South West - Alcohol Learning Centre

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South West Public Health Observatory

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Alcohol Attributable Hospital Admissions (NI39) in the South West

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About the South West Public Health Observatory The South West Public Health Observatory (SWPHO) is part of a network of regional public health observatories in the UK and Ireland. These were established in 2000 as outlined in the Government White Paper Saving lives: our healthier nation. Key tasks include: monitoring health and disease trends; identifying gaps in health information; advising on methods for health and health impact assessment; drawing together information from different sources; and carrying out projects on particular health issues. The SWPHO incorporates the National Drug Treatment Monitoring System South West (NDTMS-SW), and in April 2005 merged with the South West Cancer Intelligence Service (SWCIS). The SWPHO works in partnership with a wide range of agencies, networks and organisations regionally and nationally to provide „a seamless public health intelligence service‟ for the South West. For more information about the SWPHO and its partner organisations, please visit www.swpho.nhs.uk.

SWPHO is part of the UK & Ireland Association of Public Health Observatories.

Alcohol Attributable Hospital Admissions (NI39) in the South West Contributing authors: Churchill Ogunewe, Analyst, Ruth Shakespeare, Consultant in Public Health Medicine, Laura Juett, Regional Alcohol Manager, Liz Rolfe, Principal Analyst, Kate Kelly, South West Public Health Observatory, and Paul Brown, Deputy Director, South West Public Health Observatory

Publication date: February 2011

Contents Figures .......................................................................................................................................... 3 Tables ........................................................................................................................................... 5 Appendix tables ..................................................................................................................... 6 Foreword ...................................................................................................................................... 7 Important technical information ................................................................................................ 8 Key findings ................................................................................................................................. 8 1.

Introduction ........................................................................................................................ 12 1.1

Background and context ......................................................................................... 12

1.2

Aim .......................................................................................................................... 13

1.3

Estimating the admissions and rates ...................................................................... 13

Part 1: Alcohol Specific Hospital Admissions ....................................................................... 17 2.

3.

4.

Analysis by geographical area ......................................................................................... 18 2.1

Top Tier Local Authority ......................................................................................... 18

2.2

Middle Super Output Area (MSOA) ....................................................................... 18

Deprivation ......................................................................................................................... 22 3.1

Index of multiple deprivation 2007 .......................................................................... 22

3.2

Geodemographic segmentation .............................................................................. 23

3.3

Analysis by the People and Places segmentation tool ........................................... 23

Analysis of individuals ...................................................................................................... 25 4.1

5.

Individuals by age and sex ..................................................................................... 25

Analysis by cause of admission ...................................................................................... 26 5.1

Alcohol specific admissions by cause of admission ............................................... 26

5.2

Admissions by cause, age and sex ........................................................................ 28

5.3

Admissions for ethanol poisoning ........................................................................... 30

6.

Analyses of alcohol specific admissions by day of the week ...................................... 32

7.

Analysis by admission method (elective versus emergency admissions) ................. 34

8.

Repeat admissions ............................................................................................................ 37

9.

8.1

All alcohol specific repeat admissions (elective and emergency) .......................... 37

8.2

Alcohol specific emergency repeat admissions ...................................................... 40

Bed days ............................................................................................................................. 41 9.1

Alcohol specific admissions with bed days ............................................................. 41

9.2

Alcohol specific admissions with zero bed days ..................................................... 43

Part 2 – Alcohol Attributable Hospital Admissions ............................................................... 46 10. Analysis by geographical area ......................................................................................... 47 10.1

Top Tier Local Authority ......................................................................................... 47 1

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10.2


Middle Super Output Area (MSOA) ....................................................................... 52

11. Deprivation ......................................................................................................................... 54 11.1

Index of Multiple Deprivation 2007 ......................................................................... 54

11.2

Geodemographic segmentation .............................................................................. 55

11.3

Analysis by the People and Places segmentation tool ........................................... 55

12. Analysis of individuals ...................................................................................................... 60 12.1 13.

14.

Individuals by age and sex ..................................................................................... 60

Analysis by cause of admission ..................................................................................... 62 13.1

Hospital admission by cause .................................................................................. 62

13.2

Admissions by cause and sex ................................................................................ 63

13.3

Admissions by cause, age, and sex ....................................................................... 64

Analysis by day of the week ............................................................................................ 67

15. Analysis by admission method (elective versus emergency admissions) ................. 69 16. Repeat admissions ............................................................................................................ 72 16.1

All alcohol attributable repeat admissions (elective and emergency) ..................... 72

16.2

Repeat admissions by cause of admission............................................................. 73

16.3

Alcohol attributable emergency repeat admissions ................................................ 75

17. Bed days ............................................................................................................................. 76 17.1

Admissions with bed days ...................................................................................... 76

17.2

Admissions with zero bed days .............................................................................. 78

18. Discussion and conclusions ............................................................................................ 80 Glossary ..................................................................................................................................... 82 References ................................................................................................................................. 84 Appendix: Additional tables ..................................................................................................... 85

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Figures Figure 1.0: Alcohol attributable hospital admissions (NI39) in the South West, 2008/09, at a glance .................................................................................................................................. 11 Figure 1.1: Alcohol attributable conditions .................................................................................. 14 Figure 1.2: Possible contributions to two NI39 admissions. ........................................................ 15 Figure 2.1: Directly standardised rates of alcohol specific admissions, per 100,000 population, South West Local Authorities, 2008/09 ............................................................................... 20 Figure 2.2: Crude rates of alcohol specific admissions, South West MSOAs, 2008/09 ............. 21 Figure 3.1: Percentage of alcohol specific hospital admissions by regional IMD quintile, South West, 2008/09 ...................................................................................................................... 22 Figure 3.2: Crude rates of alcohol specific hospital admissions by People and Places segmentation sub-groups (branches), South West, 2008/09 .............................................. 24 Figure 4.1: Percentage breakdown of individuals who contributed to alcohol specific hospital admissions by age and sex, South West, 2008/09 ............................................................. 26 Figure 5.1: Percentage breakdown of alcohol specific admissions by age and cause, for top five causes, males, South West, 2008/09 .................................................................................. 29 Figure 5.2: Percentage breakdown of alcohol specific admissions by age and cause, for top five causes, females, South West, 2008/09 ............................................................................... 29 Figure 5.3: Ethanol poisoning, breakdown of individuals by age and sex, South West, 2008/09 .. ............................................................................................................................................. 31 Figure 5.4: Admissions for ethanol poisoning (toxic effect of ethanol) by day of the week, South West, 2008/09 ...................................................................................................................... 32 Figure 6.1: Alcohol specific admissions by day of the week, South West, 2008/09 ................... 33 Figure 6.2 Breakdown of alcohol specific admissions by day of the week and admission method, South West, 2008/09 ........................................................................................................... 33 Figure 7.1: Percentage contribution to the total alcohol specific admissions, of the top five causes of emergency admission, South West, 2008/09. .................................................... 35 Figure 7.2: Percentage contribution to the total alcohol specific admissions of the top five causes of elective admission, South West, 2008/09. .......................................................... 36 Figure 8.1: Elective and emergency repeat admissions for alcohol specific conditions, percentage of individuals by number of admissions, South West, 2008/09 ........................ 37 Figure 8.2: Repeat admissions as a percentage contribution of all alcohol specific admissions for the top six causes, South West, 2008/09 ....................................................................... 38 Figure 8.3: Alcohol specific emergency repeat admissions for the top six causes, as a percentage of total alcohol specific admissions for that cause, South West, 2008/09 ....... 40 Figure 9.1: Percentage of all alcohol specific bed days by the top six causes of alcohol specific bed days, South West, 2008/09 .......................................................................................... 42 Figure 9.2 Percentage of all alcohol specific zero bed days by the top causes of zero bed days, South West, 2008/09 ........................................................................................................... 44 Figure 10.1: Alcohol attributable hospital admissions, directly standardised rates, per 100,000 population, South West Local Authorities, 2002/03–2008/09.............................................. 48

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Figure 10.2: Directly standardised rates of alcohol attributable hospital admissions, per 100,000 population, South West Local Authorities, 2008/09 ............................................................. 51 Figure 10.3: Crude rates of alcohol attributable hospital admissions, South West MSOAs, 2008/09 ................................................................................................................................ 53 Figure 11.1: Percentage of alcohol attributable hospital admissions by regional IMD quintile, South West, 2008/09 ........................................................................................................... 54 Figure 11.2: Crude rates of alcohol attributable hospital admissions by People and Places segmentation sub-groups (branches), South West, 2008/09 .............................................. 56 Figure 11.3: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (i) ......... 57 Figure 11.4: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (ii) ........ 58 Figure 11.5: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (iii) ....... 59 Figure 12.1: Age and sex breakdown of individuals included in the NI39 calculation (% of all individuals), South West, 2008/09 ....................................................................................... 60 Figure 12.2: Percentage contribution to alcohol attributable hospital admissions by age and sex, South West, 2008/09 ........................................................................................................... 61 Figure 13.1 Breakdown of alcohol attributable admissions by cause, South West, 2008/09 ..... 62 Figure 13.2: Top 15 causes of alcohol attributable hospital admissions in males, South West, 2008/09 ................................................................................................................................ 64 Figure 13.3: Top 15 causes of alcohol attributable hospital admissions in females, South West, 2008/09 ................................................................................................................................ 64 Figure 13.4: Percentage breakdown of alcohol attributable admissions by age and cause, for top five causes, males, South West, 2008/09 ..................................................................... 65 Figure 13.5: Percentage breakdown of alcohol attributable admissions by age and cause, for top five causes, females, South West, 2008/09 .................................................................. 65 Figure 14.1: Percentage breakdown of alcohol attributable hospital admissions (NI39) by day of the week, South West, 2008/09 ........................................................................................... 67 Figure 14.2: Percentage breakdown of alcohol attributable admissions by day of the week and admission method, South West, 2008/09 ............................................................................ 68 Figure 15.1: Percentage contribution to the total alcohol attributable admissions by the top ten causes of emergency admissions, South West, 2008/09 .................................................... 69 Figure 15.2: Percentage contribution to the total alcohol attributable admissions of the top ten causes of elective admissions, South West, 2008/09 ......................................................... 70 Figure 16.1: Percentage breakdown of individuals by number of admissions, South West, 2008/09 ................................................................................................................................ 73 Figure 16.2: Top ten causes of repeat admissions as a percentage contribution of all alcohol attributable admissions, South West, 2008/09 .................................................................... 74 Figure 16.3: Alcohol attributable emergency repeat admissions for the top ten causes, as a percentage of total alcohol attributable admissions for that cause, South West, 2008/09 .. 75 Figure 17.1: Percentage of alcohol attributable bed days for the top ten causes, South West, 2008/09 ................................................................................................................................ 77 Figure 17.2: Top ten causes of alcohol attributable admissions resulting in zero bed days (percentage), South West, 2008/09 ..................................................................................... 79

