Minor effect of patient education for alcohol cessation intervention on outcomes after acute fracture surgery: a randomized trial of 70 patients.

BACKGROUND AND PURPOSE: High alcohol intake is associated with increased risk of postoperative complications. Alcohol cessation intervention is recommended prior to elective surgery. We investigated short- and long-term effects of perioperative intensive alcohol intervention in relation to acute ankle fracture surgery. PATIENTS AND METHODS: 70 patients requiring ankle fracture surgery and consuming ≥ 21 drinks weekly (1 drink = 12 g ethanol) were randomized to a manual-based 6-week intensive standardized alcohol cessation program, the Gold Standard Program (GSP-A), or treatment as usual (TAU), on the day of operation. GSP-A included 5 personal meetings, patient education, and motivational and pharmacological support (alcohol withdrawal prophylaxis, B vitamins, and low-dose disulfiram). Complications requiring treatment were measured after 6 weeks and 1 year. Alcohol intake was validated by biomarkers. Quality of life (QoL) was measured by the SF-36. Hospital costs were obtained from the National Hospital Costs Register. RESULTS: Postoperatively, complete alcohol cessation was higher in the GSP-A than in the TAU group (18/35 vs. 5/35, number needed to treat = 3, p ≤ 0.001), but not lowrisk consumption in the long term (10/35 vs. 7/33, p = 0.5). Number of complications in the short and long term (12/35 vs. 14/33, 16/35 vs. 18/33), the SF-36 score, or hospital costs in the short and long term (€6,294 vs. €8,024, €10,662 vs. €12,198), were similar between the groups. INTERPRETATION: Despite an effect on alcohol cessation and a positive tendency as regards the other outcomes, the postoperative complications, QoL, and costs were similar. Better perioperative strategies for acute surgical patients with high alcohol intake therefore need to be developed.

Patient education for alcohol cessation intervention at the time of acute fracture surgery: study protocol for a randomised clinical multi-centre trial on a gold standard programme (Scand-Ankle).

BACKGROUND: Patients with hazardous alcohol intake are overrepresented in emergency departments and surgical wards. These patients have an increased risk of postoperative complications with prolonged hospital stays and admissions to intensive care unit after surgery. In elective surgery, preoperative alcohol cessation interventions can reduce postoperative complications, but no studies have investigated the effect of alcohol cessation intervention at the time of acute fracture surgery. This protocol describes a randomised clinical trial that aims to evaluate the effect of a new gold standard programme for alcohol cessation intervention in the perioperative period regarding postoperative complications, alcohol intake and cost-effectiveness. METHODS/DESIGN: Patients with hazardous alcohol intake undergoing ankle fracture surgery will be recruited into the trial from multiple orthopaedic wards at university hospitals in Denmark, Sweden and Norway. Included patients will be randomly allocated to either standard care or the gold standard programme aimed at complete alcohol abstinence before, during and 6 weeks after surgery. It includes a structured patient education programme and weekly interventions meetings at the orthopaedic outpatient clinic. Furthermore, patients are provided with thiamine and B-vitamins, alcohol withdrawal prophylaxis and treatment, and disulfiram to support abstinence. Alcohol intake is biochemically validated (blood, urine and breath tests) at the weekly intervention meetings and follow-up visits. Follow-up assessments will be conducted 6 weeks and 3, 6, 9 and 12 months after surgery for all patients. The effect of the gold standard programme will be assessed comparing the outcome measures between the intervention and control group at each follow-up point. DISCUSSION: The study will provide new knowledge about how to prevent alcohol-related postoperative complications at the time of acute fracture surgery. If effective, the results will be a benefit for the clinical course, patients and society alike. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (Id: NCT00986791 ).

Preoperative alcohol cessation prior to elective surgery.

