Readmission Rates and Causes Within The First Six Months After Discharge in Patients with Alcohol Addiction

Abstract

Introduction:

Readmission rate is an important criterion that evaluates the quality of treatment and care. In this study, it was aimed to determine the rates of readmission and variables predicting readmission in patients with alcohol addiction.

Methods:

The study sample consisted of 264 alcohol addiction patients with recurrent admissions between 2005–2017 at the Gazi University Hospital Alcohol and Drug Addiction Clinic. In the study, ICD-10 diagnostic classification was used. The differences between the medical comorbidity and psychiatric comorbidity of the patients during the first and second admissions were analyzed.

Results:

The average age of the study sample was 51.45±12.04 and 89% (n=235) were male. In the second admission, the comorbid headaches (p=0.001), psychotic symptoms (p=0.013), anxiety disorder (p=0.003) and substance addiction (p=0.027) were significantly higher, and the length of hospital stay was shorter. In the first six months, 24.2% (n=64) of the sample was hospitalized again. While the comorbidity of anxiety disorder increased the risk of readmission within six months 2.2-fold (OR=2.240; p=0.031), the short duration of hospitalization (less than 35 days) increased the risk of readmission 2-fold (OR=0.492; p=0.026).

Discussion:

Patients with a short hospital stay have an increased risk of readmission within the first 6 months after discharge. Policies that reduce the length of hospital stay in health services should be reviewed. However, it is noteworthy that in the second admission of patients with alcohol dependence, the diagnosis of drug addiction is added. To prevent this, issues related to substance abuse prevention should be addressed during the treatment stages of alcohol dependence.

INTRODUCTION

Alcohol addiction is a serious psychiatric disorder which reduces quality of life of both patients and their families and also has high social costs (1). According to the TUBİM data, number of people who get information and seek help has been increasing in the last years (2).

Basic diagnostic criteria of alcohol addiction are development of tolerance and experiencing withdrawal symptoms (3). When the patients start to experience withdrawal symptoms, they tend to consume more alcohol in order to avoid these symptoms. Symptoms improve for a short period with alcohol use; however, the need to take alcohol increases day by day due to tolerance in long term. The completeness of physical and mental health of consumers disrupts after the alcohol consumption is out of control (4, 5). Hospitalization is inevitable at the end of this period. The first step in the treatment of addiction symptoms is detoxification therapy which is usually performed in the inpatient clinic (6). Afterwards, patients are admitted to outpatient rehabilitation programmes to maintain staying away from alcohol. Still, it was shown that the therapies that are operated to prevent relapse after the detoxification therapy are insufficient for 85% of the patients with alcohol addiction (7). When the underlying reasons are investigated, possible relapse markers such as severity of alcohol addiction, psychiatric comorbidities (depression, sleep disorder etc.), smoking, environmental factors (patient’s residence, number of friends etc.), some genetic factors (related with BDNF and GABRA 2 genes) and increased number of hospitalization have been detected (8, 9).

Alcohol addiction is among the most frequent conditions which patients are rehospitalized in a short time in case of relapse (10). Readmission rates are considered as important variables by means of evaluation of both quality and sufficiency of treatment and maintenance. Therefore, lowering this rate has been an important target for healthcare services (11). It is important to be aware of the factors that decrease readmission rates in order to reduce them. That is why we aimed to the readmission rates and variables that foresee readmission in alcohol addicts who were hospitalized with repeated hospitalization in our study.

METHOD

This study is a retrospective, descriptive research. We reached hospitalization records of 1921 patients who were treated between 1 January 2005 and 31 December 2017 at Gazi University, Alcohol and Substance Addiction Clinics. We received the patient hospitalization registry via hospital’s electronic database and patient files. After the records of outpatients, discharged patients at the day of hospitalization and patients with missed data were eliminated, 1449 hospitalization records were entered. These records consisted single hospitalization records of 758 patients and recurrent hospitalization records of 264 patients (691 hospitalization registry). In order to evaluate the psychiatric comorbidity in patients with recurrent hospitalization, only the first and second hospitalization records of them were included in the study. The reason of excluding the data of these patients excluding the hospitalizations except the first and second ones was to prevent limitation in the analysis caused by similar demographic and disease variables. The flow chart of the study is presented in Figure 1.