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Tables Table 3.1: People and Places sub-groups (branches) with the ten highest rates of alcohol specific hospital admissions, South West, 2008/09 ............................................................ 25 Table 5.1: Alcohol specific admissions by cause, South West, 2008/09 .................................... 27 Table 5.2: Alcohol specific admissions by cause and sex, South West, 2008/09 ...................... 28 Table 7.1: Emergency alcohol specific admissions, by cause of admission, South West, 2008/09 35 Table 7.2: Elective alcohol specific admissions, by cause of admission, South West, 2008/09 36 Table 8.1: Alcohol specific repeat admissions by cause of admission, South West, 2008/09.... 39 Table 8.2: Alcohol specific emergency repeat admissions by cause of admission, South West, 2008/09 ................................................................................................................................ 41 Table 9.1: Alcohol specific hospital admissions with bed days, by cause, South West, 2008/09 .. ............................................................................................................................................. 42 Table 9.2: Alcohol specific hospital admissions with bed days, South West Local Authorities, 2008/09 ................................................................................................................................ 43 Table 9.3: Alcohol specific hospital admissions with zero bed days, South West, 2008/09 ........... ............................................................................................................................................. 44 Table 9.4: Alcohol specific hospital admissions with zero bed days, South West Local Authorities, 2008/09 ............................................................................................................. 45 Table 10.1: Rates and year-on-year percentage changes in alcohol attributable hospital admissions for South West Local Authorities between 2002/03–2008/09 .......................... 49 Table 11.1: The ten People and Places sub-groups (branches) with the highest alcohol attributable hospital admissions in the South West, 2008/09 .............................................. 55 Table 13.1: Top ten causes of alcohol attributable hospital admissions in the South West, 2008/09 ................................................................................................................................ 63 Table 15.1: Top ten emergency alcohol attributable admissions, South West, 2008/09 ............ 70 Table 15.2: Top ten elective admissions, South West, 2008/09 ................................................. 71 Table 15.3: Top ten admissions via other (general practitioner, consultant outpatient clinics etc), South West, 2008/09 ........................................................................................................... 71 Table 16.1: Top ten causes of repeat admissions for alcohol attributable conditions, South West, 2008/09 ...................................................................................................................... 74 Table 16.2: Top ten causes of emergency repeat admissions for alcohol attributable conditions, South West, 2008/09 ........................................................................................................... 76 Table 17.1: Top ten causes of alcohol attributable admissions resulting in bed days, South West, 2008/09 ...................................................................................................................... 77 Table 17.2: Alcohol attributable bed days by Local Authority, South West, 2008/09 ................. 78 Table 17.3: Top ten alcohol attributable zero bed days by cause, South West, 2008/09 ............... ............................................................................................................................................. 79 Table 17.4: Zero bed days by Local Authority, South West, 2008/09 ......................................... 80

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Appendix tables Table A1: Alcohol attributable fractions (AAFs) for hospital admissions..................................... 85 Table A2: People and Places branch definitions ......................................................................... 86 Table A3: Overall contribution to alcohol attributable hospital admissions (NI39), South West, 2008/09 Males by age ......................................................................................................... 88 Table A4: Overall contribution to alcohol attributable hospital admissions (NI39), South West, 2008/09 Females by age ..................................................................................................... 88 Table A5: Top ten causes of alcohol attributable admissions for males, South West, 2008/09 . 89 Table A6: Top ten causes of alcohol attributable admissions for females, South West, 2008/09 89 Table A7: Overall contribution to alcohol specific conditions, South West, 2008/09 Males by age 90 Table A8: Overall contribution to alcohol specific conditions, South West, 2008/09 Females by age ....................................................................................................................................... 91

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Foreword There is a long and complex history involving alcohol and society. Over the centuries alcohol has been used for medicinal, nutritional and spiritual purposes and has been an integral part of many cultural and social occasions. The majority of people who use alcohol do so without negative consequences. However, for some, their drinking causes problems for themselves, their families and the communities within which they live. Over recent years we have developed an enhanced understanding of the impact that alcohol can have on our health. We know that over time regular drinking above recommended levels can significantly increase our risk of a number of conditions including high blood pressure, cancer and liver disease. This in turn places a significant burden on families and on health and other public services. An increasing number of people are being admitted to hospital as a result of their alcohol use. This report provides Primary Care Trusts, Local Authorities and others who will be involved in future arrangements for the commissioning and provision of services, with a detailed analysis of alcohol related hospital admissions across the South West from 2002/03 to 2008/09. Most alcohol related hospital admissions are avoidable. This report outlines the scale of the challenge and helps to inform the case for prevention, early intervention and treatment responses. Alcohol related harm will continue to present us with challenges for years to come. I recommend this report to all those concerned by the considerable harm alcohol misuse creates and I hope they will use it to inform our collective approaches to prevention and treatment. Dr Gabriel Scally Regional Director of Public Health for the South West

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Important technical information Before reading this report, it is important to familiarise yourself with alcohol specific harm, alcohol related harm and alcohol attributable harm. In brief, alcohol specific harm is harm wholly attributable to the use of alcohol, alcohol related harm, is, as it suggests, harm partially attributable to or related to the use of alcohol and alcohol attributable harm is harm caused either wholly or partially by the use of alcohol. An Alcohol-Attributable Fraction (AAF) is applied to all admissions for alcohol attributable harm and range between -0.26 and 1. The lower the AAF, the harm caused is considered to be less attributable to the use of alcohol. An AAF of 1 indicates that the harm is wholly attributable to alcohol (alcohol specific) and will account for 1 whole admission. An AAF of less than 1 indicates that the harm is partially attributable to alcohol (alcohol related) and will account for part of a whole admission. The total alcohol attributable admissions are the sum of all admissions wholly due to alcohol (AAF = 1) plus the sum of all the parts of admissions which were partially attributable to alcohol (AAF < 1). Therefore the number of individuals admitted, will be more than the number of admissions. Further information in relation to the calculation of whole admissions when applying AAFs can be found in the Introduction in Chapter 1 (1.3).

Key findings General



There were 227,074 individuals admitted for alcohol attributable conditions (specific and related combined) in the South West in 2008/09 leading to 98,460 alcohol attributable hospital admissions once the appropriate AAF had been applied. An overview of these admissions is shown in Figure 1.0.



The 98,460 alcohol attributable hospital admissions were made up of 22,311 wholly attributable admissions (alcohol specific) and 76,149 partially alcohol attributable admissions (alcohol related).

Part 1 – Alcohol Specific



The overall rate of alcohol specific hospital admissions for the South West in 2008/09 was 414 per 100,000 population (standardised for age and sex).



Torbay (785 per 100,000 population) had the highest directly standardised rate of alcohol specific hospital admissions in 2008/09 whilst Somerset (308 per 100,000 population) had the lowest directly standardised rate.

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

Individuals residing in the most deprived areas were nearly four times more likely to be admitted to hospital for alcohol specific conditions than those residing in the least deprived areas.



The 22,311 alcohol specific hospital admissions completed in 2008/09 involved 14,785 individuals, 67.1% of which were males and 32.9% females.



Repeat admissions accounted for 34% of the total of alcohol specific hospital admissions completed in 2008/09 in the South West.



Mental and behavioural disorders due to use of alcohol was the leading cause of alcohol specific hospital admissions causing 63% (of all alcohol specific admissions), followed by alcoholic liver disease (18%) and ethanol poisoning (13%).



Alcohol specific admissions occurred more via emergency (83%) than elective (14%) or any other method of admission.



In the South West and for the year 2008/09, hospital admissions for mental and behavioural disorders due to use of alcohol caused the highest number of alcohol specific bed days (73%).



Cornwall and Isles of Scilly had the highest number of bed days due to alcohol specific admissions (14% of South West alcohol specific bed days).



Alcohol specific admissions for ethanol poisoning were higher in females between the age of 15-19, 20-24, 35-39 and 40-44 than any other male age group. Of particular interest are females in the age group 15-19 whose percentage of admissions for this cause was more than twice that of males in the same age group.

Part 2 - Alcohol Attributable



In the South West, the overall rate of alcohol attributable hospital admissions for 2008/09 was 1,490 per 100,000 population (adjusted for age and sex).



There was an increase in the rate of alcohol attributable hospital admissions in Local Authorities in the South West between 2002/03 and 2008/09, with some Local Authorities experiencing up to a 100% increase.



Bristol had the highest directly standardised rate of alcohol attributable hospital admissions in the South West for 2008/09 at 2,254 per 100,000 population, while Dorset had the lowest directly standardised rate at 1,281 per 100,000 population.



Hypertensive diseases were the underlying cause for 34.8% of alcohol attributable hospital admissions completed during 2008/09 in the South West, followed by cardiac arrhythmias (20.1%), mental and behavioural disorders due to use of alcohol (14.4%), epilepsy and status epilepticus (7.4%), and alcoholic liver disease (4.0%).



The rate of alcohol attributable hospital admissions was higher in more deprived areas. For 2008/09, the rate of admission in the most deprived area was almost twice that of the least deprived area.



People and Places geographic segmentation subgroups (as defined in Chapter 3.3) „Hard to Let‟, „Cramped Flats‟ and „Impoverished Elders‟ had the highest rates for both alcohol attributable hospital admissions and alcohol specific hospital admissions completed during 2008/09.

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(See Table A2 in the Appendix for a description of these segmentation subgroups).



59% of all alcohol attributable hospital admissions completed during 2008/09 were of people aged 60 years or over.



Alcohol attributable hospital admissions occur more during the week than at weekends. However, admissions for ethanol poisoning occur more at the weekend. The majority of alcohol attributable admissions at the weekend were via Emergency Medicine services.



56.9% of alcohol attributable hospital admissions completed during 2008/09 were emergency admissions while 39.7% were elective admissions.



Of all the 227,074 individuals with admissions completed in 2008/09 for alcohol attributable conditions, 31% were admitted more than once.



There were 384,850 hospital admissions which could be partially or wholly attributable to alcohol completed in 2008/09 in the South West, 59% of these were repeat admissions.



2% (4,554) of all individuals with alcohol attributable hospital admissions completed in 2008/09 had between six and ten admissions and 0.9% (2,022) of all individuals had over 11 admissions.



Hypertensive diseases, cardiac arrhythmias, malignant neoplasm of breast and fall injures were the most common reasons for repeat admissions completed in 2008/09. Hypertensive disease, cardiac arrhythmias, fall injuries and mental and behavioural disorders due to use of alcohol were the leading reasons for emergency repeat admissions.



The total number of bed days for all alcohol attributable admissions completed during 2008/09 in the South West was 1,272,439.



56% of alcohol attributable hospital admissions completed in 2008/09 resulted in one or more hospital bed day.

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Figure 1.0: Alcohol attributable hospital admissions (NI39) in the South West, 2008/09, at a glance Admission Type

Sex

Admission Method

Source: Data: NI39 Hospital Episodes Statistics (HES) extract, 2008/09; Department of Health. Analysed by: the South West Public Health Observatory

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1.

Introduction

1.1

Background and context Alcohol presents a number of complex challenges. It can make a positive contribution to a range of social and cultural activities and occasions. It also plays an important part in the economy with the manufacturing and sales of alcohol providing a range of important employment opportunities. Despite this, alcohol can have a negative impact on individuals, families and communities. It presents one of the most significant pressures on public services, including health, public health and criminal justice services. The trend for alcohol consumption in England is one of a considerable overall increase over recent decades. In 2007, 33% of men and 16% of women (24% of adults) in England were classified as hazardous drinkers. This includes 6% of men and 2% of women estimated to be harmful drinkers, the most serious form of hazardous drinking which is likely to cause ill health (The Health and Social Care Information Centre, 2010). Alcohol misuse is directly related to deaths from certain diseases, such as cirrhosis of the liver. The number of deaths directly related to alcohol consumption in England increased by 24% between 2001 and 2008 (The Health and Social Care Information Centre, 2010). There are significant differences in the health impacts and consequences of alcohol use between affluent and deprived communities. Deprived areas experience higher levels of alcohol related poor health and premature death (Royal College of Psychiatrists (AL 49), 2009). The estimated financial burden of alcohol misuse on the NHS in England is around £2.7 billion in hospital admissions, attendance at Emergency Medicine departments and in primary care (Department of Health, 2008a). Alcohol misuse is also responsible for a broader range of costs such as those associated with crime and disorder, social and family breakdown and absence from work. In acknowledgement of the growing levels of harm, governments and health and social care organisations have implemented a range of policies and programmes to address alcohol related harms and to encourage responsible approaches to the consumption of alcohol. The Government‟s Public Service Agreements for 2008– 11 included an agreement to reduce the harm caused by drugs and alcohol (PSA25). This led to the introduction of a national target, to reduce the trend in the increase in alcohol attributable hospital admissions. National Indicator 39 (NI39) provides local measures of the rate of hospital admissions which can be attributed to alcohol for every 100,000 people for each Local Authority in England. The rate is directly standardised for age and sex making comparisons between populations with different demographic characteristics possible. To date NI39 has been used in Local Area Agreements, NHS Local Operating Plans and World Class Commissioning Plans. It has also been used as an indicator of performance, measuring the impact of local alcohol prevention and treatment interventions on rates of alcohol attributable hospital admissions.

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Under the Coalition Government efforts to reduce alcohol harm will be at the heart of the new public health system, which will focus on empowering individuals to make healthy choices and giving communities tools to address their local needs. In this context, a continued focus on reducing alcohol attributable hospital admissions remains a useful outcome measure of efforts to improve, promote and protect the health of local communities. Most alcohol attributable harm is preventable. This report provides an enhanced understanding of the populations being admitted to hospital due to alcohol and will be useful to those concerned with the planning and commissioning of alcohol misuse prevention and treatment services. It will also provide support to those involved in developing integrated responses to address a broader range of issues including alcohol related crime and disorder and harm among young people.

