Health and Social Outcomes Associated with High-Risk Alcohol...

1

Health and Social Outcomes

Associated with High-Risk

Alcohol UseN a t h a n C . N i c k e l , P h D

2 n d A n n u a l M C H P E v i d e n c e t o A c t i o n C o n f e r e n c e

S e p t e m b e r 2 5 , 2 0 1 8

2

• Nathan C Nickel, MPH, PhD

• James Bolton, MD

• Leonard MacWilliam, MSc, MNRM

• Okechukwu Ekuma, MSc

• Heather Prior, MSc

• Jeff Valdivia, MNRM, CAPM

• Christine Leong, PharmD

• Geoffrey Konrad, MD

• Greg Finlayson, PhD

• Josh Nepon, MD

• Deepa Singal, PhD

• Susan Burchill, BMus

• Randy Walld, BSc, BComm

(Hons)

• Leanne Rajotte, BComm (Hons)

• Michael Paille, BHSc

Research Team

3

• Jasmine Thomas – Liquor and Gaming Authority of Manitoba

• Stephanie Loewen – Manitoba Health, Seniors and Active Living

• Marcia Thomson – Manitoba Health, Seniors and Active Living

• Mike Routledge – Southern Health-Santé Sud

• Rusty Beardy – Northern Health Region

• Michele Jules – Manitoba Prosecution Service

• Tim Stockwell – Centre for Addictions Research of British Columbia

• Susan Maxwell – Addictions Foundation of Manitoba

• Linda Conover – Winnipeg Regional Health Authority

• Richard Lennon – Manitoba Liquor and Lotteries

• David Brown – Pathways Research Ltd.

• Susan Chipperfield – Winnipeg Regional Health Authority

Advisory Group

4

Study Objectives

1. Calculate trends in high risk alcohol consumption over the

observation period, 1990-2014;

2. Identify whether high risk alcohol consumption is associated

with increased use of health and social services;

3. Identify when someone with high risk alcohol consumption

uses the most services.

5

Today’s Presentation

Outcomes associated with high risk alcohol consumption:

1. Health services use

2. Social services use

6

MCHP Houses the De-IdentifiedManitoba Population Research Data Repository

HospitalPhysician Services

Nursing Home

Home Care

Immunization

Vital Statistics

Emergency Department

Clinical

Health Surveys

Medical Laboratory

CancerCare

Education

Family Services

Income Assistance

Healthy Child MB

Social Housing

Justice• Families First

• Healthy Baby

• EDI

• ICU

• FASD

• Pediatric

Diabetes

• Cardiac

Surgery

• K to Grade 12

• Post-Secondary

(UofM)

Census

Data at Area

Level

Pharmaceuticals

Manitoba

Population-Based

Registry

7

Self-Reported Drinking Behaviours

• Used data from the Canadian Community Health Survey: 2000 to

2011

• Respondents provide information on alcohol consumption

• Responses used to identify individuals who

− Exceeded Recommended Weekly Low-Risk Drinking Limit

− Men: Fewer than 15; Women: Fewer than 10

− Exceeded Recommended Daily Low-Risk Drinking Limit

− Men: Fewer than 3; Women: Fewer than 2

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0%

2%

4%

6%

8%

10%

12%

14%

16%

2000 2002 2003 2005 2011 2012 2013

Survey Year

Male

Female**

95% CI Male

95% CI Female

* CCHS (2000, 2003-2005 & 2007-2011; aged 12+), CCHS Healthy Aging (2008/09; aged 45+)

** Indicates a statistically significant trend over time

Note: Recommended weekly alcohol limit is 15 drinks for men, 10 drinks for women

Weighted Percent of Respondents who Reported Exceeding the

Recommended Weekly Limit of Alcohol Consumption, by Survey Year*Directly Standardized, 95% Confidence Intervals

9

0%

5%

10%

15%

20%

25%

30%

35%

40%

2000 2002 2003 2005 2011 2012 2013

Survey Year

Male

Female**

95% CI Male

95% CI Female

* CCHS (2000, 2003-2005 & 2007-2011; aged 12+), CCHS Healthy Aging (2008/09; aged 45+)

** Indicates a statistically significant trend over time

Note: Recommended daily alcohol limit is 3 drinks for men, 2 drinks for women

Weighted Percent of Respondents who Reported Exceeding the

Recommended Daily Limit of Alcohol Consumption, by Survey Year*Directly Standardized, 95% Confidence Intervals

10

Background

• Alcohol Use Disorder (AUD):

− Increased tolerance, withdrawal, impaired control of drinking

−Updated in DSM-5

11

Indications of an AUD

1. Times drank more than intended

2. Wanted to cut down but couldn’t

3. Spent a lot of time drinking or recovering from drinking

4. Wanted to drink so badly couldn’t think of anything else

5. Drinking interfered with taking care of family

6. Continued to drink in spite of problems

7. Gave up on activities that are enjoyable to drink

8. Situations that increased risk of injury

9. Drank even though made depressed/anxious

10. Had to drink more to get desired effect

11. Had withdrawal symptoms

13

Identifying Alcohol Use Disorder

in Administrative Data

Our cohort is defined by anyone meeting the following

conditions in the period 1990/91-2014/15:

1. Diagnosis of a mental health issue associated with harmful

alcohol consumption;

2. Diagnosis of a physical health issue associated with harmful

alcohol consumption; or

3. Filled prescription for drug associated with harmful alcohol

consumption.