Figure 1.

Study flow diagram

The diagnoses of patients were evaluated by psychiatrists according to DSM-IV TR. However, hospital managers use ICD-10 diagnosis classification due to the need of universally evaluating all disease groups. Therefore, the evaluated psychiatric diagnoses were recorded with the ICD-codes that are most available for the system. The diagnostic evaluations performed in our hospital undergo many revisions. The patient accepted to the service is firstly examined by the research assistant doctor. The senior inpatient clinic instructor is consulted for diagnosis and treatment planning. The patients are examined collectively in the service visits. The patients with suspicious diagnosis are re-evaluated in the usual visits at which all the instructors join.

That is why, the diagnostic evaluations of patients is addressed very comprehensively and in detail. Headache is also evaluated in a similar method. ICD-10 diagnosis system evaluates the people diagnosed with G44 (Headache, other syndromes), G44.0 (Cluster headache syndrome), G44.2 (Tension headache), G44.3 (chronic, post-traumatic headache), G44.8 (other headache syndromes, undefined) as “patient has headache”. The records of patients diagnosed with “Addiction Syndrome Due to Alcohol Use (F10.2)” according to the ICD-10 diagnosis classification formed the main study sample.

The average time of staying in the hospital detected at the first hospitalization records was 32.97±16.54 days. This variable did not present normal distribution. Therefore, the median 35 days value of this variable was based in distinguishing the long and short hospitalization times.

The time between the first and second hospitalization records of the patients with recurrent hospitalizations was named as “days between two hospitalizations”.

Variables such as “Psychiatric comorbidity is present” and “medical comorbidity is present” were created respectively for cases of any existing psychiatric disease coded for the same patient (F32-Depressive Episode, F41-Anxiety Disorder etc.) and existing coded somatic disease (R94.5-Abnormal results of hepatic function tests, G40-Epilepsy, I10-Essential Hypertension etc.). A new variable as “Psychotic symptom is present” was formed for the patients diagnosed with “Psychotic disorder due to alcohol use (F10.5) in addition to the F10.2 diagnosis.

The time limit for readmission of patients was taken as six months. Different time periods varying between 1-24 months were used in the literature for this time limit (12-24). The reason of our preference for the first six months limit is the low readmission rates within the first (n=17) and third (n=32) periods. The low sample of these periods could cause statistical limitation; therefore, six months was taken as the limit for readmission.

We detected that there were 64 people who were rehospitalized within six months following their first hospitalization. The other 200 people of the study sample had repeating hospitalizations among the 6th and 24th months.

Data Analysis

SPSS for Windows 23.0 was used to analyse the research data. The average, standard deviation, median, minimum value, maximum value, frequency and percentages were used for descriptive statistics. For the paired sample, McNemar’s test is used for comparison of the categorical variables (Medical comorbidity, Psychiatric comorbidity, depression etc.) at the first and second hospitalization records and Wilcoxon test is used for comparison of continuous variables (hospitalization duration). Logistical regression analysis was used to detect precursors of readmission situations of patients within six months. No readmission within six months was coded as “0” and hospitalization was coded as “1”. Significance value was based o 0.05 in the study.

Ethics Approval

Ethical approval with 2020-108 research code was taken in this research from Gazi University Ethics Commission. Chief Physician’s permission was also separately taken as hospitalization records were going to be used. The research was performed according to the Helsinki Declaration Ethical principles.

RESULTS

Average age of the first hospitalization in the sample was 51.45±12.04 and 18.9% of it (n=50) was detected as ages 21-40; 30.3% (n=80) was 41-50, 37.1% (n=98) was 51-65 and 13.6% (n=36) was 66 and more. Men consisted 89% of the sample (n=235).

Duration of hospitalization and comparison of psychiatric comorbidities by means of the first and second hospitalization situation were shown in Table 1. It was detected that between the first and second hospitalizations,

Table 1.