1.2

Aim The overall objective of this report is to investigate the patterns of hospital admissions due to alcohol specific and alcohol related harm in the South West (alcohol attributable). The report provides detailed analysis of rates and numbers of alcohol attributable hospital admissions (NI39) across the South West Local Authorities for the period between 2002/03 and 2008/09. The report provides analysis of those admissions completed in 2008/09 by sex, age, cause, deprivation and the People and Places geographic segmentation categories. It also considers elective and non-elective admissions, the days of the week admissions occur, repeat admissions and the number of hospital bed days used. Due to the importance of alcohol specific conditions these are separately analysed in Part 1 of the report. Part 2 then shows the analysis of alcohol attributable conditions (alcohol specific and alcohol related combined).

1.3

Estimating the admissions and rates The official definition of NI39 is “hospital admissions for alcohol related harm” (Department of Health, 2008b). However, as explained below, there is an important distinction between alcohol related and alcohol specific harm. Therefore, in the interest of clarity, throughout this report we will be using the phrase “alcohol attributable” when referring to the overall impact of alcohol used for NI39. The NI39 indicator is nationally defined by financial year (1st April to 31st March), and is made up of all alcohol attributable admissions which are completed within that year, defined according to when the admission episode ends. Admissions for any one financial year therefore include admission episodes that started in preceding financial years but are allocated to the financial year in which the admission episode was completed. This is so that over a period of years all admissions, including those that span years, are included in the indicator series. Admissions that span years would otherwise be excluded, and consequently the sum of annual figures would not result in an accurate cumulative figure. NI39 measures the rate of alcohol attributable admissions per 100,000 population using Hospital Episode Statistics (HES). It is calculated by applying alcoholattributable fractions (AAFs) to HES. HES is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. Each HES record is classified using the International Classification of Disease, 10th Revision (ICD10) (see glossary).

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AAFs define the extent of the contribution of alcohol to each condition and its consequent hospital admission (Jones L, 2008). AAFs are age and sex specific and are based on population estimates of alcohol consumption data in England and the best risk estimates from published literature. Each disease and injury is classified according to whether alcohol is part of the causal mechanism. The estimated proportion of each case that are attributable to the consumption of alcohol is then provided (details of these AAFs are shown in Table A1 in the Appendix). To calculate NI39, the AAFs are applied to the HES records. Each individual HES record is identified and examined to see if any of the ICD10 codes are categorised as alcohol attributable. Any record without an alcohol attributable ICD10 code is excluded, while those with one or more are included in the analysis. For records with more than one alcohol attributable ICD10 code, the ICD10 code with the largest AAF is used. If a record exists that has two or more ICD10 codes of the same numerical value, the first diagnostic code is used. Finally, the AAFs are totalled to give a rough estimate of NI39 admissions. There are no estimates of AAFs for children under the age of 16, except for alcohol specific diagnoses, i.e. where the AAF is 1 - where alcohol has specifically caused the condition. AAFs are calculated for 47 conditions, of which 13 are by definition wholly attributable to alcohol consumption (alcohol specific) and 34 conditions are partially 1 attributable to alcohol consumption (alcohol related) . Figure 1.1 shows that the number of alcohol attributable hospital admissions (NI39) is the sum of the admissions for alcohol specific conditions and those for alcohol related conditions. Figure 1.1: Alcohol attributable conditions

Source: SWPHO

Figure 1.2 illustrates the application of AAFs and the calculation of alcohol attributable hospital admissions (NI39). The diagram shows that two alcohol attributable admissions can be made up of: a)

two admissions for any of the alcohol specific conditions (in this example, ethanol poisoning);

b)

two male admissions for epilepsy (age 35-44) and two male admissions for epilepsy (age 75+);

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c)

five female (age 65-74) and five male (age 65-74) admissions for hypertension;

d)

twenty-five female breast cancer admissions (age.25-34)

Figure 1.2: Possible contributions to two NI39 admissions.

Source: Adapted from original diagram: Verity Bellamy et al, East Midlands Public Health Observatory

Two admissions could also be a result of a different combination of these conditions, for example:



one ethanol poisoning admission, AAF = 1

1.00



one male epilepsy admission, (age 75+) AAF = 0.42

0.42



two female admission for hypertension (age 65-74), AAF = 0.13 0.26



four breast cancer admissions (age 25-34), AAF = 0.08 x 4 Total

0.32 2.00

These examples use four alcohol attributable conditions, but with 13 alcohol specific and 34 alcohol related conditions, all broken down by age and sex, there are obviously many different combinations which could correspond to the two alcohol attributable hospital admissions. Throughout the report the unit of measurement used is that used by NI39, defined by the sum of the alcohol related and specific hospital admissions (i.e. alcohol attributable). In some instances we may also refer to the „number of individuals‟, or „all admissions‟ in order to highlight particular issues. These are defined below.



All admissions: This is the count of all admissions including the first admission as well as the subsequent admissions.



Number of individuals: This is the number of individuals that were analysed. An individual may have more than one admission but is counted only once.

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Once the number of NI39 admissions were calculated, crude rates, directly standardised rates and percentages were calculated for alcohol attributable hospital admissions as well as alcohol specific hospital admissions completed in 2008/09. These calculations used the Office for National Statistics (ONS) mid-year 2008 population estimates as the denominator for crude rates and for agestandardisation to the European standard population.

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Part 1: Alcohol Specific Hospital Admissions This section of the report describes alcohol specific hospital admissions. These are admissions that are wholly caused by alcohol use and therefore have an alcohol attributable fraction of 1. Some cells in the tables are suppressed due to small numbers. There are 13 alcohol specific conditions are described in the alcohol attributable fractions table (Table A1 in the Appendix), as follows:



Alcohol-induced pseudo Cushings syndrome



Mental and behavioural disorders due to use of alcohol



Degeneration of nervous system due to alcohol



Alcoholic polyneuropathy



Alcoholic myopathy

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Alcoholic cardiomyopathy



Alcoholic gastritis

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Alcoholic liver disease



Chronic pancreatitis (alcohol-induced)



Ethanol poisoning



Methanol poisoning



Toxic effect of alcohol unspecified



Accidental poisoning by and exposure to alcohol

Note: There were no admissions completed in the South West during 2008/09 for one condition: alcohol-induced pseudo-Cushing‟s syndrome. This condition is therefore not included in the relevant tables.

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2.

Analysis by geographical area

2.1

Top Tier Local Authority There are 16 Top Tier Local Authorities in the South West. For the purpose of this report, due to small numbers and subsequent indicator reliability, Cornwall and the Isles of Scilly have been combined to provide a more reliable indicator. A summary of the analysis for each of the local areas within this report will shortly be available. The summary for Cornwall and the Isles of Scilly will, where possible, highlight any issues specific to the Isles of Scilly. The analysis of the alcohol specific hospital admissions completed during 2008/09 by local area is shown in Figure 2.1. The data show that:

2.2



the South West directly standardised rate (2008/09) for alcohol specific admissions (413.7 per 100,000 population) were lower than the England rate (452.3 per 100,000 population);



across the South West the highest directly standardised rate for alcohol specific hospital admissions was in Torbay (784.7 per 100,000 population) whilst Somerset (308.1 per 100,000 population) had the lowest rate;



all Local Authorities with directly standardised hospital admission rates shown in red in Figure 10.1 had rates statistically significantly higher than the South West rate, while those in green were statistically significantly lower. The Local Authorities in blue did not show any significant difference to the South West rate;



two Local Authorities in the South West (Torbay and Bristol) had directly standardised hospital admission rates statistically higher than England and the South West;



five additional Local Authorities in the South West (Bournemouth, Cornwall and Isles of Scilly (combined), Plymouth, North Somerset and Poole) had directly standardised hospital admission rates statistically higher than the South West;



six Local Authorities in the South West (Swindon, South Gloucestershire, Wiltshire, Gloucestershire, Dorset and Somerset) had directly standardised hospital admission rates statistically lower than the South West.

Middle Super Output Area (MSOA) Middle Super Output Areas are areas of geography that have a minimum population of 5,000. The South West has approximately 700 MSOAs and nationwide, the population mean for a MSOA is 7,200. Figure 2.2 shows the crude rate of alcohol specific hospital admissions by Middle Super Output Area (MSOA) in the South West completed during 2008/09. A crude

18

SWPHO


rate was preferred here as it provides a direct measure of the burden of disease in the local population, allowing interventions to be targeted appropriately. The MSOAs shown in red have a statistically significantly higher alcohol specific admission rate compared to the South West rate, while those in green have a statistically significantly lower rate. MSOAs are described in Chapter 2 of this report. The majority of areas with high levels of alcohol specific admissions are in deprived urban areas and coastal areas, whilst the areas of low levels of alcohol specific admissions are predominantly in rural or affluent urban areas.

19

SWPHO


Figure 2.1: Directly standardised rates of alcohol specific admissions, per 100,000 population, South West Local Authorities, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and ONS mid-year (2008) population estimates. Analysed by: SWPHO Note: Cornwall and the Isles of Scilly have been combined due to small numbers.

20

SWPHO


Figure 2.2: Crude rates of alcohol specific admissions, South West MSOAs, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and ONS mid-year (2008) population estimates. Analysed by: SWPHO

21

SWPHO


3.

Deprivation

3.1

Index of multiple deprivation 2007 The Index of Multiple Deprivation 2007 (IMD 2007) is a relative ranking of areas based on their deprivation. There are 38 indicators that cover different aspects of deprivation, e.g. income, barriers to housing, living conditions and crime, which are weighted and combined to give a single deprivation value. The regional deprivation quintile for the South West divides the area‟s population into fifths using these deprivation measures. Analysis using deprivation is important because it shows the association between the deprivation of an area and the health of the residents. The relationship between deprivation and alcohol specific admissions completed in the South West in 2008/09 is shown in Figure 3.1. Figure 3.1: Percentage of alcohol specific hospital admissions by regional IMD quintile, South West, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and IMD 2007, Communities and Local Government. Analysed by: SWPHO

The data show that:



residents of the most deprived quintile account for 39.7% of admissions and are almost four times more likely to be admitted to hospital for alcohol specific conditions, than those in the least deprived quintile;



61.0% of all alcohol specific admissions are from the two most deprived quintiles;



if all deprivation quintiles in the South West had the same admission rate as the least deprived quintile, then 10,685 alcohol specific hospital

22

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admissions (48.3% of all alcohol specific admissions) completed during 2008/09 would have been prevented.

3.2

Geodemographic segmentation Geodemographic segmentation can be described as the analysis of people by where they live or come from (Harris R, 2005). The main assumption of any geodemographic analysis is that similar people live in similar places and have similar lifestyles. This is a result of the complex interplay between factors such as deprivation, housing and environmental issues which are important determinants of public health. In its application, people or distinct groups are seen as a „markets‟ and this has become a common component of social marketing approaches to target a particular sub-group who would potentially benefit from specific interventions. Most geodemographic segmentation tools use maps to characterise the subjects of the analysis.

3.3

Analysis by the People and Places segmentation tool The people and places geodemographic segmentation tool classifies people into clusters on the basis of their similarities. It is based on ONS 2001 data and the hierarchical clusters are ranked in order of affluence using income data. The basic clusters are called „trees‟ and these are further divided into „branches‟ and „leaves‟. A brief description of People and Places segmentation sub-groups (branches) used for the analysis are given in Table A2 in the Appendix. In the analysis below, alcohol specific admission rates in the South West (2008/09) are matched to People and Places segmentation branches (sub-groups) so that the groups where the rates are disproportionately high can be identified. The aim is to identify places with the highest rates for alcohol specific hospital admissions. Figure 3.2 and Table 3.1 show the crude rates of alcohol specific admissions completed in the South West during 2008/09, by People and Places segmentation sub-groups (branches). The data show that:



there is significant variation in the alcohol specific admission rates between the various People and Places branches in the South West. „Cramped Flats‟ had the highest rate 3.5 times that of „Wordly Horizons‟, the group with lowest rate:



the sub-groups „Hard to Let‟, „Impoverished Elders‟ and „Cramped Flats‟ had the highest rates of alcohol specific admissions;



Working Singles, Struggling Single Parents, Student Life and Young Parents contributed the highest number of alcohol specific hospital admissions completed in 2008/09 in the South West.

