Approaches and reporting of alcohol and other drug testing for injured patients in hospital-based studies: A systematic review.

ISSUE: Hospital alcohol and/or other drug (AOD) testing is important for identifying AOD-related injuries; however, testing methods vary. This systematic review aimed to examine biological AOD testing methods from hospital-based studies of injured patients and quantify what proportion reported key information on those testing methods. APPROACH: Observational studies published in English from 2010 onwards involving biological AOD testing for injured patients presenting to hospital were included. Studies examining single injury causes were excluded. Extracted data included concentration thresholds for AOD detection (e.g., lower limits of detection, author-defined cut-offs), test type (e.g., immunoassay, breathalyser) and approach (e.g., routine, clinical discretion), timing of testing, sample type and the proportion of injured cases tested for AODs. KEY FINDINGS: Of 83 included studies, 76 measured alcohol and 37 other drugs. Forty-nine studies defined blood alcohol concentration thresholds (ranging from 0 to 0.1 g/100 mL). Seven studies defined concentration thresholds for other drugs. Testing approach was reported in 39/76 alcohol and 18/37 other drug studies. Sample type was commonly reported (alcohol: n = 69/76; other drugs: n = 28/37); alcohol was typically measured using blood (n = 60) and other drugs using urine (n = 20). Studies that reported the proportion of cases tested (alcohol: n = 53/76; other drugs: n = 28/37), reported that between 0% and 89% of cases were not tested for alcohol and 0% and 91% for other drugs. Timing of testing was often unreported (alcohol: n = 61; other drugs: n = 30). IMPLICATIONS AND CONCLUSION: Variation in AOD testing methods alongside incomplete reporting of those methods limits data comparability and interpretation. Standardised reporting of testing methods will assist AOD-related injury surveillance and prevention.

Prevalence of alcohol and other drug detections in non-transport injury events.

OBJECTIVE: To measure the prevalence of alcohol and/or other drug (AOD) detections in suspected major trauma patients with non-transport injuries who presented to an adult major trauma centre. METHODS: This registry-based cohort study examined the prevalence of AOD detections in patients aged ≥18 years who: (i) sustained non-transport injuries; and (ii) met predefined trauma call-out criteria and were therefore managed by an interdisciplinary trauma team between 1 July 2021 and 31 December 2022. Prevalence was measured using routine in-hospital blood alcohol and urine drug screens. RESULTS: A total of 1469 cases met the inclusion criteria. Of cases with a valid blood test (n = 1248, 85.0%), alcohol was detected in 313 (25.1%) patients. Of the 733 (49.9%) cases with urine drug screen results, cannabinoids were most commonly detected (n = 103, 14.1%), followed by benzodiazepines (n = 98, 13.4%), amphetamine-type substances (n = 80, 10.9%), opioids (n = 28, 3.8%) and cocaine (n = 17, 2.3%). Alcohol and/or at least one other drug was detected in 37.4% (n = 472) of cases with either a blood alcohol or urine drug test completed (n = 1263, 86.0%). Multiple substances were detected in 16.6% (n = 119) of cases with both blood alcohol and urine drug screens (n = 718, 48.9%). Detections were prevalent in cases of interpersonal violence (n = 123/179, 68.7%) and intentional self-harm (n = 50/106, 47.2%), and in those occurring on Friday and Saturday nights (n = 118/191, 61.8%). CONCLUSION: AOD detections were common in trauma patients with non-transport injury causes. Population-level surveillance is needed to inform prevention strategies that address AOD use as a significant risk factor for serious injury.

Prevalence of Alcohol and Other Drug Use in Patients Presenting to Hospital for Violence-Related Injuries: A Systematic Review.

Substance use is a risk factor for being both a perpetrator and a victim of violence. The aim of this systematic review was to report the prevalence of acute pre-injury substance use in patients with violence-related injuries. Systematic searches were used to identify observational studies that included patients aged ≥15 years presenting to hospital after violence-related injuries and used objective toxicology measures to report prevalence of acute pre-injury substance use. Studies were grouped based on injury cause (any violence-related, assault, firearm, and other penetrating injuries including stab and incised wounds) and substance type (any substance, alcohol only, drugs other than alcohol only), and they were summarized using narrative synthesis and meta-analyses. This review included 28 studies. Alcohol was detected in 13%-66% of any violence-related injuries (five studies), 4%-71% of assaults (13 studies), 21%-45% of firearm injuries (six studies; pooled estimate = 41%, 95% CI: 40%-42%, n = 9,190), and 9%-66% of other penetrating injuries (nine studies; pooled estimate = 60%, 95% CI: 56%-64%, n = 6,950). Drugs other than alcohol were detected in 37% of any violence-related injuries (one study), 39% of firearm injuries (one study), 7%-49% of assaults (five studies), and 5%-66% of penetrating injuries (three studies). The prevalence of any substance varied across injury categories: any violence-related injuries = 76%-77% (three studies), assaults = 40%-73% (six studies), firearms = n/a, other penetrating injuries = 26%-45% (four studies; pooled estimate = 30%, 95% CI: 24%-37%, n = 319).Overall, substance use was frequently detected in patients presenting to hospital for violence-related injuries. Quantification of substance use in violence-related injuries provides a benchmark for harm reduction and injury prevention strategies.

