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Long-term mortality from alcoholism: a descriptive analysis *.

Article Excerpt
BEFORE RECEIPT OF A GRANT FROM the National Institute of Alcoholism and Alcohol Abuse more than 30 years ago to develop a comprehensive treatment program for persons diagnosed with alcoholism, the city of San Antonio, TX, had only a patchwork quilt of alcoholism services (Costello et al., 1973). Costello et al. (1974) demonstrated that the clients served by one of the facilities (i.e., what would become the intermediate care component) contracting into the comprehensive network were chronic and essentially derelict alcoholics. After the program was developed, Costello and Hodde (1981) demonstrated that the progress of care for these clients was very discontinuous. Clients rarely progressed through the various treatment phases in a logical manner from high-cost treatment components to components of lesser cost and treatment intensity. Costello and Hodde (1981) also demonstrated that the costs of care varied widely across patients, ranging from $15 to nearly $54,000, and that costs for treatment in inpatient units consumed 73% of program resources but were attributed to only 40% of the alcoholics treated. The fact that operational costs were not distributed equally across patients raised an ethical issue. The fact that inpatient units consumed a disproportionate share of funding while serving a relative minority of patients raised the question of whether the money was not better spent elsewhere in the program. When treatment resources are in scarce supply, it is important to debate the question of how resources should be distributed and to have some policy in place to manage care (Valliant, 1983).

Costello and Schneider (1974) addressed the question of which, how, and when alcoholics in a comprehensive treatment program die in the short term, with limited follow-up resources. The answers were relevant to program planning strategy. This early study confirmed Dahlgren's (1951) assertion that the first 3-4 years following public identification of alcoholism represent high-risk years for death, not from the physically debilitating effects of alcoholism but from the "socially and mentally injurious" effects of a period he referred to as "active psychopathia." During this period, he found that death was more likely to be the result of violence (e.g., accidents, drowning, and suicide) and to involve relatively younger people.

During the early years of the development of the San Antonio program, Dahlgren's concept of active psychopathia was a guiding concept to develop treatment components responsive to the psychological and social factors of alcoholism leading to premature death. In later years of program development, however, this concept had less influence for program planning, as the literature was then, and still is now, less clear regarding long-term mortality consequences of chronic alcoholism. Few studies have followed a treatment cohort more than a few years with a focus on case-fatality rates and cause-specific mortality rates. A study like Robinette et al. (1979), extending across a 29-year period, is very rare. More commonly, studies track treatment cohorts across much shorter periods (e.g., a 3-5 year span: DeLint and Levinson [1975], Lipscomb [1959], and Patterson et al. [1997]; a 5-9 year span: Lindelius et al. [1974]; and a 10-14 year span: Edwards et al. [1978] and Finney and Moos [1990]).

Studies of short follow-up lengths are necessarily limited in their ramifications for long-term, comprehensive treatment planning. It is for this reason that this project was pursued for more than 30 years. We were interested in program planning ramifications with answers to questions such as the following: (1) Does case-fatality rate (CFR) vary over time when the follow-up period is very long; (2) does cause-specific mortality rate vary over time; and (3) because of the particular demographics of the city of San Antonio, does cause-specific mortality rate vary with ethnicity?

Method

Five hundred clients of the intermediate care component, admitted in five cohorts of 100 in 1963,...

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