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Figure 3.2: Crude rates of alcohol specific hospital admissions by People and Places segmentation sub-groups (branches), South West, 2008/09

Source: Data: P2 People & Places © Beacon Dodsworth 2004–2009, www.p2peopleandplaces.co.uk, NI39 HES, 2008/09; Department of Health and Office for National Statistics mid-year (2008) population estimates. Analysed by: SWPHO

24

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Table 3.1: People and Places sub-groups (branches) with the ten highest rates of alcohol specific hospital admissions, South West, 2008/09

People and places subgroup (branch)

Crude rate of alcohol specific hospital Number of alcohol admissions per specific hospital 100,000 admissions

Cramped Flats

2355.6

243

Hard to Let

1714.2

143

Impoverished Elders

1512.2

85

Students Life

1402.2

608

Cultural Enterprise

1384.3

21

Working Singles

1287.3

1861

Multicultural Key Workers

1183.2

143

Struggling Single Parents

1064.6

771

882.4

589

878.2

248

Young Parents Deprived Youth 2

Source: Data: P People & Places © Beacon Dodsworth 2004–2009, www.p2peopleandplaces.co.uk, NI39 HES, 2008/09; Department of Health and ONS midyear (2008) population estimates. Analysed by: SWPHO

4.

Analysis of individuals

4.1

Individuals by age and sex Figure 4.1 shows a breakdown of individuals who contributed to alcohol specific admissions completed in the South West during 2008/09, by age and sex. The data show that:



there are relatively high levels of admission for alcohol specific conditions in the younger age groups (aged 15–34) and a peak in those aged 40–44 for both males and females;



males contributed 67.1% of alcohol specific admissions while females contributed 32.9%.

This analysis provides useful evidence in support of education and treatment interventions and initiatives that target young people and young adults. Tables A7 and A8 (in the Appendix) provide further details of the contributions each age and sex group make to alcohol specific hospital admissions completed in the South West during 2008/09.

25

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Figure 4.1: Percentage breakdown of individuals who contributed to alcohol specific hospital admissions by age and sex, South West, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

5.

Analysis by cause of admission

5.1

Alcohol specific admissions by cause of admission As previously discussed, alcohol specific conditions are those wholly attributable to alcohol with an AAF of 1. They include mental and behavioural disorders due to use of alcohol, alcoholic liver disease and ethanol poisoning. Table 5.1 shows alcohol specific admissions completed in the South West in 2008/09 by cause. The data show that:



the leading cause of admission for alcohol specific conditions was mental and behavioural disorders due to use of alcohol, accounting for 63.4% of all alcohol specific admissions;



alcoholic liver disease was the second largest cause of alcohol specific admissions, accounting for 17.9%;



other top contributors to alcohol specific hospital admissions were ethanol poisoning (13.4%), alcohol induced chronic pancreatitis (2.9%), and toxic effect of alcohol, unspecified (0.9%).

26

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Table 5.1: Alcohol specific admissions by cause, South West, 2008/09 Percentage of alcoholic Percentage All specific of admissions admissions Individuals Individuals

Cause of admission Mental and behavioural disorders due to use of alcohol

14,146

63.4

9,898

66.9


3,999

17.9

1830

12.4

Ethanol poisoning (toxic effect of ethanol)

2,992

13.4

2,393

16.2

Alcohol-induced Chronic Pancreatitis

642

2.9

296

2.0

Toxic effect of alcohol, unspecified

206

0.9

165

1.1

Alcoholic gastritis

123

0.6

77

0.5


97

0.4

60

0.4


59

0.3

28

0.2


29

0.1

22

0.1

Accidental Poisoning by and exposure to alcohol

10

0.0

9

0.1

Alcoholic myopathy

Suppressed

Suppressed Suppressed Suppressed

Toxic effect of methanol

Suppressed

Suppressed Suppressed Suppressed

Alcohol-induced pseudo-cushing's syndrome

0

All Alcohol specific causes

22,311

0.0

0

0.0

100.0

14,785

100.0

Notes: Small numbers have been suppressed in line with ONS guidelines. Therefore, the numbers in the columns, when added may not equal the totals shown. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

Table 5.2 shows alcohol specific admissions completed in the South West during 2008/09 by cause and sex. The data show that:



mental and behavioural disorders due to use of alcohol accounted for 67.6% of all male alcohol specific admissions and 54.8% of all female alcohol specific admissions;



the top four causes (mental and behavioural disorders due to use of alcohol, alcoholic liver disease, ethanol poisoning (toxic effect of ethanol) and alcohol induced chronic pancreatitis) were the same for both males and females.

27

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Table 5.2: Alcohol specific admissions by cause and sex, South West, 2008/09

Cause of Admissions Mental and Behavioural disorde due to use of alcohol use

Males

Females

Percentage of all male Male alcohol alcohol specific specific admissions admissions Individuals

Percentage Female of all female alcohol alcohol specific specific admissions admissions Individuals

10,123

67.6

7,030

4,023

54.8

Alcoholic Liver Disease

2,655

17.7

1,217

1,344

18.3

624

Ethanol Poisoning (Toxic effect of ethanol)

1,311

8.8

1,021

1,681

22.9

1,362


530

3.5

247

112

1.5

49


83

0.6

64

123

1.7

98

Alcoholic gastritis

90

0.6

55

33

0.4

20

Alcoholic cardiomyopathy Degeneration of nervous system due to alcohol

92

0.6

57

5

0.1 Suppressed

52

0.3

26

7

0.1 Suppressed

Alcoholic polyneuropathy Accidental poisoning by and exposure to alcohol

21

0.1

14

8

0.1

7

Suppressed

6

7 Suppressed Suppressed Suppressed

Alcoholic myopathy

Suppressed

Suppressed Suppressed Suppressed Suppressed Suppressed


Suppressed

Suppressed Suppressed Suppressed Suppressed Suppressed

All Alcohol Specific Causes

14,971

100.0

9,744

7,340

Note: Small numbers have been suppressed in line with ONS guidelines. Therefore, the numbers in the columns, when added may not equal the totals shown. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

5.2

2,874

Admissions by cause, age and sex The top five causes that contribute most to alcohol specific admissions completed in the South West during 2008/09 are mental and behavioural disorders due to use of alcohol, ethanol poisoning (toxic effect of alcohol), alcoholic liver disease, alcohol induced chronic pancreatitis and toxic effect of alcohol, unspecified. These are broken down by cause, age and sex and shown in Figures 5.1 (males) and 5.2 (females). The data show that:



the age distribution of alcohol specific admissions are generally young compared to the older demographics of the region;



a number of these conditions, in particular those resulting from immediate impact of alcohol (mental and behavioural disorders due to use of alcohol, ethanol poisoning, toxic effect of alcohol unspecified) show a younger demographic with larger proportions of admissions in those aged 0-19, 20-29 and 30-39.

28

100.0

5,041

SWPHO


Figure 5.1: Percentage breakdown of alcohol specific admissions by age and cause, for top five causes, males, South West, 2008/09


Figure 5.2: Percentage breakdown of alcohol specific admissions by age and cause, for top five causes, females, South West, 2008/09


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The main findings for each of the top five causes were: Mental and behavioural disorders due to use of alcohol



Admissions for this cause were highest in the 40–49 age groups for both sexes (males, 22.4%; females 24%).



Admissions in the 0–19 age group accounted for 4.7% of all admissions for this cause for males and 9.3% for females.

Alcoholic liver disease:



Admissions for this cause were highest for males in the 50–59 age group (30.8%) and for females in the 40–49 age group (28.9%).



There were no admissions in the 0–19 age group for either males or females.



Admissions in the 20–29 age group were small in terms of overall contribution to all alcoholic liver disease admissions but these admissions are important markers, as they provide evidence of prolonged misuse of alcohol at an early age.




Admissions for this cause were highest in the 40–49 age group for both males (27.1%) and females (25.9%).



14.2% of all female admissions for this cause were in the 0–19 age group compared with 8.3% of males.

Alcohol induced pancreatitis



Admissions for this cause were highest in the 40–49 age group for both males (39.4%) and females (36.6%).




5.3

Admissions for this cause were highest in the 30–39 age group for males (33.7%) and in the 40–49 age group for females (26%).

Admissions for ethanol poisoning Ethanol poisoning is an alcohol specific condition caused by excessive consumption of alcohol. It is of interest to those responsible for developing integrated responses to alcohol misuse such as those concerned with licensing and sales and the management of night time economies. It is also an important indicator of current levels of harmful drinking in the population. There were 2,992 admissions for ethanol poisoning completed in the South West during 2008/09: 2,393 individuals (1,021 males and 1,372 females). The breakdown of admissions by age and sex is shown in Figure 5.3. This highlights the percentage contribution made by each age and sex group to the total number of individuals hospitalised for ethanol poisoning.

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Figure 5.3: Ethanol poisoning, breakdown of individuals by age and sex, South West, 2008/09


The data show that:



more females, (57.3%, 1,372) were admitted than males (42.7%, 1,021);



the three leading age groups for ethanol poisoning admissions were: 

for males, 35–39 (6.5%), 20–24 (6.3%) and 40–44 (5.8%);



for females, 15–19 (8.2%), 20–24 (8.2%) and 40–44 (8.1%)



overall contributions to ethanol poisoning admissions were notably high in females in the 15–19, 20–24, 35-39 and 40-44 age groups which were higher than all male age groups;



two peaks in admissions appear to suggest two significant population groups engaging in high risk drinking: those aged 15–24 and 35–44 and, again, were considerably higher in females.

The daily pattern of admissions for ethanol poisoning was also examined and the results are shown in Figure 5.4.

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Figure 5.4: Admissions for ethanol poisoning (toxic effect of ethanol) by day of the week, South West, 2008/09 18

Percentage of ethanol poisoning admissions

16 14 12 10 8 6 4 2 0 Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Day of the week


The data show that:



the numbers admitted as a result of ethanol poisoning peaked during the weekend, with 16.8% of overall weekly admissions being on Sunday and 15.8% on Saturday;



admissions during the week days were fairly constant from Monday to Friday, averaging 14.8% daily.

It is clear from this analysis that admissions from ethanol poisoning have a significant impact on Emergency Medicine departments and hospital services at particular times of the week. The provision of structured responses is key to reducing repeat presentations and overall levels of hospital admissions. Emergency Medicine departments are appropriate settings for the provision of „Identification and Brief Advice‟ which has been shown to have an impact on levels of consumption among those drinking at increasing and higher risk levels (Crawford, 2004).

6.

Analyses of alcohol specific admissions by day of the week All alcohol specific admissions were analysed by the day of the week in order to understand the days with higher pressure of admissions (Figures 6.1 and 6.2).

32

Saturday

SWPHO


Figure 6.1: Alcohol specific admissions by day of the week, South West, 2008/09


Figure 6.2 Breakdown of alcohol specific admissions by day of the week and admission method, South West, 2008/09


33

SWPHO


The data show that:



alcohol specific hospital admissions completed in the South West during 2008/09 peaked on Mondays (15.5%), reducing towards the end of the week;



Saturday and Sunday each contributed 13.2% of the weekly alcohol specific hospital admissions;



when compared with other methods of admission, only a small percentage of elective alcohol specific admissions occur during the weekend: Saturday (1.3%) and Sunday (1.9%);



when examining the admission method:



7.



elective admissions were highest on a Monday (24.6% of all elective alcohol specific admissions);



alcohol specific emergency admissions were highest on weekends (Saturday 15.4% and Sunday 15.3%) but these were relatively constant throughout the week.

other sources of emergency admissions (not Emergency Medicine departments) were higher during the week, compared to weekends.

Analysis by admission method (elective versus emergency admissions) Figure 7.1 and Table 7.1 show emergency alcohol specific admissions completed in the South West during 2008/09 by cause of admission, while Table 7.2 and Figure 7.2 show elective alcohol specific admissions by cause of admission. The data show that:



for alcohol specific admissions there were considerably more emergency admissions (83.4%) than for elective admissions (14.4%);



mental and behavioural disorders due to use of alcohol had the highest proportion of admissions for both emergency (53.9%) and elective admissions (7.8%);



99.8% of admissions for ethanol poisoning and 63.5% of admissions for alcoholic liver disease were emergencies.