Biases in the collection of blood alcohol data for adult major trauma patients in Victoria, Australia.

BACKGROUND: In-hospital alcohol testing provides an opportunity to implement prevention strategies for patients with high risk of experiencing repeated alcohol-related injuries. However, barriers to alcohol testing in emergency settings can prevent patients from being tested. In this study, we aimed to understand potential biases in current data on the completion of blood alcohol tests for major trauma patients at hospitals in Victoria, Australia. METHODS: Victorian State Trauma Registry data on all adult major trauma patients from 1 January 2018 to 31 December 2021 were used. Characteristics associated with having a blood alcohol test recorded in the registry were assessed using logistic regression models. RESULTS: This study included 14 221 major trauma patients, of which 4563 (32.1%) had a blood alcohol test recorded. Having a blood alcohol test completed was significantly associated with age, socioeconomic disadvantage level, preferred language, having pre-existing mental health or substance use conditions, smoking status, presenting during times associated with heavy community alcohol consumption, injury cause and intent, and Glasgow Coma Scale scores (p<0.05). Restricting analyses to patients from a trauma centre where blood alcohol testing was part of routine clinical care mitigated most biases. However, relative to patients injured while driving a motor vehicle/motorcycle, lower odds of testing were still observed for patients with injuries from flames/scalds/contact burns (adjusted OR (aOR)=0.33, 95% CI 0.18 to 0.61) and low falls (aOR=0.17, 95% CI 0.12 to 0.25). Higher odds of testing were associated with pre-existing mental health (aOR=1.39, 95% CI 1.02 to 1.89) or substance use conditions (aOR=2.33, 95% CI to 1.47-3.70), and living in a more disadvantaged area (most disadvantaged quintile relative to least disadvantaged quintile: aOR=2.30, 95% CI 1.52 to 3.48). CONCLUSION: Biases in the collection of blood alcohol data likely impact the surveillance of alcohol-related injuries. Routine alcohol testing after major trauma is needed to accurately inform epidemiology and the subsequent implementation of strategies for reducing alcohol-related injuries.

Alcohol-related trauma presentations among older teenagers.

OBJECTIVE: The objectives of the present study were to report the proportion of older teenagers, including the subgroup operating a motor vehicle, presenting to an adult major trauma centre after injury with a positive blood alcohol concentration (BAC) over a 12-year period. METHODS: This was a registry-based cohort study, including all patients aged 16-19 years presenting to an adult major trauma centre in Victoria, Australia from January 2008 to December 2019 and included in the trauma registry. A Poisson regression model was used to test for change in incidence of positive BAC associated trauma and summarised using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: There were 1658 patients included for analysis and alcohol was detected in 368 (22.2%; 95% CI 20.2-24.3). Most alcohol positive presentations were on weekend days (n = 207; 56.3%) and most were males (n = 307). Over the 12-year period, there was a reduction in the incidence of older teenagers presenting with a positive BAC (IRR 0.95; 95% CI 0.93-0.98; P = 0.001). Among patients presenting after trauma in the setting of operating a motor vehicle (n = 545), alcohol was detected in 80 (14.7%) with no significant change in incidence of positive BAC (IRR 0.95; 95% CI 0.89-1.02; P = 0.17). CONCLUSIONS: A substantial proportion of older teenagers included in the registry had alcohol exposure prior to trauma. Despite a modest down-trending incidence, the need for continuing preventive measures is emphasised. In particular, preventive efforts should be targeted at male, older teenagers undertaking drinking activities on weekend days and driving motor vehicles.

Comparison of routine blood alcohol tests and ICD-10-AM coding of alcohol involvement for major trauma patients.