Duration of hospitalization and comparison of psychiatric comorbidities by means of the first and second hospitalization situations

Variables		First hospitalization (n=264)		Second hospitalization (n=264)		Statistical analysis P
		n	%	n	%
Admittance for:	Urgent	1	0.4	3	1.1	0.500
	Normal	263	99.6	261	98.9
Headache	Yes	5	1.9	16	6.0	0.001
Medical comorbidity (except headache)	Yes	8	3.0	18	6.8	0.064
Psychiatric comorbidity	Yes	165	62.5	174	65.9	0.374
Psychotic symptom	Yes	12	4.5	23	8.7	0.013
Schizophrenia	Yes	5	1.9	9	3.4	0.219
Delusional disorder	Yes	1	0.4	1	0.4	1.000
Bipolar mood disorder	Yes	18	6.8	10	3.8	0.096
Depression	Yes	92	34.8	89	33.7	0.828
Anxiety disorder	Yes	51	19.3	66	25.0	0.003
Personality disorder	Yes	10	3.8	15	5.7	0.359
Substance addiction*	Yes	19	7.2	30	11.4	0.027
Opiates addiction	Yes	2	0.8	6	2.3	0.289
Cannabinoid addiction	Yes	7	2.7	10	3.8	0.453
Cocaine addiction	Yes	2	0.8	3	1.1	1.000
Drug addiction	Yes	10	3.8	16	6.1	0.146
Volatile addiction	Yes	1	0.4	2	0.8	1.000
Hospital stay duration (days)	Avg. +sd	32.97	16.54	28.73	14.98	<0.001
	Median (min-max.	35	1–96	29	1–116
Time between two hospitalizations (day)	Avg. +sd	593.49±547.484
	Median (min-max.	384 (3–2754)

^*Presence of any substance addiction.

Significant difference by means of headache, anxiety disorders, psychotic symptoms, substance addiction and hospitalization duration variables (p=0.001; p=0.013; p=0.003; p=0.027; p<0.001, respectively). Psychotic symptoms, anxiety disorder and substance addiction were higher at the second hospitalization (Table 1). Hospitalization duration was higher at the first hospitalization (32.97 vs. 28.73).

Evaluation of readmission situation of the patients within six months by logistic regression analysis was shown in Table 2. Readmission risk within six months for 41-50 and 51-65 age ranges was 3.49 times (OR=0.286; 95% Confidence Interval 0.124-0.660) and 4.65 times (OR=0.215; 95% Confidence Interval 0.094-0.493) lower when compared with the risk of 21-40 age group. We determined that anxiety disorder comorbidity in alcohol addiction patients increased readmission within six months risk by 2.2-fold (OR=2.240; 95% Confidence Interval 1.076-4.662). Readmission within six months risk was two times lower in patients with longer than 35 days hospitalization duration when compared with the ones with 35 days or lower hospitalization duration (OR=0.492; 95% Confidence Interval 0.263-0.919). Cumulative percentage distributions according to the time ranges of recurrent hospitalizations were shown in Figure 2. Accordingly, 6% of patients (n=16) were rehospitalized within the first month; 12.1% (n=32) within the first three months; 24.2% (n=64) within the first six months and 47.7% (n=126) were rehospitalized within the first year.

Table 2.

Evaluation of readmission situation of the patients within six months by logistic regression analysis (n=264)

Variables		Readmission within six months		p	OR (95% confidence interval)
		None (n=200)	Yes (n=64)
		n	n
	21–40	26	24		1.000
	41–50	65	15	0.003	0.286 (0.124–0.660)
	51–65	83	15	<0.001	0.215 (0.094–0.493)
	66	26	10	0.203	0.523 (0.193–1.417)
Gender	Kadın	19	10	1.000
	Erkek	181	54	0.430	0.690 (0.274–1.737)
Hospitalization duration (day)	≤35	91	42	1.000
	>35	109	22	0.026	0.492 (0.263–0.919)
Medical comorbidity*	None	189	62	1.000
	Yes	11	2	0.578	0.532 (0.072–5.526)
Psychotic symptom	None	189	63	1.000
	Yes	11	1	0.254	0.277 (0.031–2.514)
Unipolar depression	None	134	38	1.000
	Yes	66	26	0.197	1.524 (0.804–2.888)
Anxiety disorder	None	167	46	1.000
	Yes	33	18	0.031	2.240 (1.076–4.662)
Personality disorder	None	191	63	1.000
	Yes	9	1	0.162	0.205 (0.022–1.886)
Substance addiction	None	187	58	1.000
	Yes	13	6	0.542	1.416 (0.463–4.334)

Results of model analysis; X²=35.896; p<0.001; Nagelkerke R²=0.190

Hosmer and Lemeshovv test; X²=3.499; df=8; p=0.899

^*Headaches are included.