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Figure 7.1: Percentage contribution to the total alcohol specific admissions, of the top five causes of emergency admission, South West, 2008/09.


Table 7.1: Emergency alcohol specific admissions, by cause of admission, South West, 2008/09 All emergency alcohol Specific admissions

Cause of admission Mental and behavioural disorders due to use of alcohol

Individuals

Percentage of all alcohol specific admissions

12,033

8,077

53.9


2,987

2,509

13.4


2,541

1,124

11.4


568

275

2.5


203

183

0.9

Alcoholic gastritis

116

75

0.5


70

45

0.3


42

18

0.2


23

16

0.1

Accidental Poisoning by and Exposure to Alcohol

10

10

0.0

Alcoholic myopathy

Suppressed

Suppressed

Suppressed


Suppressed

Suppressed

Suppressed

18,600

12,338

83.4

All emergency alcohol specific causes


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SWPHO


Figure 7.2: Percentage contribution to the total alcohol specific admissions of the top five causes of elective admission, South West, 2008/09.


Table 7.2: Elective alcohol specific admissions, by cause of admission, South West, 2008/09 All elective alcohol specific admissions

Individuals

Percentage of all alcohol specific admissions


1,751

1,436

7.8


1,342

818

6.0


65

48

0.3


23

18

0.1


16

10

0.1

7

5

0.0


Suppressed

Suppressed

Suppressed


Suppressed

Suppressed

Suppressed


Suppressed

Suppressed

Suppressed

Alcoholic myopathy

Suppressed

Suppressed

Suppressed

3,213

2,344

14.4

Cause of admission

Alcoholic gastritis

All elective alcohol specific causes


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8.


Repeat admissions Analysis of repeat admissions can be used to inform the development of initiatives that aim to reduce alcohol related Emergency Medicine department attendances and non-elective alcohol attributable admissions. This analysis is particularly useful in developing bespoke models of intervention to target individuals who frequently attend Emergency Medicine departments and are frequently admitted to hospital. In this report we have analysed repeat admissions rather than the more commonly used readmissions. Readmissions are defined by relating the date of readmission to the previous date of discharge (e.g. „Emergency Readmission within 28 days of Discharge‟ or „Emergency Readmission within 60 days of Discharge‟). The focus of the analysis in this chapter is not simply to evaluate emergency short-term readmissions, but to quantify and analyse the extent that multiple alcohol specific admissions of the same individuals contribute to NI39, and how these are being managed. Repeat admissions were calculated in two ways. Firstly, all individuals admitted were analysed according to how many admissions for that individual were completed in 2008/09. Secondly, analysis based on those individuals by cause was examined.

8.1

All alcohol specific repeat admissions (elective and emergency) Figure 8.1 shows elective and emergency repeat admissions for alcohol specific conditions in the South West completed during 2008/09. Of 14,785 individuals who were admitted, 9,722 (65.8%) had only one admission, 3,714 (25.1%) had 2–3 admissions, 835 (5.6%) had 4–5 admissions, 435 (2.9%) had 6–10 admissions and 79 (0.5%) were admitted 11 times or more. Figure 8.1: Elective and emergency repeat admissions for alcohol specific conditions, percentage of individuals by number of admissions, South West, 2008/09


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Figure 8.2 and Table 8.1 show all alcohol specific repeat admissions completed during 2008/09 in the South West by cause of admission, total admissions for that cause and percentage contribution of repeat admissions to all admissions for that cause. Figure 8.2: Repeat admissions as a percentage contribution of all alcohol specific admissions for the top six causes, South West, 2008/09

Note: Only causes where the number of total alcohol specific conditions is more than 100 are included. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

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Table 8.1: Alcohol specific repeat admissions by cause of admission, South West, 2008/09 Alcohol specific repeat admissions as a percentage of Alcohol total alcohol specific Total alcohol specific repeat specific admissions for the admissions Individuals admissions same cause

Cause of admission Mental and behavioural disordes due to use of alcohol

7,422

3,133

14,146

52.5


3,117

1,011

3,999

77.9


1,225

619

2,992

40.9

Alcohol-induced chronic pancreatitis

527

178

642

82.1


87

44

206

42.2

Alcoholic gastritis

75

21

123

61.0


71

35

97

73.2


44

12

59

74.6


15

5

29

51.7

Alcoholic myopathy

Suppressed Suppressed

Suppressed

Suppressed



Suppressed

Suppressed



Suppressed

Suppressed

All alcohol specific causes 12,589 5,064 22,311 Note: Small numbers have been suppressed in line with ONS guidelines. Therefore, the numbers in the columns, when added may not equal the totals shown. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

The data show that:



56.4% of all alcohol specific admissions were repeat admissions (for the same cause);



the highest number of repeat admissions for the same cause was 7,422, for mental and behavioural disorders due to use of alcohol;



the leading causes for repeat admissions for the same cause (where n>100) were:

  

alcohol-induced chronic pancreatitis (82.1% of all alcohol-induced chronic pancreatitis admissions were repeat admissions); and alcoholic liver disease (77.9%)

40.9% of admissions for ethanol poisoning were repeat admissions.

39

56.4

SWPHO

8.2


Alcohol specific emergency repeat admissions Figure 8.3 and Table 8.2 show alcohol specific emergency repeat admissions completed in the South West during 2008/09 by cause of admission. The data show that:



there were 10,129 alcohol specific emergency repeat admissions relating to 4,145 individuals;



mental and behavioural disorders due to use of alcohol (2,623 individuals), alcoholic liver disease, (638 individuals) and ethanol poisoning (617 individuals) were the three leading causes of emergency repeat admissions;



of all admissions for alcohol-induced chronic pancreatitis, 72.9% were repeat admissions.

Figure 8.3: Alcohol specific emergency repeat admissions for the top six causes, as a percentage of total alcohol specific admissions for that cause, South West, 2008/09

Note: Only causes where the number of total alcohol specific conditions is more than 100 are included. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

40

SWPHO


Table 8.2: Alcohol specific emergency repeat admissions by cause of admission, South West, 2008/09 Alcohol specific emergency repeat admissions as a percentage of total alcohol specific admissions for the same cause

Emergency alcohol specific repeat admissions

Individuals


6,142

2,623

14,146

43.4


1,945

638

3,999

48.6


1,221

617

2,992

40.8

468

160

642

72.9


86

44

206

41.7

Alcoholic gastritis

70

20

123

56.9


49

25

97

50.5

31

Cause of admission



Total alcohol specific admissions

9

59

52.5



Suppressed

Suppressed

Alcoholic myopathy


Suppressed

Suppressed



Suppressed

Suppressed

22,311

45.4

All alcohol specific causes

10,129

4,145


9.

Bed days A hospital admission bed day is defined as an admission that lasts beyond midnight of the day of admission. A zero bed day is an admission that does not pass through midnight. They are an important consideration in managing patients, meeting targets and reducing costs.

9.1

Alcohol specific admissions with bed days Figure 9.1 and Table 9.1 show alcohol specific admissions, which resulted in bed days, by cause, for admissions completed in the South West during 2008/09, Table 9.2 shows the breakdown by Local Authority.

41

SWPHO


Figure 9.1: Percentage of all alcohol specific bed days by the top six causes of alcohol specific bed days, South West, 2008/09

Note: Only causes which contribute 0.5% or more of the total alcohol specific bed days are included. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

Table 9.1: Alcohol specific hospital admissions with bed days, by cause, South West, 2008/09

Cause of Admission

Bed days

Percentage Alcohol of all alcohol specific specific bed admissions days Individuals with bed days


49,644

72.8

5,839

8,582


13,013

19.1

1,214

2,607


2,123

3.1

240

510


2,001

2.9

1,049

1,343


359

0.5

19

26


352

0.5

43

64


297

0.4

22

43


200

0.3

70

98

Alcoholic gastritis

137

0.2

49

81

30

0.0

5

6

Alcoholic myopathy Toxic effect of methanol

Suppressed


Suppressed


Suppressed


Suppressed

All alcohol specific causes 68,171 100.0 8,554 Note: Small numbers have been suppressed in line with ONS guidelines. Therefore, the numbers in the columns, when added may not equal the totals shown. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

42

13,364

SWPHO


Table 9.2: Alcohol specific hospital admissions with bed days, South West Local Authorities, 2008/09

Top Tier Local Authority

Percentage of all Alcohol specific alcohol specific hospital admissions Bed days bed days Individuals with bed days

Cornwall and Isles of Scilly

9,606

14.1

847

1,752

Devon

7,414

10.9

1,109

1,013

Dorset

6,851

10.0

641

1,369

Gloucestershire

6,773

9.9

826

1,094

Somerset

6,400

9.4

738

1,650

Wiltshire

6,287

9.2

624

1,249

Bath and North East Somerset

5,167

7.6

322

904

Bristol

2,909

4.3

975

493

North Somerset

2,840

4.2

361

791

South Gloucestershire

2,789

4.1

302

588

Plymouth

2,739

4.0

537

543

Torbay

2,512

3.7

356

471

Bournemouth

2,052

3.0

365

588

Poole

1,958

2.9

258

420

Swindon

1,770

2.6

274

404

Unallocated

104

0.2

19

35

South West

68,171

100.0

8,554

13,364

Note: Cornwall and the Isles of Scilly have been combined due to small numbers . Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

The data show that:

9.2



there were 68,171 bed days due to alcohol specific causes, the result of 13,364 alcohol specific admissions of 8,554 individuals;



72.8% (49,644) of the total bed days for alcoholic specific causes was accounted for by mental and behavioural disorder due to use of alcohol;



other top contributors were alcoholic liver disease at 19.1% (13,013), alcohol induced chronic pancreatitis at 3.1 % (2,123) and ethanol poisoning at 2.9 % (2,001). These conditions combined accounted for 94.9% (66,781) of the bed days due to alcohol specific hospital admissions;



Cornwall and Isles of Scilly had the highest number of bed days, 9,606 (14.1% of all bed days for alcohol specific conditions), while Swindon had the lowest number of bed days 1,170 (2.6%).

Alcohol specific admissions with zero bed days Figure 9.2 and Table 9.3 show alcohol specific admissions with zero bed days, by cause, completed in the South West during 2008/09. Table 17.4 shows the breakdown by Local Authority.

43

SWPHO


Figure 9.2 Percentage of all alcohol specific zero bed days by the top causes of zero bed days, South West, 2008/09

Note: Only causes which contribute 0.5% or more of the total alcohol specific zero bed days are included. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

Table 9.3: Alcohol specific hospital admissions with zero bed days, South West, 2008/09 Percentage Alcohol of all alcohol specific zero specific zero bed days bed days

Cause of admission

Individuals


5,564

62.1

4,059

Ethanol Poisoning (toxic effect of ethanol)

1,649

18.4

1,344


1,392

15.5

616


132

1.5

56


108

1.2

95

Alcoholic gastritis

42

0.5

28


33

0.4

17

16

0.2

6


Accidental poisoning by and exposure to alcohol Suppressed




Suppressed

All alcohol specific causes

8,947

100.0

6,231


44

SWPHO


Table 9.4: Alcohol specific hospital admissions with zero bed days, South West Local Authorities, 2008/09

Top Tier Local Authority

Percentage of all alcohol specific Zero bed days zero bed days Individuals


1,397

15.6

956

Devon

1,321

14.8

853

Dorset

1,183

13.2

832

Gloucestershire

664

7.4

486

Somerset

651

7.3

471

Wiltshire

575

6.4

446


460

5.1

294

Bristol

424

4.7

278

North Somerset

398

4.4

247


398

4.4

294

Plymouth

333

3.7

240

Torbay

315

3.5

232

Bournemouth

313

3.5

236

Poole

243

2.7

174

Swindon

240

2.7

172

Unallocated

31

0.4

20

South West

8,947

100.0

6,231

Note: Cornwall and the Isles of Scilly have been combined due to small numbers. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

The data show that:



there were a total of 8,947 zero bed days for alcohol specific admissions;



there were 5,564 zero bed days for mental and behavioural disorders due to use of alcohol (62.1% of all alcohol specific zero bed days);



Ethanol poisoning (1,649) and alcoholic liver disease (1,392) were the next leading causes of zero bed days;



Cornwall and Isles of Scilly had the highest number alcohol specific zero bed days (1,397) while Swindon had the lowest number (240).