BACKGROUND: Alcohol use is a key preventable risk factor for serious injury. To effectively prevent alcohol-related injuries, we rely on the accurate surveillance of alcohol involvement in injury events. This often involves the use of administrative data, such as International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding. OBJECTIVE: To evaluate the completeness and accuracy of using administrative coding for the surveillance of alcohol involvement in major trauma injury events by comparing patient blood alcohol concentration (BAC) with ICD-10-AM coding. METHOD: This retrospective cohort study examined 2918 injury patients aged ≥18 years who presented to a major trauma centre in Victoria, Australia, over a 2-year period, of which 78% (n = 2286) had BAC data available. RESULTS: While 15% of patients had a non-zero BAC, only 4% had an ICD-10-AM code suggesting acute alcohol involvement. The agreement between blood alcohol test results and ICD-10-AM coding of acute alcohol involvement was fair (κ = 0.33, 95% confidence interval: 0.27-0.38). Of the 341 patients with a non-zero BAC, 82 (24.0%) had ICD-10-AM codes related to acute alcohol involvement. Supplementary factors Y90 Evidence of alcohol involvement determined by blood alcohol level codes, which specifically describe patient BAC, were assigned to just 29% of eligible patients with a non-zero BAC. CONCLUSION: ICD-10-AM coding underestimated the proportion of alcohol-related injuries compared to patient BAC. IMPLICATIONS: Given the current role of administrative data in the surveillance of alcohol-related injuries, these findings may have significant implications for the implementation of cost-effective strategies for preventing alcohol-related injuries.

Prevalence of alcohol and other drug use in patients presenting to hospital for fall-related injuries: a systematic review.

BACKGROUND: Alcohol and other drug (AOD) use is a key preventable risk factor for serious injuries. Prevention strategies to date have largely focused on transport injuries, despite AOD use being a significant risk factor for other injury causes, including falls. This systematic review aimed to report the prevalence of AOD use in patients presenting to hospital for fall-related injuries. METHODS: This systematic review includes studies published in English after the year 2010 that objectively measured the prevalence of AOD use in patients presenting to hospital for a fall-related injury. Screening, data extraction and risk of bias assessments were completed by two independent reviewers. Data were presented using narrative synthesis and, where appropriate, meta-analyses. RESULTS: A total of 12 707 records were screened. Full texts were retrieved for 2042 records, of which 29 were included. Four studies reported the combined prevalence of any alcohol and/or drug use, generating a pooled prevalence estimate of 37% (95% CI 25% to 49%). Twenty-two records reported on the prevalence of acute alcohol use alone and nine reported specifically on the prevalence of drugs other than alcohol, with prevalence ranging from 2% to 57% and 7% to 46%, respectively. The variation in prevalence estimates likely resulted from differences in toxicology testing methods across studies. CONCLUSIONS: AOD exposure was common in hospitalised fall-related injuries. However, research addressing prevalence across different types of falls and the use of drugs other than alcohol was limited. Future research should address these areas to improve our understanding of which populations should be targeted in AOD and injury prevention strategies . PROSPERO REGISTRATION NUMBER: CRD42020188746.

Patterns and predictors of personal responsibility attributions after major trauma.

BACKGROUND: External responsibility attributions after injury are associated with worse recovery. However, there remains limited understanding of who accepts personal responsibilityfor their injury and whether or how responsibility attributions change over time. METHODS: This prospective cohort study included patients who received care from recovery co-ordinators following serious injury and admission to a major trauma centre in Victoria, Australia (n=850). Self-reported personal responsibility attributions (totally, partially, not responsible, or did not know) were collected at three timepoints (admission, discharge, and six months post-injury) and linked to demographic, injury and clinical characteristics from the Victorian State Trauma Registry. RESULTS: Mixed effects multinomial analyses revealed that female sex (adjusted relative risk ratio, aRRR=3.11-4.66) and compensable injury (aRRR=7.83-15.27) were associated with reporting lower personal responsibility relative to total responsibility. Falls and motorcyclists had decreased risk of reporting lower personal responsibility than non-drivers (motor vehicle/motorcycle passengers, cyclists and pedestrians) (aRRR=0.11-0.19). More than one-third of participants changed their personal responsibility attribution within six months post-injury. Kappa analyses revealed fair to moderate agreement between the three timepoints (kappa=0.38-0.59), and Stuart-Maxwell tests showed unidirectional bias towards reporting lower levels of personal responsibility between admission and discharge (p<0.001). No demographic, health or injury characteristics predicted a change in responsibility attributions in logistic regression analyses. CONCLUSIONS: Personal responsibility attributions often change over time. Therefore, responsibility attributions should not be considered static, and attributions made at different times post-injury should not be used interchangeably in research or clinical settings. Given that external responsibility attributions are associated with worse post-injury outcomes, potential interventions to optimise recovery should be prioritised for patients who predominantly report lower levels of personal responsibility, especially women and people with compensable injuries. Meanwhile, factors associated with high levels of personal responsibility highlight opportunities to implement targeted injury prevention strategies.

Evaluation of text mining to reduce screening workload for injury-focused systematic reviews.