BACKGROUND: Hazardous drinking has been associated with an increased postoperative complication rate after surgery. Common complications include postoperative infections, cardiopulmonary complications, and bleeding episodes. Preoperative abstinence may to some degree reverse alcohol-induced pathophysiological processes and thus prevent postoperative complications. OBJECTIVES: To assess the effect of preoperative alcohol cessation interventions on the rate of postoperative complications including mortality in hazardous drinkers. To assess the effect of preoperative alcohol cessation interventions for hazardous drinkers on alcohol use in the postoperative period and in the long term. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 9); Ovid MEDLINE (1966 to September 2011); Ovid EMBASE (1966 to September 2011); CINAHL via EBSCOhost (1982 to September 2011). We combined the MEDLINE search strategy with the Cochrane highly sensitive search strategy, as contained in the Cochrane Handbook for Systematic Reviews of Interventions, to identify randomized controlled trials (RCTs). SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that evaluated the effects of a preoperative alcohol cessation intervention on postoperative complications or postoperative alcohol consumption, or both, in the short and long term in hazardous drinkers . We excluded intraoperative and postoperative alcohol interventions. DATA COLLECTION AND ANALYSIS: Three authors independently assessed studies to determine eligibility and extracted data using a tool based on guidance in the Cochrane Handbook for Systematic Reviews of Interventions. Where required, we obtained additional information through collaboration with the original author. We presented the main outcomes as dichotomous variables. Where data were available, we planned to conduct subgroup analyses as well as a sensitivity analysis to explore risk of bias. MAIN RESULTS: We included two studies which involved 69 patients. Both studies were RCTs evaluating the effect of intensive alcohol cessation interventions including pharmacological strategies for alcohol withdrawal and relapse prophylaxis.Our primary outcome measure was postoperative complications and in-hospital and 30-day mortality. Meta-analysis showed an effect on the overall complication rates (odds ratio (OR) 0.22; 95% confidence interval (CI) 0.08 to 0.61; P = 0.004). There was no significant reduction of in-hospital and 30-day mortality (OR 0.39; 95% CI 0.06 to 2.83; P = 0.35).Secondary outcomes included length of stay and postoperative alcohol use. No significant reduction was found. AUTHORS' CONCLUSIONS: Based on the finding of two studies, it appears that intensive preoperative alcohol cessation interventions, including pharmacological strategies for relapse prophylaxis and withdrawal symptoms, may significantly reduce postoperative complication rates. No effect was found on mortality rates and length of stay.The effect of preoperative alcohol cessation intervention should be further explored in an effort to reduce the adverse effect of alcohol use on surgical outcomes. The number needed to screen to identify eligible patients for alcohol intervention studies in surgical settings seems to be extremely high. This may indicate that these studies are difficult to perform. Nevertheless, timing, duration and intensity of alcohol cessation interventions need to be subject to further investigation.

Alcohol-related hospital admissions: missed opportunities for follow up? A focus group study about general practitioners' experiences.

AIMS: To explore general practitioners' (GPs') follow-up experiences with patients discharged from hospital after admittance for alcohol-related somatic conditions. DESIGN AND PARTICIPANTS: Two focus groups with GPs (four women and 10 men), calling for stories about whether the intervention given in the hospital had been recognised by the GP and how this knowledge affected their follow up of the patient's alcohol problem. Systematic text condensation was applied for analysis. FINDINGS: A majority of the GPs had experienced patients with already recognised alcohol problems being rediscovered by the hospital staff. Still, they presented examples of how seeing the patient in a different context might present new opportunities. Few participants had received adequate information from the hospital about their patient's alcohol status, and they emphasised that a report about what had happened and what was planned was needed for follow up. Care pathways for patients with alcohol problems were seen as fragmented. Yet they described how alcohol-related hospital admissions might function as an eye-opener for the patient and a window of opportunity for lifestyle change. CONCLUSIONS: Hospital admittances provide important opportunities for change, but hospital care is seen as fragmented and poorly communicated to the GPs. For shared responsibility and follow up, all participating agents, including the patient, must be sufficiently informed about what has happened and what will follow. For the patient, hospital admittance is usually brief, while the relationship with their GP is long term, even lifelong. GPs are therefore key partners for programme development.

Health and the need for health promotion in hospital patients.

BACKGROUND: Integrated health promotion improves clinical outcomes after hospital treatment. The first step towards implementing evidence-based health promotion in hospitals is to estimate the need for health promoting activities directed at hospital patients. The aim of this study was to identify the distribution and association of individual health risk factors in a Norwegian hospital population and to estimate the need for health promotion in this population. METHODS: We used a validated documentation model (HPH-DATA Model) to identify the prevalence of patients with nutritional risk (measurements of waist and weight), self-reported physical inactivity, daily smoking and hazardous drinking. We used logistic regression to describe the associations between health risk factors and demographic characteristics. RESULTS: Out of 10 included patients, 9 (N = 1522) had one or more health risk factors. In total 68% (N = 1026) were overweight, 44% (N = 660) at risk of under-nutrition, 38% (N = 574) physically inactive, 19% (N = 293) were daily smokers and 4% (N = 54) hazardous drinkers. We identified a new clinical relevant association between under-nutrition and smoking. The association between hazardous drinking and smoking was sustained. CONCLUSION: Nearly all patients included in this study had one or more health risk factors that could aggravate clinical outcomes. There is a significant need, and potential, for health-promoting interventions. Multi-factorial interventions may be frequently indicated and should be the subject of interventional studies.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review.

BACKGROUND: In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs. METHODS: A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics. RESULTS: The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up. CONCLUSIONS: Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.