45

SWPHO


Part 2 – Alcohol Attributable Hospital Admissions This section of the report describes alcohol attributable hospital admissions, as defined in Chapter 1 of the report (i.e. alcohol specific and alcohol related combined). The analyses in this section broadly follow the same sequence as Part 1, where the methodologies are explained in full.

46

SWPHO

10.


Analysis by geographical area This chapter provides an analysis of alcohol attributable hospital admissions (NI39) by common areas of geography.

10.1

Top Tier Local Authority The North West Public Health Observatory (NWPHO) provides rates of alcohol attributable admissions, by Local Authority. Figure 10.1 and Table 10.1 are based on the trend data published by NWPHO. Figure 10.2 and all other analyses within this report are based on 2008/09 data obtained directly from the Department of Health. The SWPHO analysis showed a small difference with the NWPHO figures in the number of hospital admissions after application of the alcohol-attributable fractions (AAF) (0.1% overall). The reasons for the differences are two-fold: i)

A more recent and revised version of NI39 has been used by NWPHO in calculating the rates shown on their website. The latest AAF technical description includes an additional ICD10 code compared to the earlier version.

ii)

A more accurate and recently revised ONS 2008 Mid-year Estimates (MYE) has been used as the denominator for the SWPHO calculations.

Figure 10.1 and Table 10.1 compare the directly standardised rates for alcohol attributable hospital admissions for all Local Authorities in the South West between 2002/03 and 2008/09. The data show that:



the rate of alcohol attributable hospital admissions increased in all Local Authorities in the South West between 2002/03 and 2008/09.



between 2002/03 and 2008/09 the five highest percentage increases occurred in Bath and North East Somerset (132%), Torbay (100%), Wiltshire (98%), Swindon, (94%) and Bristol (84%);



Somerset had the lowest percentage increase at 25%.

47

SWPHO


Figure 10.1: Alcohol attributable hospital admissions, directly standardised rates, per 100,000 population, South West Local Authorities, 2002/03–2008/09

Note: Cornwall and the Isles of Scilly have been combined due to small numbers Source: Data: NI39 HES, NWPHO, Local Alcohol profiles (2002/03-2008/09). Analysed by: SWPHO

48

SWPHO


Table 10.1: Rates and year-on-year percentage changes in alcohol attributable hospital admissions for South West Local Authorities between 2002/03–2008/09 Directly standardised rates per 100,000 population Local Authority Name Bristol, City of

Percentage Change (%) 2002/03 - 2003/04 - 2004/05 - 2005/06 - 2006/07 - 2007/08 - 2002/03 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2008/09 1,231

1,351

1,709

1,848

1,897

1,940

2,266

10

27

8

3

2

17

84

993

974

1,073

1,349

1,621

1,914

1,989

-2

10

26

20

18

4

100

Plymouth

1,263

1,437

1,383

1,537

1,753

1,773

1,899

14

-4

11

14

1

7

50

North Somerset South Gloucestershire Cornwall and Isles of Scilly

1,109

1,229

1,488

1,376

1,479

1,544

1,708

11

21

-8

7

4

11

54

1,068

1,198

1,323

1,561

1,533

1,566

1,559

12

10

18

-2

2

0

46

910

1,028

1,050

1,185

1,224

1,401

1,522

13

2

13

3

14

9

67

Gloucestershire

952

1,023

1,125

1,285

1,275

1,382

1,479

7

10

14

-1

8

7

55

Poole

975

959

1,245

1,315

1,230

1,238

1,406

-2

30

6

-6

1

14

44

Swindon

723

858

1,065

1,147

1,166

1,182

1,400

19

24

8

2

1

18

94

Devon

864

971

1,075

1,185

1,248

1,345

1,387

12

11

10

5

8

3

60

Bournemouth

860

824

942

1,119

1,168

1,243

1,369

-4

14

19

4

6

10

59


590

880

997

1,134

1,151

1,254

1,368

49

13

14

1

9

9

132

Wiltshire

677

912

1,059

1,070

1,137

1,121

1,338

35

16

1

6

-1

19

98

1,062

1,093

1,190

1,215

1,357

1,233

1,327

3

9

2

12

-9

8

25

779

799

872

944

1,045

1,053

1,172

3

9

8

11

1

11

50

Torbay

Somerset Dorset

Note: Cornwall and the Isles of Scilly have been combined due to small numbers Source: Data: NI39 HES, NWPHO, Local Alcohol profiles (2002/03-2008/09). Analysed by: SWPHO

49

SWPHO


Figure 10.2 shows variations within the South West in alcohol attributable hospital admissions rates by Local Authority for 2008/09. The data show that:



the South West directly standardised rate for 2008/09, 1,490 per 100,000 population, was lower than the directly standardised rate for England, 1,583 per 100,000 population;



four Local Authorities in the South West (Bristol, Torbay, Plymouth and North Somerset) had significantly higher directly standardised rates than England and the South West;



two additional Local Authorities in the South West (South Gloucestershire and Cornwall and Isles of Scilly) had significantly higher directly standardised rates than the South West;



the directly standardised rate in Bristol for 2008/09, 2,254 per 100,000 population, was the highest, while the Dorset directly standardised rate for 2008/09, 1,280 per 100,000 population, was the lowest in the South West;



Dorset, Somerset, Wiltshire, Swindon, Bournemouth and Bath and North East Somerset were all significantly lower than the South West rate;



the Local Authorities whose directly standardised hospital admission rates are shown in red in Figure 10.2 were significantly higher than the South West rate, while those in green were significantly lower. The Local Authorities in blue did not show any significant difference to the South West rate.

50

SWPHO


Figure 10.2: Directly standardised rates of alcohol attributable hospital admissions, per 100,000 population, South West Local Authorities, 2008/09

Note: Cornwall and the Isles of Scilly have been combined due to small numbers Source: Data: NI39 HES, 2008/09; Department of Health and ONS mid-year (2008) population estimates. Analysed by: SWPHO

51

SWPHO

10.2


Middle Super Output Area (MSOA) MSOAs are defined in Section 2.2 of the report. The South West crude rates for hospital admissions for alcohol attributable harm completed during 2008/09 by MSOA range from 682.7 to 4,357.4 per 100,000 population. A crude rate was preferred here, as it provides a direct measure of the burden of disease in the local population, allowing interventions to be targeted appropriately. In Figure 10.3, the green areas indicate the MSOAs where the crude rates are significantly lower than the South West rate while the red areas show areas significantly higher than the South West rate. The areas that are not significantly different from the South West rate are shown as grey. The map shows that the areas with significantly higher rates than the South West crude rate are primarily urban deprived and coastal areas. In contrast, areas of significantly lower rates are predominantly in rural areas or urban areas of relative affluence.

52

SWPHO


Figure 10.3: Crude rates of alcohol attributable hospital admissions, South West MSOAs, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and ONS mid-year (2008) population estimates. Analysed by: SWPHO

53

SWPHO

11.


Deprivation For details of definitions and methodologies see Chapter 3.

11.1

Index of Multiple Deprivation 2007 Figure 11.1 shows alcohol attributable admissions in the South West completed during 2008/09, by the regional deprivation quintiles. Individuals are assigned to a quintile based on the deprivation level of the Lower Super Output Area (LSOA) of their residence. For details of LSOAs please see the glossary. Figure 11.1: Percentage of alcohol attributable hospital admissions by regional IMD quintile, South West, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and IMD 2007, Communities and Local Government. Analysed by: SWPHO

The data show that:



the likelihood of being admitted to hospital for alcohol attributable harm was significantly greater in more deprived areas;



residents in the most deprived quintile were significantly more likely to be admitted to hospital for alcohol attributable conditions than all other quintiles. Admissions from this quintile accounted for 26.5% of the total alcohol attributable admissions completed during 2008/09;



the percentage of admissions for the least deprived quintile, 16%, was significantly less than that of all the other quintiles;



the percentage of admissions for the most deprived quintile was 1.7 times higher than that of the least deprived quintile;



if all deprivation quintiles in the South West had the same admission rate as the least deprived quintile, then 20,065 alcohol attributable hospital admissions (20.4% of all NI39 admissions) would have been prevented.

54

SWPHO

11.2


Geodemographic segmentation For details of the definitions of the People and Places geodemographic segmentation branches, see Chapter 3 and Appendix A2.

11.3

Analysis by the People and Places segmentation tool For details of the People and Places Segmentation Tool see Chapter 3. Table 11.1 shows the People and Places branches with the 10 highest rates of admission. Table 11.1: The ten People and Places sub-groups (branches) with the highest alcohol attributable hospital admissions in the South West, 2008/09 People and Places Group

Crude rate of Number of NI39 admissions admissions

M35. Impoverished Elders

4546.9

256

M38. Hard to Let

4520.6

377

M40. Cramped Flats

4456.0

460

K31. Struggling Single Parents

3139.2

2273

I33. Multicultural Key Workers

3065.1

370

H25. Working Singles

3002.3

4340

K36. Sheltered Singles

2880.5

595

K29. Blue Collar Elders

2844.4

2864

H26. Students Life

2806.4

1217

I24. Cultural Enterprise

2706.0

41

Source: Data: NI39 HES, 2008/09; Department of Health and P 2 People & Places © Beacon Dodsworth 2004–2009 www.p2peopleandplaces.co.uk and ONS mid-year (2008) population estimates. Analysed by: SWPHO

Figure 11.2 shows crude rates for alcohol attributable hospital admissions completed during 2008/09 in the South West by People and Places branches. The data show that: there is significant variation in alcohol attributable hospital admission rates in the South West by People and Places branches; the sub-groups „Hard to Let‟, „Impoverished Elders‟ and „Cramped Flats‟ had the highest rates of alcohol attributable admissions; The group with the lowest rate, (thriving families) had a rate four times lower than the group with the highest rate (impoverished elders). Working Singles, Blue Collar Elders, Struggling Singles Parents and Student Life contributed the highest number of alcohol attributable admissions in the South West completed in 2008/09 Figures 11.3, 11.4 and 11.5 show the geographical distribution of the 10 People and Places branches with the highest alcohol attributable hospital admission rates in the South West for 2008/09. These are distributed across the South West, but are concentrated in deprived urban areas.

55

SWPHO


Figure 11.2: Crude rates of alcohol attributable hospital admissions by People and Places segmentation sub-groups (branches), South West, 2008/09

Source: Data: NI39 HES, 2008/09; Department of Health and P2 People & Places © Beacon Dodsworth 2004–2009 www.p2peopleandplaces.co.uk and ONS mid-year (2008) population estimates. Analysed by: SWPHO

56

SWPHO


Figure 11.3: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (i)

2

Source: Data: NI39 HES, 2008/09; Department of Health and P People & Places © Beacon Dodsworth 2004–2009 www.p2peopleandplaces.co.uk and ONS mid-year (2008) population estimates. Analysed by: SWPHO

57

SWPHO


Figure 11.4: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (ii)

2


58

SWPHO


Figure 11.5: The geographical distribution of the ten People and Places branches with the highest alcohol attributable hospital admission rates in the South West, 2008/09 (iii)

2


59

SWPHO


12.