INTRODUCTION: Text mining to support screening in large-scale systematic reviews has been recommended; however, their suitability for reviews in injury research is not known. We examined the performance of text mining in supporting the second reviewer in a systematic review examining associations between fault attribution and health and work-related outcomes after transport injury. METHODS: Citations were independently screened in Abstrackr in full (reviewer 1; 10 559 citations), and until no more citations were predicted to be relevant (reviewer 2; 1809 citations, 17.1%). All potentially relevant full-text articles were assessed by reviewer 1 (555 articles). Reviewer 2 used text mining (Wordstat, QDA Miner) to reduce assessment to full-text articles containing ≥1 fault-related exposure term (367 articles, 66.1%). RESULTS: Abstrackr offered excellent workload savings: 82.7% of citations did not require screening by reviewer 2, and total screening time was reduced by 36.6% compared with traditional dual screening of all citations. Abstrackr predictions had high specificity (83.7%), and low false negatives (0.3%), but overestimated citation relevance, probably due to the complexity of the review with multiple outcomes and high imbalance of relevant to irrelevant records, giving low sensitivity (29.7%) and precision (14.5%). Text mining of full-text articles reduced the number needing to be screened by 33.9%, and reduced total full-text screening time by 38.7% compared with traditional dual screening. CONCLUSIONS: Overall, text mining offered important benefits to systematic review workflow, but should not replace full screening by one reviewer, especially for complex reviews examining multiple health or injury outcomes. TRIAL REGISTRATION NUMBER: CRD42018084123.

The Association Between Fault Attribution and Work Participation After Road Traffic Injury: A Registry-Based Observational Study.

Purpose To characterise associations between fault attribution and work participation and capacity after road traffic injury. Methods People aged 15-65 years, working pre-injury, without serious brain injury, who survived to 12 months after road traffic injury were included from two Victorian trauma registries (n = 2942). Fault profiles from linked compensation claims were defined as no other at fault, another at fault, denied another at fault, claimed another at fault, and unknown. Claimant reports in the denied and claimed another at fault groups contradicted police reports. Patients reported work capacity (Glasgow outcome scale-extended) and return to work (RTW) at 6, 12 and 24 months post-injury (early and sustained RTW, delayed RTW (≥ 12 months), failed RTW attempts, no RTW attempts). Analyses adjusted for demographic, clinical and injury covariates. Results The risk of not returning to work was higher if another was at fault [adjusted relative risk ratio (aRRR) = 1.67, 95% confidence interval (CI) 1.29, 2.17] or was claimed to be at fault (aRRR = 1.58, 95% CI 1.04, 2.41), and lower for those who denied that another was at fault (aRRR = 0.51, 95% CI 0.29, 0.91), compared to cases with no other at fault. Similarly, people had higher odds of work capacity limitations if another was at fault (12m: AOR = 1.49, 95% CI 1.24, 1.80; 24m: 1.63, 95% CI 1.35, 1.97) or was claimed to be at fault (12m: AOR = 1.54, 95% CI 1.16, 2.05; 24m: AOR = 1.80, 95% CI 1.34, 2.41), and lower odds if they denied another was at fault (6m: AOR = 0.67, 95% CI 0.48, 0.95), compared to cases with no other at fault. Conclusion Targeted interventions are needed to support work participation in people at risk of poor RTW post-injury. While interventions targeting fault and justice-related attributions are currently lacking, these may be beneficial for people who believe that another caused their injury.

A systematic review of the association between fault or blame-related attributions and procedures after transport injury and health and work-related outcomes.

Attributions of fault are often associated with worse injury outcomes; however, the consistency and magnitude of these impacts is not known. This review examined the prognostic role of fault on health, mental health, pain and work outcomes after transport injury. A systematic search of five electronic databases (Medline, Embase, CINAHL, PsycINFO, Cochrane Library) yielded 16,324 records published between 2000 and January 2018. Eligibility criteria were: adult transport injury survivors; prospective design; multivariable analysis; fault-related factor analysed; pain, mental health, general health or work-related outcome. Citations (n = 10,558, excluding duplicates) and full text articles (n = 555) were screened manually (Reviewer 1), and using concurrent machine learning and text mining (Reviewer 2; using Abstrackr, WordStat and QDA miner). Data from 55 papers that met all inclusion criteria were extracted, papers were evaluated for risk of bias using the QUIPS tool, and overall level of evidence was assessed using the GRADE tool. There were six main fault-related factors classified as: fault or responsibility, fault-based compensation, lawyer involvement or litigation, blame or guilt, road user or position in vehicle, and impact direction. Overall there were inconsistent associations between fault and transport injury outcomes, and 60% of papers had high risk of bias. There was moderate evidence that fault-based compensation claims were associated with poorer health-related outcomes, and that lawyer involvement was associated with poorer work outcomes beyond 12 months post-injury. However, the evidence of negative associations between fault-based compensation claims and work-related outcomes was limited. Lawyer involvement and fault-based compensation claims were associated with adverse mental health outcomes six months post-injury, but not beyond 12 months. The most consistent associations between fault and negative outcomes were not for fault attributions, per se, but were related to fault-related procedures (e.g., lawyer engagement, fault-based compensation claims).