Figure 2.

Cumulative percentage distributions according to the time ranges of recurrent hospitalizations (n=264).

DISCUSSION

This study aimed to investigate readmission rates and the reasons of recurrent hospitalization within six months in alcohol addicts. One of four patients was rehospitalized within the first six months and one of two patients was rehospitalized within one year after discharge (Figure 2). While medical comorbidity and psychiatric comorbidity rates in the second hospitalization of patients increase in general when compared with the first hospitalizations, presence of psychotic symptoms and any substance addiction increased significantly (Table 1). Readmission risk of patients within six months decreases for middle and advanced age periods. However, presence of anxiety disorder diagnosis increased hospitalization risk within six months by 2.2 folds; meanwhile readmission risk decreases by two folds for the patients hospitalized for longer than 35 days (Table 2).

Hospitalization and readmission of discharged patient is a very costly situation. These repeating hospitalizations are among the crucial problems for both medical and psychiatric diseases (11). In a study which evaluated emergency service applications of all medical and psychiatric patients, it was found that 18% of patients were rehospitalized within the first month after discharge (15). Psychiatric diseases are found as the second medical diseases group after heart failure (27.7%) with 25.1% readmission rate to the emergency service. However, we determined that psychiatric diseases are the first disease group that required hospital based acute treatment need (47.0%) (15). This conclusion showed that the disease group which requires the most hospitalizations at emergency applications are psychiatric disorders. In another research, researchers investigated readmission rates of psychiatry patients within one year after discharge (10). As a result of this research, it was found that 30% of the patients were rehospitalized within one year. Two diseases with the highest readmission rates were schizophrenia and alcohol addiction.

Variables such as study population, treatment program and follow-up durations in the researches investigating readmission rates in alcohol addiction displayed differences at the results. Slater et al. reported that 30% of 238 alcohol addicts whom they followed for six months were rehospitalized (16). Booth et al. determined that 38.4% of 255 patients were rehospitalized in a 15 months period as well (17). In our study, 24.2% of the patients were rehospitalized within the first six months and 47.7% of them were rehospitalized within one year. Readmission rates within six months seem to be compliant with the literature but we found them partially higher for one year. Alcohol consumption is quite lower than the European region specified by World health Organization but similar or slightly higher readmission rates can be explained by smaller number of centres that provide treatment services for psychiatric disease or alcohol consumption, than the ones in this region (2, 18). Although the number of rehospitalized patients is low, similar or slightly higher rates might have been found due to the lesser bed capacity.

In the studies performed in the past years, authors concluded that personal characteristics are important in predicting readmission rather than the treatment process (19, 20). In a study it was shown that patients with alcohol addiction diagnosis and good psychosocial support had lower readmission rates (16). As an example, being married, working or having a regular social life have been suggested as the characteristics that decrease readmission. Yet, more recent studies showed that keeping the outpatient follow up long after the detoxification decrease readmission rates and hospitalization durations (21). Nonetheless, though questionable results are present for marital status, it is a common opinion that readmission is lower in patients with good psychosocial support (22, 23). It has been shown in many studies that other psychiatric disorders accompany alcohol addiciton with high frequency and these disorders effect the readmission condition (10, 22, 24). It was reported that readmission rates increase in anxiety disorder, depression, substance addiction, personality disorder and psychosis in addition to alcohol addiction diagnosis (10). In another study of similar characteristics it was found that psychiatric comorbidities such as short hospitalization duration, accompanying medical diseases (cirrhosis, pancreatitis, diabetes, hypertension etc.), adjustment disorder, anxiety disorder, attention deficit, mood disorders, psychotic disorders and substance use disorder increase the readmission rates within one month (22). In our study, readmission risk within six months in 41-50 and 51-65 age ranges was 3.4 and 4.6 times lower, respectively, compared with data of 21-40 age group. Accompanying anxiety disorder in addition to alcohol addiction increases readmission risk 2.2 times and presence of short hospitalization duration (35 days or lesser) increases the risk two times. In addition to these results headache, psychotic symptom, anxiety disorder and substance addiction rates at the second hospitalization of patients were significantly higher (Table 1). Alcohol causes analgesia in humans and animals dose-dependently (25). In a study, it was reported that 25% of people living with pain (tooth, chin, face etc.) use alcohol to control their pain (26). Alcohol use might lower the pain intensity in short term. However, long term alcohol use lowers the pain threshold and increases pain sensitivity (25). In our study, headache frequency of patients at their second hospitalization was higher when compared with their first hospitalization (6% vs. 1.9%). Alcohol use of patients between two hospitalizations is unknown. Nevertheless, when we consider that they were hospitalized with alcohol addiction diagnosis for the second time, one can assume that alcohol use more or less continued. With this presumption, psychiatric comorbidities and headache increase at further hospitalizations in alcohol addicts.

