at follow up.

Several previous studies have explored the idea that medical illness or one's perception of their physical health may be associated with or lead to changes in drinking. Multiple successful alcohol-related interventions have focused on addressing a medical issue via ongoing monitoring of abnormal alcohol-related lab tests or blood pressure (Fleming et al., 2004; Kristenson et al., 1983; Kristenson et al., 2002; Maheswaran R et al., 1992; Willenbring and Olson, 1999). One study of patients with HIV and past alcohol problems found that those who were told they had hepatitis C were more likely to reduce drinking at follow-up than those who were not (Tsui et al., 2007), and interventions in patients identified as heavy drinkers based on physical health problems were associated with reduced drinking and improved health outcomes (Israel et al., 1996; Kristenson et al., 1983; Willenbring and Olson, 1999). Finally, three randomized trials of interventions for unhealthy alcohol use found that the intervention was associated with improved outcomes for patients with an alcohol-related diagnosis but not for those without (Saitz et al., 2009; Walton et al., 2008; Weisner et al., 2001). Only one previous study that examined physical health and alcohol outcomes was conducted in medical inpatients with unhealthy alcohol use (Stewart and Connors, 2007). That study identified associations between readiness to change drinking and self-reported health status and alcohol-related physical consequences but found that only alcohol-related physical consequences were significantly associated with taking steps to change drinking (Stewart and Connors, 2007). Together, findings of previous studies suggest that poor physical health may motivate patients to consider changes in drinking and that, in combination with an intervention, alcohol-related illness can be a strong motivator of actual changes in drinking.

Our findings support and extend findings of previous studies in two ways. First, while the previous study in medical inpatients evaluated associations between self-reported physical health and readiness to change drinking (Stewart and Connors, 2007), our study evaluated associations between both self-report and medical-record-derived measures of physical health and patients' self-reported drinking 3 months after hospitalization. Though not statistically significant, estimates of associations between physical health and drinking went in the expected direction such that poorer physical health was associated with decreased drinking at follow-up. Second, we found that, independent of an intervention, admission to a hospital for a problem resulting from drinking was associated with less heavy drinking for non-dependent patients and those who did not perceive their excessive drinking to be problematic at the time of their hospitalization.

Several previous studies have demonstrated that high levels of readiness to change when defined as problem recognition are strongly correlated with more severe unhealthy alcohol use (Maisto et al., 2001; Samet and O'Connor, 1998; Williams et al., 2007; Williams et al., 2006). And, although some measures of readiness to change predict decreases in drinking (Heather et al., 1993; Williams et al., 2007), greater Problem Perception has previously been demonstrated to predict increases in drinking (Bertholet et al., 2009a). Further, decreasing drinking may be more difficult for and require more intensive interventions with patients with alcohol dependence (Bischof et al., 2008; Fleming and Manwell, 1999). As such, our finding of decreased incidence of heavy drinking days among participants with non-dependent unhealthy alcohol use who may have become aware of consequences of their drinking, but not among participants with alcohol dependence, is consistent with prior research.

We expected but did not find that poor physical health would be associated with decreased drinking among all participants. It could be that the relationship between health and drinking is more complex or that the expected associations are weaker than expected and thus were not statistically significant in this relatively small sample. Our finding that having an alcohol-attributable principal admitting diagnosis was associated with decreased drinking in subgroups of patients may have clinical implications. Brief alcohol counseling interventions that have reliably decreased alcohol consumption in primary care patients do not have confirmed efficacy for medical inpatients with unhealthy alcohol use (Emmen et al., 2004; Freyer-Adam et al., 2008; Holloway et al., 2007; Saitz et al., 2009; Saitz et al., 2007). Although further research is needed to confirm this, our findings suggest that being hospitalized for an alcohol-attributable illness may serve as a catalyst of change (Orford et al., 2006) for someone whose drinking or perception of drinking is more malleable to begin with (i.e., patients without dependence or who have little recognition upon hospital admission of their unhealthy drinking). As such, it could be that hospitalizations for alcohol-attributable illness may be a meaningful aspect to focus on during brief interventions for inpatients with less severe unhealthy alcohol use. But, most patients identified by alcohol screening in hospital settings are alcohol dependent (Saitz et al., 2006), a phenomenon which could account for lack of efficacy of brief interventions in this population (Guth et al., 2008). Further, 45 of the 51 (88%) patients who were hospitalized for alcohol-attributable illnesses in this study met criteria for alcohol dependence, and results of this study suggest that alcohol-attributable illness was not a strong catalyst of change for these patients. However, the study did not address whether an intervention focused on poor physical health impacted drinking outcomes. It could be that building upon the presence of an alcohol-attributable illness, or focusing on alcohol-related symptoms or problems (such as trauma) in the absence of alcohol-attributable illness, during brief interventions in hospital settings would help catalyze change for all patients along the spectrum of unhealthy alcohol use.

This study is limited in several ways. First, these analyses were conducted in a cohort of patients who consented to participate in a randomized controlled trial, which may limit the generalizability of findings. However, those who enrolled were identified by screening all medical inpatients. In addition, the parent study was not designed to answer the questions posed and, therefore, our ability to detect associations of the observed magnitude was limited both in the overall analyses and particularly in subgroup analyses exploring effect modification. In particular, the group of patients who were not alcohol-dependent, for whom changes in drinking may be easier than they are for alcohol dependent patients, was small, which may have limited our ability to detect important associations (although it was in this group that we did find an association between physical health and drinking). Future research should be pursued to confirm the results of this exploratory study. However, we found that, in exploring whether multiple dimensions of physical health were associated with changes in drinking, point estimates generally went in the expected direction, some results were significant, and consistent patterns emerged in subgroup analyses. Finally, the observational nature of our data makes us unable to determine a causal association between poor physical health and subsequent drinking. However, because it is impossible to randomize patients to medical illnesses or perceptions of their physical health status as poor, prospective data collection and adjusted analyses as in this study may be the best way to answer the research question.

Despite the limitations, some conclusions can be drawn from these findings, which merit further research. Some dimensions of physical health (e.g., medical illness) may not be associated with subsequent drinking among medical inpatients with unhealthy alcohol use. However, among participants with non-dependent unhealthy alcohol use and those less aware that they are drinking at unhealthy levels, being admitted to the hospital for an alcohol-attributable diagnosis was associated with less heavy drinking. Although further research should confirm these findings, they suggest that, among medical inpatients with less severe unhealthy alcohol use, medical illness attributable to alcohol use may serve as a catalyst for positive changes in drinking. Hospital clinicians may be uniquely positioned to offer assistance to inpatients with less severe unhealthy alcohol use by helping patients to recognize a link between their drinking and medical diagnoses.

Acknowledgments

This study was supported by NIAAA grant RO1-AA 12617 (Saitz, PI). Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, or Boston University. Preliminary versions of this work were presented at the 2007 meeting of the International Network on Brief Interventions for Alcohol Problems and the 2008 Research Society on Alcoholism annual meeting, as well as included in the dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy from the University of Washington (ECW). This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington.

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