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Mental Illness

79.5%

Physical

Illness

7.6%

Administrative Data CohortN = 53,622

11.8%

0.15% Mental Illness & Prescription Drug

“S” Physical Illness & Prescription Drug

“S” Prescription Drug

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Question:We looked at whether the incident rate (the number of new

cases of Alcohol Use Disorder) has changed over time.

What do you think?

Between 1990 and 2014, the incident rate for Alcohol Use

Disorder has …

A) Increased

B) Decreased

C) Remained the same

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Crude Incidence Rate of Alcohol Use Disorderper 1,000 person-years at risk

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Males

Females

17

Cohort Descriptives – Sex Breakdown

Male

Female

n = 19,072(35.6%)

n = 34,553(64.4%)

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Cohort Descriptives – Income Breakdown

0% 5% 10% 15% 20% 25%

Low Income (Rural 1)

R2

R3

R4

High Income (Rural 5)

Low Income (Urban 1)

U2

U3

U4

High Income (Urban 5)

19

Matching Criteria

At time of diagnosis, cases and matches are the same age, same sex, living in same area, at the same time.

Analyses

Followed people in the data from 5 years before diagnosis to 20 years after diagnosis

Identifying Matches

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Premature Mortality

23

0

5

10

15

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Number of Years Since Index Date

Cases

Matches

95% Confidence Interval Cases

95% Confidence Interval Matches

*AUD: Alcohol Use Disorder

Index Date: Date of first diagnosis of AUD

Female Matched Rates of Premature Mortalityper 1,000 person-years

24

0

5

10

15

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Number of Years Since Index Date

Cases

Matches

95% Confidence Interval Cases

95% Confidence Interval Matches

*AUD: Alcohol Use Disorder

Index Date: Date of first diagnosis of AUD

Male Matched Rates of Premature Mortalityper 1,000 person-years

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Healthcare and Healthcare

Use Indicators:

1. Hospitalizations

2. Ambulatory visits to primary care

3. Prescription drugs

4. Emergency department use

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Inpatient Hospitalizations

27

0

100

200

300

400

500

600

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Rates of Hospitalizationper 1,000 person-years

28

0

100

200

300

400

500

600

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Rates of Hospitalizationper 1,000 person-years

29

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Rate Ratio 95% CI Statistical Significance

Females Adjusted Rate Ratio of Inpatient Hospitalizations

Before and After Index DateAdjusted for mental health disorders, age at diagnosis, region, and income

30

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


Males Adjusted Rate Ratio of Inpatient Hospitalizations


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Hospitalizations

1. Female and male cases: spike in hospitalizations in diagnosis year

2. Female and male cases: hospitalizations remained elevated after the spike in the diagnosis year (more so for males)

3. Females and males: cases had more (statistically higher) hospitalizations than matches

32

Ambulatory Visits

33

0

2

4

6

8

10

12

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Rates of Ambulatory Visitsper person-year

34

0

2

4

6

8

10

12

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Rates of Ambulatory Visitsper person-year

35

0

0.5

1

1.5

2

2.5

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


Females Adjusted Rate Ratio of Ambulatory Visits


38

Number of Different Drugs

39

0

1

2

3

4

5

6

7

8

9

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Number of Different Drugsper person-year

40

0

1

2

3

4

5

6

7

8

9

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Number of Different Drugsper person-year

41

0

0.5

1

1.5

2

2.5

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


Females Adjusted Rate Ratio of Number of Different Drugs


44

Emergency Department Use

45

0

20

40

60

80

100

120

140

160

180

200

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Rates of Emergency Department Useper 100 person-years

46

0

20

40

60

80

100

120

140

160

180

200

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Rates of Emergency Department Useper 100 person-years

48

0

1

2

3

4

5

6

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


Males Adjusted Rate Ratio of Emergency Department Use


50

Pharmacotherapy for AUD

• Systematic review of evidence2:

• Disulfiram: equivocal evidence

• Naltrexone: majority show positive effects

• Acamprosate: mixed; either positive or no effect

• Patient type3:

• Higher prevalence of other mental disorders

• Frequent discontinuation4,5

• Physician survey6

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Percentage of Individuals with AUD Dispensed a Pharmaceutical (N=37,388)