Analysis of individuals

12.1

Individuals by age and sex Except for alcohol specific hospital admissions, the number of alcohol attributable hospital admissions differs from the number of individuals actually admitted to hospital due to alcohol. This is due to the application of alcohol-attributable fractions (AAF) where alcohol specific conditions have an AAF of 1 and alcohol related conditions have an AAF of less than 1, as previously described in Section 1.3. Figure 12.1 shows the age distribution of the individuals who completed an admission for alcohol attributable conditions during 2008/09 in the South West. Figure 12.2 shows the contribution each of these age groups made to the overall alcohol attributable admission figures. Figure 12.1: Age and sex breakdown of individuals included in the NI39 calculation (% of all individuals), South West, 2008/09


60

SWPHO


Figure 12.2: Percentage contribution to alcohol attributable hospital admissions by age and sex, South West, 2008/09


These figures highlight that the majority of hospital admissions attributable to alcohol, completed in 2008/09, occurred in later life. This is likely to be as a result of long-term alcohol misuse and suggests that, as the percentage of the population aged over 50 increases, the burden of alcohol attributable admissions on the NHS is likely to increase. However, a comparison of figures 12.1 and 12.2 also suggests that, although the number of individuals admitted for alcohol attributable conditions had an elderly demographic (Figure 12.1), the contributions made by younger age groups, especially the 55–79 year-old age groups to the overall NI39 rates (Figure 12.2) were substantial, especially for males. Further evidence of the differential effect of age and sex-specific AAFs is provided by the fact that although females made up a larger proportion of the individuals (52.8%), they only contributed 38.5% to alcohol attributable hospital admissions (NI39) completed during 2008/09. There are a variety of reasons for this, one of which is that men contribute more to alcohol specific admissions, (i.e. those with an AAF of 1) than women, (see Tables A7 and A8 in the Appendix), suggesting that higher numbers of women being admitted, especially in older age is predominantly due to the age demographic of the South West (which has a higher than average older population and considerably higher numbers of women in the oldest age groups) and the age profile of the conditions included in alcohol attributable alcohol admissions. The data also show that:



227,074 individuals completed an admission for an alcohol attributable condition during 2008/09 in the South West;



for males, the percentage contribution to alcohol attributable admissions peaked in those aged 60–64 years (7.4%), while for females rates were highest in those aged 85 years and older (5.1%).



except in the age groups 0–14, 15–19 and 85 years and above, men accounted for more alcohol attributable admissions than women.

61

SWPHO




the age distribution of alcohol specific admissions was younger than the age profile for all alcohol attributable admissions (see figure 4.1);

Tables A3 and A4 (in the Appendix) show these breakdowns in greater detail.

13. 13.1

Analysis by cause of admission Hospital admission by cause Analysis has been carried out on the conditions which contribute most to the total alcohol attributable admissions. The following analyses (Figure 13.1 and Table 13.1) show the distribution of hospital admissions completed during 2008/09 in the South West by cause. The data show that:



the leading cause of admission was hypertensive disease with 34,275 alcohol attributable admissions accounting for 34.8% of all NI39 admissions;



the second largest cause for all alcohol attributable admissions was cardiac arrhythmias, accounting for 20.1% of admissions;



other top contributors to alcohol attributable admissions were mental and behavioural disorders due to use of alcohol (14.4%), epilepsy and status epilepticus (7.4%), and alcoholic liver disease (4.1%);



ethanol poisoning accounted for 3% of alcohol attributable admissions and fall injuries 2.8%;

Figure 13.1 Breakdown of alcohol attributable admissions by cause, South West, 2008/09

Note. Conditions included are those which contribute at least 0.5% of the total NI39 admissions Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

62

SWPHO


Table 13.1: Top ten causes of alcohol attributable hospital admissions in the South West, 2008/09

Cause of Admission Hypertensive diseases

Percentage All Percentage of NI39 of NI39 Admissions Individuals all Individuals Admissions Admissions 179,075

110,812

48.8

34,275

34.8

Cardiac arrhythmias

69,936

44,010

19.4

19,803

20.1


14,146

9,898

4.4

14,146

14.4

Epilepsy and status epileptics

13,756

8,341

3.7

7,251

7.4


3,999

1,830

0.8

3,999

4.1

Ethanol poisoning (Toxic effect of ethanol)

2,992

2,393

1.1

2,992

3.0

Fall Injuries

27,876

19,295

8.5

2,716

2.8

Intentional self-harm/event of undetermined Intent

6,154

4,339

1.9

2,078

2.1

Malignant neoplasm of breast

21,969

4,736

2.1

1,716

1.7

1,795

826

0.4

1,103

1.1

Chronic hepatitis


13.2

Admissions by cause and sex Figures 13.2 and 13.3 show, for both male and female alcohol attributable hospital admissions completed during 2008/09, conditions that contribute at least 0.5%. The data show that:



for males, the five leading causes of alcohol attributable admissions are hypertensive diseases (37.1%), cardiac arrhythmias (19.4%), mental and behavioural disorders due to use of alcohol (16.7%), malignant neoplasm of the oesophagus (5.8%) and epilepsy and status epilepticus (5.7%).



the pattern is the similar for females, with hypertensive diseases (31.1%), cardiac arrhythmias (21.2%), mental and behavioural disorders due to use of alcohol (10.6%), epilepsy and status epilepticus (10%) and malignant neop lasm of the breast (4.5%) being the leading causes of admission.

Tables A5 and A6 (in the Appendix) show a more detailed comparison of the top 10 contributors to alcohol attributable admissions for males and females. These highlight the overall contributions for each sex to the overall alcohol attributable rates.

63

SWPHO


Figure 13.2: Top 15 causes of alcohol attributable hospital admissions in males, South West, 2008/09


Figure 13.3: Top 15 causes of alcohol attributable hospital admissions in females, South West, 2008/09


13.3

Admissions by cause, age, and sex The top five causes that contributed most to NI39 for 2008/09 were hypertensive disease, cardiac arrhythmias, mental and behavioural disorders due to use of alcohol, epilepsy and status epilepticus and alcoholic liver disease. These are broken down by cause, age and sex and are shown in Figures 13.4 (males) and 13.5 (females).

64

SWPHO


Figure 13.4: Percentage breakdown of alcohol attributable admissions by age and cause, for top five causes, males, South West, 2008/09


Figure 13.5: Percentage breakdown of alcohol attributable admissions by age and cause, for top five causes, females, South West, 2008/09


When these five conditions are compared, the age profile in both sexes shows more contributions from younger age groups in mental and behavioural disorders due to use of alcohol and epilepsy and status epilepticus, than either hypertensive disease or cardiac arrhythmias, whilst alcoholic liver disease peaks in the 40-49, 50-59 and 60-69 age groups. For males, the combined 0–49 age group contributed 59.1% towards mental and behavioural disorders due to use of alcohol admissions and 41% towards epilepsy and status epilepticus admissions, which is substantial when compared to the 7.2% contribution for hypertensive diseases and 4.4% for cardiac arrhythmias. Also, for females, the contributions of the combined 0–49 age group to mental and behavioural disorders due to use of alcohol admissions was

65

SWPHO


60.9%, epilepsy and status epilepticus 40.9%, whilst lower contributions from these age groups were observed for hypertensive diseases (5.6%) and cardiac arrhythmias (3.2%). These distributions may be as a result of the differential development of hypertensive disease and cardiac arrhythmias, which develop and are exacerbated over time. This compares to the shorter term impact of alcohol misuse on mental and behavioural disorders due to use of alcohol and epilepsy and status epilepticus, whilst alcoholic liver disease develops over the medium term. The main findings for each of the top four causes were: Hypertensive diseases



The age breakdown shows that admissions were highest in the 70–79 age group for males (31.1%) and the 80 years and above age group for females (34.0%).



In males, there was a gradual increase in the percentage of admissions with age, until a peak in the 70–79 age group. Whereas in females, there was a gradual increase in the percentage admitted, peaking in the oldest age groups.

Cardiac arrhythmias



There was an increase in admissions across the age groups until 80 years and above, in which there was the highest percentage of admissions in both males (38.3%) and females (57.3%).



For individuals there was an increase in admissions after the 40–49 age group for both sexes, with the 50 years and above age group contributing 95.6% of NI39 admissions in males and 96.2% in females.




For both sexes, there was a gradual increase in percentage of admissions until the 40–49 age group and then a decrease in admissions to the oldest age group (80 years and above).

Epilepsy and status epilepticus



The highest percentage of admissions were in the 60–69 age group (16.8%) for males and 80 years and above age group for females (16.4%).



The lowest percentage of admissions was in the 0–19 age group – 4.8% for males and 6.4% for females.



The percentage of admissions for both sexes are above 10% from the 20–29 age group onwards.

Alcoholic Liver Disease The highest percentage of admissions were in the 50-59 age group for males (30.8%) and 40-49 age group for females (28.9%). The lowest percentage of admissions was in the 20-29 age group for both males (0.5%) and females (1.6%). Admissions for individuals aged between 40 and 69 made up 80.2% of male and 79.3% of female admissions.

66

SWPHO

14.


Analysis by day of the week Analysis of alcohol attributable hospital admissions (NI39) by day of the week provides a further dimension of understanding. NI39 admissions completed during 2008/09, analysed by day of the week are shown in Figure 14.1, and by day of the week and admission method in Figure 14.2. Figure 14.1: Percentage breakdown of alcohol attributable hospital admissions (NI39) by day of the week, South West, 2008/09


67

SWPHO


Figure 14.2: Percentage breakdown of alcohol attributable admissions by day of the week and admission method, South West, 2008/09


The data show that:



Alcohol attributable hospital admissions were lower at the weekend, with Saturday and Sunday each contributing 7.2% of the total weekly admissions (as shown in figure 14.1). This is primarily because the majority of admissions are elective and occur during the week (95.8% of elective admissions). Overall admissions (emergency and elective combined) were highest on Monday and Tuesday.



The highest level of emergency admissions occurred on Mondays, (15.6% of weekly emergency admissions) although levels of emergency admissions were higher than elective admissions during the weekend (Saturday and Sunday, both 12.3%).



Emergency admissions via Emergency Medicine department were relatively constant throughout the week, whereas emergency admissions through other sources were higher on week days.

68

SWPHO

15.


Analysis by admission method (elective versus emergency admissions) The NHS data model (NHS Connecting for Health, 2011) defines an elective admission as “admission, when the decision to admit could be separated in time from the actual admission” and emergency admission as “admission when it is unpredictable and at short notice because of clinical need." Because emergency admissions are unplanned and can often require the reassignment of priorities and resources, it is necessary to have a comparison of alcohol attributable hospital admissions by admission method so that patterns of emergency admissions can be known and the impacts on services identified. Figures 15.1 and 15.2 and Tables 15.1, 15.2 and 15.3 provide a breakdown of emergency, elective and other admissions completed during 2008/09 in the South West. Figure 15.1: Percentage contribution to the total alcohol attributable admissions by the top ten causes of emergency admissions, South West, 2008/09


69

SWPHO


Table 15.1: Top ten emergency alcohol attributable admissions, South West, 2008/09

Cause of admissions

All All Percentage Emergency Percentage of emergency of all NI39 all NI39 admissions Individuals Individuals admissions admissions

Hypertensive diseases

71,240


12,033 43,117 8,601

Cardiac arrhythmias Epilepsy and status epilepticus Ethanol poisoning (toxic effect of ethanol) Alcoholic liver disease Fall injuries Intentional self-harm/event of undetermined intent Alcohol-induced chronic pancreatitis

47,592

21.0

13,086

13.3

8,650

3.8

12,033

12.2

29,595

13.0

11,912

12.1

5,441

2.4

4,470

4.5

2,987

2,391

1.1

2,987

3.0

2,541

1,215

0.5

2,541

2.6

21,106

16,491

7.3

2,068

2.1

6,033

4,281

1.9

2,038

2.1

568

267

0.1

568

0.6

Assault

1,920

1,723

0.8

518

0.5

Spontaneous abortion

2,346

2,096

0.9

511

0.5

730

338

0.1

433

0.4

188,061

129,628

57.1

55,987

56.9

Chronic hepatitis Total emergency admissions


Figure 15.2: Percentage contribution to the total alcohol attributable admissions of the top ten causes of elective admissions, South West, 2008/09


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Table 15.2: Top ten elective admissions, South West, 2008/09 Percentage Percentage of All elective of all Elective NI39 all NI39 Admissions Individuals Individuals Admissions Admissions

Cause of admissions Hypertensive diseases

101,852

61,679

27.2

20,234

20.6

22,389

13,111

5.8

6,719

6.8

4,356

2,599

1.1

2,374

2.4

1,751

1,139

0.5

1,751

1.8

20,146

4,221

1.9

1,587

1.6

Malignant neoplasm of oesophagus Malignant neoplasm of lip, oral cavity and pharynx

3,510

721

0.3

810

0.8

1,870

667

0.3

800

0.8

Fall injuries

5,639

2,098

0.9

534

0.5

Malignant neoplasm of colon

9,061

1,333

0.6

306

0.3

Cardiac arrhythmias Epilepsy and status epileptics Mental and behavioural disorders due to use of alcohol Malignant neoplasm of breast

