BACKGROUND/RATIONALE:
European studies have found that surgical patients with severe alcohol misuse have an increased risk of post-operative complications and mortality compared with low-level drinkers. Abstinence for 30 days pre-operatively can improve surgical outcomes and alcohol withdrawal is often preventable if alcohol misuse is identified pre-operatively. However, to date no research has evaluated the prevalence of severe alcohol misuse among US surgical patients or its association with post-operative complications or mortality in the US. The VA Health Care System offers an ideal opportunity to conduct studies of alcohol misuse and surgical outcomes because alcohol misuse is particularly common among veterans and high-quality national data on surgical outcomes can be linked to national alcohol screening data.
OBJECTIVE(S):
The overall aim of this study is to understand the impact of alcohol misuse on surgical outcomes in the VA. The specific objectives are to: (1) estimate the screening prevalence of varying levels of alcohol misuse in a national sample of VA major surgery patients based on the AUDIT-C alcohol screening questionnaire, and (2) determine whether there is an association between severity of alcohol misuse and risk for post-operative complications or 30-day mortality.
METHODS:
This retrospective cohort study of alcohol misuse and surgical outcomes included 9,197 men and 494 women veterans who completed the AUDIT-C on the VA's mailed Survey of Health Experiences of Patients (SHEP) during fiscal years 2004-2006 and had a major surgery in the subsequent year assessed by the National Surgical Quality Improvement Program (NSQIP). Patients were excluded if they were younger than 21 years old, if they had another surgery in the 90 days prior to the first surgery following completion of the AUDIT-C, or if the surgery was not conducted within the first 3 days of hospitalization. Alcohol misuse was identified with standard AUDIT-C screening cut-points (>=3 women; >=4 men) and severe alcohol misuse was defined by AUDIT-C scores >=8. For Aim 1, descriptive analyses were used to estimate the gender-specific screening prevalence and severity of alcohol misuse. For Aim 2, multivariate logistic regression adjusted for risk factors and clinical characteristics will be used to estimate the odds of any alcohol-related surgical complications and the odds of 30-day post-op mortality among major surgery patients who screen positive for mild, moderate and severe alcohol misuse, compared to low-level drinkers.
FINDINGS/RESULTS:
Preliminary Aim 1 analyses revealed that the prevalence of alcohol misuse was 24.2% (95% CI 23.3%-25.0%) in men and 16.4% (95% CI 13.1%-19.7%) in women. The prevalence was significantly higher in men <50 years (28.5%) and 50-64 (27.6%) compared to men >64 years (19.9%) and in divorced men (32.1%) compared to married (20.9%) or never married (23.8%) men. The prevalence did not vary by race/ethnicity in men or by age, marital status or race/ethnicity in women. Compared to non-smokers, active smokers were much more likely to screen positive for alcohol misuse (33.1% vs. 20.2% in men, and 21.2% vs. 14.2% in women). The prevalence of severe alcohol misuse was 6.3% (95% CI 5.8%-6.8%) in men and 2.2% (95% CI 0.9%-3.5%) in women. Severe alcohol misuse was more common in male VA surgical patients who were <65 years old (8.9%), Hispanic (9.4%), unmarried (9.6%), or who were active smokers (11.7%). Similarly stratified analyses of women were not conducted due to small numbers.
IMPACT:
A significant minority of VA surgical patients drink above recommended levels, including more than a quarter of men who are younger than 64 years or divorced. Men were three times as likely as women to have severe alcohol misuse. Based on the large prevalence of alcohol misuse and the potential to improve preventable postoperative complications through preoperative abstinence, surgical patients may be particularly important targets for alcohol screening and intervention. We expect findings from this study to provide surgical patients, clinicians, and quality improvement nurses with a convenient measure for assessing alcohol-related surgical risks. The long-term aim of this research is to support improved management of VA surgical patients with alcohol misuse by building an epidemiologic understanding of the AUDIT-C as a marker of alcohol-related surgical risk.
PUBLICATIONS:
Journal Articles
- Beste LA, Sun H, Maynard C, Bishop MJ, Henderson W, Schifftner T, Hughes G, Todd-Stenberg J, Kivlahan DR, Hawkins E, Harris A, DeBeneditti A, Bradley K. Prevalence of alcohol misuse in patients undergoing common surgeries in VA (Abstract). Journal of General Internal Medicine. 2008; 23: 377.
