Healthcare Utilization in Medical Intensive Care Unit Survivors with Alcohol Withdrawal

Abstract

Background Rehospitalization is an important and costly outcome that occurs commonly in several diseases encountered in the medical intensive care unit (ICU). Although alcohol use disorders are present in 40% of ICU survivors and alcohol withdrawal is the most common alcohol-related reason for admission to an ICU, rates and predictors of rehospitalization have not been previously reported in this population. Methods We conducted a retrospective cohort study of medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal using two administrative databases. The primary outcome was time to rehospitalization or death. Secondary outcomes included time to first emergency department or urgent care clinic visit in the subset of ICU survivors who were not rehospitalized. Cox proportional hazard models were adjusted for age, gender, race, homelessness, smoking, and payer source. Results Of 1,178 patients discharged from the medical ICU over the study period, 468 (40%) were readmitted to the hospital and 54 (4%) died within 1 year. Schizophrenia (HR 2.23, 95% CI 1.57, 3.34, p < 0.001), anxiety disorder (HR 2.04, 95% CI 1.30, 3.32, p < 0.01), depression (HR 1.62, 95% CI 1.05, 2.40, p = 0.03), and Deyo comorbidity score ≥ 3 (HR 1.43, 95% CI 1.09, 1.1.89, p = 0.01) were significant predictors of time to death or first rehospitalization. Bipolar disorder was associated with time to first emergency department or urgent care clinic visit (HR 2.03, 95% CI 1.24, 3.62, p < 0.01) in the 656 patients who were alive and not rehospitalized within one year. Conclusion The presence of a psychiatric comorbidity is a significant predictor of multiple measures of unplanned healthcare utilization in medical ICU survivors with a primary or secondary discharge diagnosis of alcohol withdrawal. This finding highlights the potential importance of targeting longitudinal multidisciplinary care to patients with a dual diagnosis.

Psychiatric Symptoms and Acute Care Service Utilization Over the Course of the Year Following Medical-Surgical ICU Admission

“…Clark and colleagues conducted a retrospective cohort investigation of potential risk factors for death and acute care service utilization among medical ICU survivors admitted with alcohol withdrawal as a primary or secondary diagnosis (23), finding that a wide range of pre-ICU psychiatric diagnoses were independently associated with risk of rehospitalization. However, post-ICU psychiatric symptoms/disorders were not examined.…”

Facilitators and barriers to initiating change in medical intensive care unit survivors with alcohol use disorders: A qualitative study

“…Psychiatric comorbidities such as anxiety and depression also serve as a barrier to change. We previously demonstrated that the presence of anxiety, depression, or schizophrenia is independently associated with the time to death or first rehospitalization in medical ICU survivors with alcohol withdrawal [10]. Psychiatric comorbidities are more common in ICU survivors with an AUD and are associated with poor treatment compliance and worse treatment related outcomes in patients with an AUD [40].…”

“…Because of improvements in care, more than 80% of patients admitted to an ICU survive their hospitalization [9]. However, within one year of hospital discharge 44% of patients with an AUD who required ICU care are readmitted to the hospital or die [10]. As an enforced period of abstinence, admission to the hospital presents an ideal opportunity to address a patient’s underlying AUD and prevent future alcohol-related illness [11].…”

The Intoxicated ICU Patient

“…In a similarly young cohort without medical comorbidities, 4% of patients admitted to the ICU with alcohol withdrawal died within a year of hospital discharge while 40% were rehospitalized (10). Defining rates of rehospitalization for intoxicated patients may provide an opportunity to engage hospital systems and garner resources to improve outcomes.…”

“…Therefore, substance use disorders, other psychiatric diagnoses (such as depression, anxiety, and bipolar disorder), or both are likely to be the underlying cause of intoxication. Prior studies demonstrate that ICU survivors with a dual diagnosis – an alcohol or substance use disorder plus another psychiatric diagnosis - are at the highest risk of recurrent morbidity and mortality following hospital discharge (10). Understanding whether these findings extend to patients admitted to the ICU with an acute intoxication may help identify those patients at highest risk of poor outcomes and, thus, focus resources following hospital discharge.…”