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Article Excerpt
EMERGENCY DEPARTMENT (ED) STUDIES in the United States have found that substantial proportions of both injured and noninjured patients report frequent use of the ED. One study found more than half of the ED patients in a county reported prior use of the ED during the previous year, compared with only 7% in the general population of the same county (Cherpitel, 1995a). Greater overall health services use, including both inpatient and outpatient services, has been found among ED patients compared with those in the general population in the United States (Cherpitel et al., 1996), and studies of use and costs have found higher rates of use, including ED and other injury-related medical care, among alcohol-dependent patients, with significant declines in use following alcohol treatment (Blose and Holder, 1991 a,b; Holder, 1989).
Although greater use of the ED would be expected of those who fall into probability samples of ED patients, ED studies of both injured and noninjured patients have also found relatively high rates of prior alcohol-related injuries (Cherpitel, 1988), and alcohol-related ED admissions for injury have been found to be predictive of future injury admissions. Victims of violence who misused alcohol were found to be almost twice as likely to sustain a second injury that was treated in an ED within 5 years compared with those who did not misuse alcohol (Sims et al., 1989). Another study found those intoxicated at the time of admission to the trauma center were 2.5 times more likely to be readmitted than those who were not intoxicated, and those who screened positive for alcohol misuse were 3.5 times more likely to be readmitted during a 2- to 3-year period than those who did not misuse alcohol (Rivara et al., 1993).
Data from National Alcohol Surveys of the U.S. general population have also found that heavier drinking, consequences related to drinking, and prior alcohol treatment were all predictive of ED use during the preceding year, but the data suggested that associations may vary by region of the country (Cherpitel, 1999).
Data on the association of alcohol-related ED admissions and chronic alcohol misuse with ED services use have come primarily from U.S. studies. Additionally, little is known about contextual variables, either sociocultural factors or those factors related to the organization and administration of ED services delivery, and which might affect this association. For example, Canada has a more generous system of health insurance coverage than the United States and provides coverage at a lower gross national product (GNP). However, we do not know what effect such health coverage may have on injured patients presenting in the ED and associated alcohol use. The U.S. data suggest that uninsured patients are overrepresented in the ED (O'Brien et al., 1997), and analysis of the National Hospital Ambulatory Medical Care Survey found the uninsured were also more likely to make alcohol-related ED visits than the insured (Li et al., 1998).
Reported here is a multilevel analysis of the association of demographic characteristics, drinking before the event, heavy drinking, and alcohol dependence with prior ED use during the preceding year among injured patients from 37 EDs in 14 countries. Contextual variables, including those related to the organization of the ED and services delivery that might affect access to care and use of services, and sociocultural variables thought to reflect the degree of integration of alcohol in society (per capita consumption, drinking pattern, stigmatization of alcohol used, legal drinking age, legal level of intoxication for driving), as well as GNP, are used to evaluate heterogeneity in the magnitude of association found across ED studies.
This analysis is important for a better understanding of ED use and its relationship to drinking patterns and alcohol-related problems, and of the contribution of contextual variables in explaining differences in association across EDs from a number of countries. These findings would contribute to a better understanding of the burden that alcohol places on the ED caseload and the potential impact of the ED setting as a point for identification of and intervention with problem-drinking patients for a reduction in health services use and associated costs.
Method
Samples
To explore the influence of individual-level and contextual variables on ED services use, data were analyzed from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP; Cherpitel et al., 2003) and the World Health Organization (WHO) Collaborative Study on Alcohol and Injuries (WHO Collaborative Study Group, 2002; see Table 1). Methods for both the ERCAAP and WHO studies were developed by Cherpitel (1989).
Data from the WHO study included only those patients arriving at the ED within 6 hours of the injury event. To maintain comparability, ERCAAP data analyzed here were selected to include only those injured patients also meeting this 6-hour criterion. In the ERCAAP study, one ED study (Trieste, Italy) was excluded because the time between injury and arrival at the ED was not available, and four other EDs from two studies (Acapulco, Mexico, and Fremantle, Australia) were excluded because the question of whether the respondent had visited an ED within the past 12 months was not asked. An additional two EDs in ERCAAP (Alberta and Quebec, Canada) and one in the WHO study (Bangalore, India) were also excluded because data on the number of visits to an ED within the past 12 months was not obtained. Overall, data from 37 EDs in 14 countries reported in 23 studies (N = 9,743 patients) were retained in the analysis.
In both the ERCAAP and WHO projects, probability samples of patients 18 years and older were obtained by sampling consecutive arrivals to each ED in the study with equal representation of each shift for each day of the week. Studies in which patients were disproportionately sampled were weighted to ensure that hours of the day and days of the week were equally represented within a study. Each patient was asked to sign an informed...
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