Questionable results about the effect of age on readmission are present in the literature. According to some researchers age is not age is not a significant variable for readmission risk (17, 22), yet some studies reveal that advanced age can be a risk for readmission (27). They suggested that medical and psychiatric comorbidities increase at advanced ages, and this itself could increase readmission rates. In our study, we determined that the higher readmission risk consisting group was patients between ages of 21-40. This might be caused by the medical comorbidities of the sample. Some researchers mentioned that treatment incompatibility, early discharge despite medical advice and relapses are higher at young age groups (28-30). We have not evaluated compliance to the treatment in our study but keeping this fact of the literature in mind, increased readmission rate at young adulthood can partially be explained.

It was also shown that readmission rates are increased in the alcohol addiction accompanying psychiatric diseases (31, 32). 300 patients with major depression diagnosis were followed up for one year and it was detected that 51.3% of them were rehospitalized (31). Accompanying alcohol addiction diagnosis was considered as a significant variable which increases readmission rate. Similar results were also found for patients with psychiatric disorders (32). However, a study was performed with patients hospitalized in the internal medicine service and it was shown that treating alcohol addiction that accompany internal diseases decreased readmission rates in 30 days from 23.4% to 8.2% (33). Emergency service application frequency of these patients decreased from 18.8% to 6.1%. Alcohol addiction is a problem that all the clinics should approach when it is evaluated from this part of it, rather than a problem that only psychiatry approaches.

Our study has strengths and limitations. Involving a long-term and serious sample by means of readmission, being performed at a centre on area of alcohol and substance addictions which provides non-profit comprehensive services are the strong parts of our study. Another strength is use of DSM-IV TR and ICD-10 diagnosis classifications rather than patient feedbacks, but one should consider that different clinicians performed the evaluations in this diagnostic classification at different times. Nonetheless, limitations are data collection from a single center and not evaluating variables like demographic data, psychosocial life experience characteristics, alcohol use characteristics and follow up of polyclinic applications of patients. The registry mentioned as the first and second hospitalization re the records of patients at our hospital. It is possible that patients were treated at another institution than our hospital. Comparative analyses of these two data could cause some deficiencies. Also, 35 days median of hospitalization duration is based in distinguishing short- and long-term hospitalizations. Keeping a relatively long time of 35 days as the limit for short- and long-term hospitalizations for the variable of hospitalization duration might also cause a limitation. However, one must evaluate this 35-days limit considering the sample (patients with recurrent hospitalizations) and interpret the results about his variable accordingly.

CONCLUSION

One of each four alcohol addiction diagnosed patients was rehospitalized within six months after discharge and one of two patients was rehospitalized within one year. These data comply with the results taken at Western countries. People of Europe region of WHO consume much higher alcohol than averages in our country. Despite this fact, similarity in readmission rates can result from inadequate number of clinics of alcohol and substance addiction. Studies on readmission rates of both psychiatric disorders and alcohol/substance addiction must be performed in order to better understand this relationship; people staying short-term (35 days and shorter) at the hospital at first hospitalization have two times more readmission risk in six months compared with the ones staying long-term. Policies about decreasing hospitalization duration in healthcare services must be reviewed again and studies must be performed in our country in this area, too. At the second hospitalization, patients had lower hospitalization duration while anxiety disorder, psychotic symptom and substance addictions increased. This seems to be a contradiction. However, addition of substance addiction diagnosis to the people with alcohol addiction in the further periods is remarkable. Topics for prevention of occurrence of substance addiction must be considered to prevent this issue.