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Article Excerpt
ALCOHOL USE CONTRIBUTES to the high cost of health care. Heavy consumers of alcohol have been shown to underutilize medical services and delay seeking care until their condition has worsened and requires expensive treatment (Cherpitel, 1999). Untreated alcoholics have also been shown to have higher health-care costs than nonalcoholics (Forsythe et al., 1982; Holder, 1998). This evidence of heavy drinkers underutilizing and delaying medical care is important in that policy makers require evidence-based information to make decisions about resource allocations and improvements in health-care delivery systems. Heavy drinkers, for example, would benefit from medical treatment early in their drinking careers, which would result in lower health care costs later in life.
The purpose of this study was to investigate the relationship between alcohol consumption and health-care utilization in Germany. The relationship has been examined previously; however, no consistent conclusion has been reached. Some studies found heavy drinkers most likely to have utilized hospitalization and acute services (Cryer et al., 1999; Klatsky et al., 1981). This is in contrast with other studies showing that among members of a health maintenance organization (HMO), abstainers had a higher mean number of outpatient visits, hospitalizations, and hospital days compared with light, moderate, and heavier drinkers (Armstrong et al., 1998). Based on patients of three primary-care clinics in a managed-care organization in the United States, Zarkin et al. (2004) concluded that more extensive drinking patterns were associated with lower utilization of outpatient and inpatient care. Alcohol consumers were associated with lower utilization when compared with abstainers, with heavier drinkers using fewest services. In Japan, a survey on National Health Insurance beneficiaries found an inverse linear relation between alcohol consumption and outpatient visits but a U-shaped curve between alcohol consumption and inpatient visits (Anzai et al., 2005).
This study first examines the relationship between alcohol use and health-care utilization in two general population samples in Germany. Several studies have been conducted in the United States (Armstrong et al., 1998; Hunkeler et al., 2001; Rice et al., 2000; Zarkin et al., 2004); however, little is known about this relationship in the German population. Comparisons between Germany and the United States reveal higher per capita alcohol consumption and a greater incidence of heavy drinking among German adults (Bloomfield et al., 2002; Meyer et al., 2000). Furthermore, Germany is one of five countries with the highest per capita consumption of pure alcohol, according to the alcohol beverage industry, with little change over the past 15 years (Meyer and John, 2003). Studying a population with such high numbers of heavy drinkers may result in new insight on the impact of alcohol on utilization. In addition, few studies have explored this relationship among the general population; most of the research has been focused on members of health plans (Anzai et al., 2005; Armstrong et al., 1998; Hunkeler et al., 2001; Zarkin et al., 2004). Members of HMOs have been shown to be better educated and more aware of health matters (Armstrong et al., 1998).
We address two hypotheses. First, a U-shaped or linear inverse relation exists between alcohol consumption and health-care utilization in Germany. Research conducted in the United States and Japan has shown a U-shaped or linear inverse relation between hospital stays and outpatient visits and alcohol consumption (Anzai et al., 2005; Rice et al., 2000; Zarkin et al., 2004). Second, in light of epidemiological findings showing adverse health effects of heavy alcohol use (Rehm et al., 2003), we hypothesized that abstainers with former heavy-drinking histories will seek out more health services than those without heavy-drinking histories. Some studies have shown that abstainers have higher utilization and costs compared with drinkers (Armstrong et al., 1998; Rice et al., 2000; Zarkin et al., 2004). Other studies have pointed out that among abstainers, those with a history of heavy drinking have poorer mental and physical health (Cryer et al., 2001; Wannamethee and Shaper, 1988). No conclusive point has been reached, however, as to why abstainers use more services than drinkers. We classified abstainers into two categories, those with and those without a history of heavy drinking.
This study uses data from two surveys conducted in Germany--the Study of Health in Pomerania (SHIP) and the German National Health Interview and Examination Survey 1998 (GNHIES). The SHIP dataset was used because it contains critical variables that separate the abstainers into the two categories described above. After testing our hypotheses, we conducted pooled analyses to generalize the results to the adult population of Germany using GNHIES. The Behavioral Model of Health Services (Andersen and Davidson, 2001) was used to identify other important predictors of access in the empirical models (e.g., age, gender, income, smoking, and self-rated health status). These covariates were added to isolate the effect of alcohol consumption on utilization.
Method
Samples and procedures
SHIP targeted adult residents of West Pomerania in northeastern Germany (ages 20-81). The study area is composed of three cities and 29 communities, with a total population of 212,157. A sample of 7,008 was drawn from the residents' registration offices. The net sample comprised 6,267 eligible subjects, from which 4,310 persons participated (response rate = 68.8%). The Human Ethics Research Committee of the Medical School at the University of Greifswald approved the study. Data were collected from 1997 to 2001 by means of computer-assisted personal interviews on history of disease, health-care utilization, and health behaviors. (For a detailed description of the methodology, see John et al., 2001.)
GNHIES was conducted by the Robert-Koch-Institute of the German Federal Ministry of Health...
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