Starting Treatment at Discharge for Alcohol-Related Hospital Stays Shows Benefits

Starting medication for alcohol use disorder (MAUD) at hospital discharge reduced readmission risk, a cohort study suggested.

Of nearly 10,000 alcohol-related hospitalizations of Medicare beneficiaries, only 2% (192) involved initiation of MAUD at the time of discharge, Eden Bernstein, MD, of Massachusetts General Hospital in Boston, and colleagues found.

In this small number, MAUD initiation at discharge was linked with a 42% decreased incidence of returning to the hospital within 30 days (incident rate ratio [IRR] 0.58, 95% CI 0.45-0.76, the researchers reported in JAMA Network Open. The absolute risk difference was -0.18 (95% CI -0.26 to -0.11).

“We know from randomized trials that these medications can help patients reduce their alcohol intake. However, we didn’t know whether this would translate to improved clinical outcomes in the post-hospitalization setting,” Bernstein told MedPage Today, saying he was surprised to find these medications were tied with such a drop in rehospitalization.

However, he added that “major barriers” to prescribing these medications persist, including knowledge gaps, concern about discharge follow-up, lack of institutional prioritization, and stigma toward patients’ alcohol use disorder. But for these patients, hospital discharge “is an important setting that can be leveraged to initiate medication treatment and meaningfully improve short-term clinical outcomes,” he pointed out.

“I hope that this study empowers frontline clinicians to engage with their patients about medication treatment options for alcohol use disorder,” he said.

Echoing this sentiment, accompanying editorial authors Jonathan Zipursky, MD, PhD, of Sunnybrook Health Sciences Centre in Toronto, and colleagues said that during a hospitalization, “patients experience health vulnerability which may drive behavior change,” and clinicians should take advantage of these opportunities to offer MAUD.

These findings ultimately affirm the underuse of MAUDs seen in prior studies, they observed.

“Among the nearly 10,000 admitted patients eligible for study inclusion, only 1 in 50 filled a discharge prescription,” they noted. “Readers are left wondering in what ways the 2% of patients who filled a discharge prescription for MAUD are different from the 98% who did not.”

“The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients,” Zipursky and co-authors wrote.

Only a few clinical factors predicted who did or did not receive MAUD at discharge. A lower proportion of patients who started MAUD at discharge had prior psychosis and tobacco use disorder. A higher proportion of those who started had prior remote MAUD use, had received care at psychiatric hospitals, or had received prior psychiatry or addiction medicine care when hospitalized at general hospitals.

However, information about “potentially important patient characteristics” was left out of the study, including data on the severity of alcohol use and motivation for treatment, the editorialists noted.

The retrospective analysis drew upon a national sampling of administrative and pharmacy claims of Medicare beneficiaries continuously enrolled in Parts A, B, and D from 2015 to 2017; Medicare Advantage beneficiaries were excluded. About 84% of the study population received Medicare due to the presence of a disability.

The cohort consisted of patients with acute care alcohol use disorder hospitalizations in 2016 who were discharged to the community. The researchers identified 9,834 alcohol-related hospitalizations, which represented 6,794 unique patients with a median age of 54. About a third (32.6%) of hospitalizations were among females, and 71.8% were among white patients.

Of 192 hospitalizations that started MAUD at discharge, 112 (58.3%) involved naltrexone, 53 (27.6%) involved acamprosate, and 32 (16.7%) involved disulfiram initiations.

When breaking down components of the primary outcome, the researchers found that starting MAUD at discharge was linked with a significantly lower incidence of all-cause return to hospital, all-cause emergency department visits, and all-cause readmissions. MAUD initiation was also tied with a 51% decreased incidence of specifically an alcohol-related return to hospital. Mortality data were not reported due to extremely low numbers.

Limitations of the study included a lack of data about nonpharmacological alcohol use disorder treatments like 12-step programs or behavioral interventions. Unmeasured confounding may have influenced results, and findings may not apply to people who are younger, do not have disabilities, or are Medicare Advantage beneficiaries.

“It’s important to remember that alcohol use disorder is a chronic disease,” Bernstein noted. “While prescribing medications after discharge is important, we also need institutional investment and policy changes to help facilitate long-term outpatient follow-up.”

Kristen Monaco is a senior staff writer, focusing on endocrinology, psychiatry, and nephrology news. Based out of the New York City office, she’s worked at the company since 2015.

Disclosures

The study was funded from an Institutional National Research Service award, the Massachusetts General Hospital Division of General Internal Medicine, Massachusetts General Hospital Research Scholars Program, the Agency for Healthcare Research and Quality, and a grant from the National Institute on Aging.

Bernstein and co-authors reported personal fees from Alosa Health, and grants from the American Heart Association, American College of Cardiology, U.S. Deprescribing Research Network, and Boston Claude D. Pepper Older Americans Independence Center.

Zipursky reported receiving personal fees from private law firms for medicolegal opinions regarding the safety and effectiveness of drugs.

Primary Source

JAMA Network Open

Source Reference: Bernstein EY, et al “Outcomes after initiation of medications for alcohol use disorder at hospital discharge” JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.3387.

Secondary Source

JAMA Network Open

Source Reference: Yaseen W, et al “Sobering perspectives on the treatment of alcohol use disorder” JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.3340.

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