1.3%

98.7%

Dispensed Pharmaceutical Therapy

Not Dispensed Pharmaceutical Therapy

52

Income Distribution of Manitobans with an AUD

0% 5% 10% 15% 20% 25%

R1 (lowest)

R2

R3

R4

R5 (highest)

U1 (lowest)

U2

U3

U4

U5 (highest)

Not Dispensed Pharmaceutical Therapy Dispensed Pharmaceutical Therapy

53

Percent of Manitobans with an AUD with Mental Health Comorbidities

* indicates statistically significant difference

Chi-square, p < 0.001

0% 10% 20% 30% 40% 50% 60% 70%

Mood and Anxiety Disorders

Personality Disorders

Pyschoses

Not Dispensed Pharmaceutical Therapy Dispensed Pharmaceutical Therapy

54

Distribution of Prescriber Specialty for First Alcohol Dependence Drug Prescription Dispensed

0% 10% 20% 30% 40% 50% 60%

General Practice (Urban)

General Practice (Rural)

Internal Medicine

Psychiatry

Percentage

55

Health Services Indicators

1. Significantly elevated rate of health system use the year of and year before Dx.

2. Coordinated system-level approach to identify and treat individuals with an AUD

3. Need to increase access to treatment services

4. Alcohol Screening and Brief Interventions

56

Social Services Use Indicators

1. Justice System (charges)

• Driving While Impaired (DWI)

• Domestic Violence

• Any Justice Charge

2. Social Housing

3. Children in Care

57

Driving While Impaired (DWI)

58

0

0.5

1

1.5

2

2.5

3

3.5

4

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Incidence Rates of Charges for DWIper 100 person-years, new case within 1 year, before and after Index date, MB Justice System

59

0

0.5

1

1.5

2

2.5

3

3.5

4

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Incidence Rates of Charges for DWIper 100 person-years, new case within 1 year, before and after Index date, MB Justice System

61

Relative Rates for Males Charged with DWIAdjusted Incidence per 100 Person-Years, new case within 1 year,

cases vs. matches, before and after Index date, MB Justice System

0

5

10

15

20

25

30

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


62

Domestic Violence Incident

63

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Female Matched Incidence Rates of Charges for Domestic Violenceper 100 person-years, new case within 1 year, before and after Index date, MB Justice System

64

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2.2

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Male Matched Incidence Rates of Charges for Domestic Violenceper 100 person-years, new case within 1 year, before and after Index date, MB Justice System

66

0

10

20

30

40

50

60

70

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10


Relative Rates for Males Charged with Domestic ViolenceAdjusted Incidence per 100 Person-Years, new case within 1 year,

cases vs. matches, before and after Index date, MB Justice System

80

Children in Care(Female cases and matches only)

81

0

5

10

15

20

25

30

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

Crude Case

Crude Match

95% CI Crude Case

95% CI Crude Match

Prevalence of Children taken into Care of CFSper 100 person-years, Before and After Index Date

82

0

5

10

15

20

25

30

35

40

45

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10


Relative Rates of Children taken into Care of CFSAdjusted Prevalence per 100 Person-Years, Cases vs. Matches, Before and After Index Date

84

• Observed a consistent pattern in healthcare utilization across several indicators

Individuals with an Alcohol Use Disorder access services during year of diagnosis

• Social service and emergency department use spikes a year before receiving diagnosis

Conclusions & Recommendations

85

• Found that individuals appear across a variety of sectors supports recommendations in Mental Health and Addictions Strategy

• Enhance coordination of services adopting a “whole-of-government” and “whole-of-society” approach

• Improve access to alcohol treatment options

• Explore and consider reasons for socioeconomic gradients in high risk drinking and Alcohol Use Disorders


86

• Mental Health and Addictions Strategy

• Continued work to raise awareness around high-risk drinking behaviors

• Education for healthcare workers about high risk drinking and brief interventions

• Better access to community data


87

Thank You / Questions

umanitoba.ca/centres/mchp

facebook.com/mchp.umanitoba

@um_mchp

Nathan C. Nickel, PhD

[email protected]

https://www.facebook.com/mchp.umanitoba

https://twitter.com/um_mchp

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0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%

R1

R2

R3

R4

R5

U1

U2

U3

U4

U5

Males: Exceed Weekly Limit

Exceed Weekly Limit Did not Exceed Weekly Limit

89

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%

R1

R2

R3

R4

R5

U1

U2

U3

U4

U5

Males: Exceed Weekly Limit


90

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

R1

R2

R3

R4

R5

U1

U2

U3

U4

U5

Females: Exceed Weekly Limit


91

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

R1

R2

R3

R4

R5

U1

U2

U3

U4

U5

Females: Exceed Weekly Limit


Health and Social Outcomes Associated with High-Risk Alcohol...

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