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BACKGROUND: Alcohol withdrawal is a common reason for admission to acute care hospitals. Prescription of medications for alcohol-use disorder (AUD) and close outpatient follow-up are commonly recommended, but few studies report their effects on postdischarge outcomes. OBJECTIVES: The objective of this study is to evaluate the effects of medications for AUD and follow-up appointments on readmission and abstinence. METHODS: This retrospective cohort study evaluated veterans admitted for alcohol withdrawal to medical services at 19 Veteran Health Administration hospitals between October 1, 2018 and September 30, 2019. Factors associated with all-cause 30-day readmission and 6-month abstinence were examined using logistic regression. RESULTS: Of the 594 patients included in this study, 296 (50.7%) were prescribed medications for AUD at discharge and 459 (78.5%) were discharged with follow-up appointments, including 251 (42.8%) with a substance-use clinic appointment, 191 (32.9%) with a substance-use program appointment, and 73 (12.5%) discharged to a residential program. All-cause 30-day readmission occurred for 150 patients (25.5%) and 103 (17.8%) remained abstinent at 6 months. Medications for AUD and outpatient discharge appointments were not associated with readmission or abstinence. Discharge to residential treatment program was associated with reduced 30-day readmission (adjusted odds ratio [AOR]: 0.39, 95% confidence interval [95% CI]: 0.18-0.82) and improved abstinence (AOR: 2.50, 95% CI: 1.33-4.73). CONCLUSIONS: Readmission and return to heavy drinking are common for patients discharged for alcohol withdrawal. Medications for AUD were not associated with improved outcomes. The only intervention at the time of discharge that improved outcomes was discharge to residential treatment program, which was associated with decreased readmission and improved abstinence.
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OBJECTIVES: Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS: We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS: Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS: Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.
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BACKGROUND: The clinical significance of mildly elevated troponins in patients presenting to the emergency room (ER) with atrial fibrillation (AF) is not well understood. HYPOTHESIS: We hypothesized that mildly elevated troponin in these patients is associated with adverse cardiovascular outcomes. METHODS: In a multi-center, retrospective study, 662 patients with AF were divided into 3 groups based on troponin levels: group 1, mildly elevated; group 2, normal; and group 3, troponin not measured. Primary outcome was the combined endpoint of all-cause mortality and myocardial infarction (MI) at one year. RESULTS: Levels of TnI were measured in 503 (76%) patients. They were elevated in 220 patients (33%, group 1; mean, 0.56 ng/mL), normal in 283 patients (43%, group 2), and not measured in 159 patients (24%, group 3). Significantly more cardiac testing was done at index hospitalization in group 1 (50%) compared with groups 2 and 3 (28% and 29%, P ≤ 0.001) and in the following year (29%, vs 20% and 17%, P = 0.02). Group 1 had more positive tests (62%) compared with groups 2 and 3 (25% and 43%, P ≤ 0.001). Group 1 had a significantly higher occurrence of the primary endpoint (22%, vs 10% and 15%, P = 0.002), driven primarily by a higher incidence of MI in group 1 (7%, vs 1% and 2%, P = 0.001). CONCLUSIONS: Troponin levels are routinely checked in a majority of patients presenting to the emergency department with AF. Even mildly elevated TnI is associated with a greater incidence of coronary artery disease on diagnostic testing and a higher 1-year incidence of MI.