Malignant neoplasm of rectum Total Elective Admissions

3,678

772

0.3

231

0.2

182,479

92,958

40.9

39,063

39.7


Table 15.3: Top ten admissions via other (general practitioner, consultant outpatient clinics etc), South West, 2008/09

Cause of Admission

All Percentage All NI39 Percentage of admissions of all admissions all NI39 via other Individuals Individuals via other admissions

Cardiac arrhythmias

4,430

1,305

0.6

1,172

1.2


5,983

1,541

0.7

955

1.0

Epilepsy and status epilepticus Mental and behavioural disorders due to use of alcohol

799

302

0.1

408

0.4

362

109

0.0

362

0.4


116

17

0.0

116

0.1

1,131

707

0.3

114

0.1

Haemorrhagic stroke

347

89

0.0

60

0.1

Psoriasis

Fall injuries

120

30

0.0

37

0.0

Chronic hepatitis

49

14

0.0

30

0.0

Spontaneous abortion

83

77

0.0

18

0.0

14,310

4,493

2.0

3,410

3.5

Total admissions via other


The data show that:



56.9% of all alcohol attributable hospital admissions were emergency admissions while 39.7% were elective admissions;



the remaining 3.4% were for categories such as general practitioner, consultant outpatient clinics, transfers and unknown;

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16.




hypertensive diseases were the most common reason for both emergency and elective admissions constituting 13.3% of emergency alcohol attributable hospital admissions and 20.6% of elective alcohol attributable hospital admissions;



the other leading causes of emergency alcohol attributable admissions were mental and behavioural disorders due to use of alcohol (12.2%), cardiac arrhythmias (12.1%), and epilepsy and status epilepticus (4.5%);



for elective admissions, the leading causes of of alcohol attributable admissions were cardiac arrhythmias (6.8%), epilepsy and status epilecticus,(2.4%) and mental and behavioural disorders due to use of alcohol.

Repeat admissions For definitions and the methodology used for calculating repeat admissions see Chapter 8 in Part 1 of this report.

16.1

All alcohol attributable repeat admissions (elective and emergency) The data were analysed based on how many times an individual was admitted. Cause and admission method (whether emergency or elective) of repeat admissions were also analysed. Figure 16.1 shows all individuals who completed an alcohol attributable hospital admission during 2008/09, and the number of times they were admitted. The data show that: of the 227,074 individuals who completed an admission for alcohol attributable conditions in 2008/09, 157,400 (69.3%) had only one admission; 54,488 (24%) had 2–3 admissions; 8,610 (3.8%) had 4–5 admissions, 4,554 (2.0%) had 6–10 admissions: and 2,022 (0.9%) were admitted 11 times or more.

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Figure 16.1: Percentage breakdown of individuals by number of admissions, South West, 2008/09


16.2

Repeat admissions by cause of admission In these analyses, the causes of repeat admissions completed during 2008/09 are considered. The most common reason for repeat admissions is hypertensive diseases which accounts for 100,907 of the 227,450 repeat admissions. This and the other top 10 causes of repeat admissions are shown in Figure 16.2 and Table 16.1. The data shows that 59.1% of all admissions completed during 2008/09 in the South West were repeat admissions. The data show that: For a number of the leading causes of repeat admissions, the vast majority of admissions were repeat admissions. These included malignant neoplasm of oesophagus (92.4%), malignant neoplasm of colon (91.7%), malignant neoplasm of rectum (91.5%) and malignant neoplasm of breast (90.0%). Apart from cancers, causes of repeat admissions which made substantial contributions to their overall admissions were alcoholic liver disease (77.9%), cardiac arrhythmias (63.6%) and hypertensive diseases (56.3%). The majority of these repeat admissions are likely to be planned (elective) and appropriate part of the treatment pathway. This is reflected in figure 16.2 which shows that the four leading causes of repeat admissions as a percentage contribution of all alcohol attributable admissions are cancers.

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Figure 16.2: Top ten causes of repeat admissions as a percentage contribution of all alcohol attributable admissions, South West, 2008/09


Table 16.1: Top ten causes of repeat admissions for alcohol attributable conditions, South West, 2008/09

Repeat admissions

Cause of admission Hypertensive diseases

Repeat admissions as a percentage of total admissions Total for the same admissions cause

100,907

179,075

56.3

Cardiac arrhythmias

44,445

69,936

63.6


19,780

21,969

90.0

Fall injuries

10,362

27,876

37.2


9,566

10,436

91.7

Epilepsy and status epilepticus Mental and behavioural disorders due to use of alcohol

8,652

13,756

62.9

7,422

14,146

52.5

Malignant neoplasm of oesophagus

4,204

4,550

92.4

Malignant neoplasm of rectum

3,807

4,159

91.5

3,117

3,999

77.9

227,450

384,850

59.1

Alcoholic liver disease All causes


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16.3


Alcohol attributable emergency repeat admissions The top ten causes of emergency repeat admissions completed in 2008/09 in the South West are shown in Figure 16.3 and Table 16.2. The data show that for six causes of admissions, emergency repeat admissions accounted for over 35% of the total admissions for that cause. These were:



alcoholic liver disease (48.6%);



mental and behavioural disorders due to use of alcohol (43.4%);



ethanol poisoning (40.8%);



epilepsy and status epilepticus (39.4%);



intentional self-harm/event of undetermined intent (39.3%);



cardiac arrhythmias (37.2% of all admissions for this cause).

Clearly these conditions account for a large number of hospital repeat admissions and have a significant impact on service capacity and cost. The development of clear treatment pathways between acute settings and community based settings can also be key to reducing repeat admissions. (Department of Health, 2009a) Figure 16.3: Alcohol attributable emergency repeat admissions for the top ten causes, as a percentage of total alcohol attributable admissions for that cause, South West, 2008/09


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Table 16.2: Top ten causes of emergency repeat admissions for alcohol attributable conditions, South West, 2008/09 Emergency repeat admissions as a Emergency percentage of repeat Total total admissions readmissions admissions for that cause

Cause of admission Hypertensive diseases

38,139

179,075

21.3

Cardiac arrhythmias Mental and behavioural disorders due to use of alcohol

26,048

69,936

37.2

6,142

14,146

43.4

Fall injuries

5,878

27,876

21.1


5,426

13,756

39.4

Intentional self-harm/event of undetermined intent

2,418

6,154

39.3


1,945

3,999

48.6


1,378

21,969

6.3


1,221

2,992

40.8

912

10,436

8.7

All causes 96,118 384,850 Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

25.0


17.

Bed days As detailed in Chapter 9, a hospital admission bed day is defined as an admission that lasts beyond midnight of the day of admission. A zero bed day is an admission that does not pass through midnight. They are an important consideration in managing patients, meeting targets and reducing costs.

17.1

Admissions with bed days The total number of bed days for all alcohol attributable admissions completed during 2008/09 in the South West was 1,272,439. Some admissions did not last beyond midnight on the day of admission. These are referred to as zero bed days. (See next section 17.2 for details). Figure 17.1 and Table 17.1 provide a breakdown of bed days by cause and Table 17.2 by Local Authority in the South West for those alcohol attributable admissions completed during 2008/09.

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Figure 17.1: Percentage of alcohol attributable bed days for the top ten causes, South West, 2008/09


Table 17.1: Top ten causes of alcohol attributable admissions resulting in bed days, South West, 2008/09

Cause of admission

Percentage NI39 of all bed Total number admissions Bed days days Individuals of admissions with bed days


535,167

42.1

60,012

92,469

17,183

Cardiac arrrhythmias

331,502

26.1

30,700

47,422

13,161

Fall Injuries

138,840

10.9

13,368

17,350

1,692

Epilepsy and status epileptics

59,184

4.7

5,288

8,684

4,510


49,644

3.9

5,839

8,582

8,582


20,054

1.6

2,546

4,507

327


16,826

1.3

930

2,267

67

Haemorrhagic stroke

15,807

1.2

797

1,462

245


13,013

1.0

1,214

2,607

2,607

9,695

0.8

640

1,048

99

Ischaemic stroke All causes

1,272,439

100.0

133,926


77

205,681

55,238

SWPHO


Table 17.2: Alcohol attributable bed days by Local Authority, South West, 2008/09

Top tier local authorities

NI39 admissions Percentage of with bed all bed days Individuals days

Bed days

Devon

194,431

15.3

18,152

7,568


144,623

11.4

14,065

5,856

Somerset

143,633

11.3

13,393

5,359

Gloucestershire

131,411

10.3

14,301

5,850

Dorset

130,646

10.3

12,794

4,749

Wiltshire

104,544

8.2

11,300

4,279

Bristol

79,662

6.3

10,032

4,876

Plymouth

67,761

5.3

7,538

3,212


57,232

4.5

5,772

2,345

North Somerset

44,712

3.5

5,485

2,379


39,148

3.1

4,439

1,795

Swindon

38,159

3.0

4,197

1,764

Torbay

33,342

2.6

4,019

1,888

Poole

32,068

2.5

4,325

1,648

Bournemouth

30,778

2.4

4,062

1,621

Unallocated

289

0.0

52

48

South West

1,272,439

100.0

133,926

55,238

Note: Cornwall and the Isles of Scilly have been combined due to small numbers Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

The data show that:

17.2



a total of 1,272,439 bed days were used in the South West for all alcohol attributable hospital admissions completed during 2008/09;



the highest contribution to bed days was hypertensive diseases (42.1% of all bed days);



other top contributors were cardiac arrhythmias (26.1%), accidental falls (10.9 %) and epilepsy and status epilepticus (4.7 %);



combined, these conditions contributed 83.8% of all bed days;



across the South West, Devon had the highest number of alcohol attributable bed days, 194,431 (15.3% of all bed days in the South West), while Bournemouth had the fewest 30,778 (2.4%).

Admissions with zero bed days As detailed in Chapter 9, a zero bed day is an admission that does not pass through midnight. They are an important consideration in managing patients, meeting targets and reducing costs. Figure 17.2 and Table 17.3 provide a breakdown of zero bed days by cause and Table 17.4 by Local Authority in the South West, for those alcohol attributable admissions completed during 2008/09.

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Figure 17.2: Top ten causes of alcohol attributable admissions resulting in zero bed days (percentage), South West, 2008/09


Table 17.3: Top ten alcohol attributable zero bed days by cause, South West, 2008/09

Cause of admission

NI39 Percentage admissions Zero bed of all zero with zero bed days bed days Individuals Days


86,606

48.3

50,800

17,092

Cardiac arrhythmias

22,514

12.6

13,310

6,642


17,462

9.7

2,190

1,390

10,526

5.9

5,927

1,024


8,169

4.6

953

280


5,564

3.1

4,059

5,564


5,072

2.8

3,053

2,741

Malignant neoplasm of rectum

3,167

1.8

546

202

Malignant neoplasm of oesophagus Intentional self-harm/event of undetermined intent

2,925

1.6

627

674

2,892

1.6

2,094

985

179,169

100.0

Fall Injuries

All causes

93,148


79

43,222

SWPHO


Table 17.4: Zero bed days by Local Authority, South West, 2008/09

Top tier local authorities

NI39 Percentage of admissions all zero bed with zero days Individuals bed days

Zero bed days

Devon

25,890

14.5

12,073

6,512

Gloucestershire

24,372

13.6

10,540

5,085


18,580

10.4

10,349

4,787

Bristol

17,739

9.9

9,310

4,790

Somerset

17,210

9.6

9,718

3,917

Wiltshire

12,695

7.1

7,956

3,165


10,499

5.9

5,536

2,436

Dorset

10,136

5.7

5,720

2,245

North Somerset

9,227

5.1

4,775

2,198

Plymouth

8,933

5.0

4,928

2,224

Bournemouth

6,373

3.6

2,362

1,142

Torbay

5,166

2.9

2,342

1,453

Swindon

4,769

2.7

2,596

1,189


4,563

2.5

2,896

1,184

Poole

2,965

1.7

2,011

855

Unallocated

52

0.0

36

38

South West

179,169

100.0

93,148

43,222

Note: Cornwall and the Isles of Scilly have been combined due to small numbers Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

The data show that:

18.



overall, there were 179,169 zero bed days;



hypertensive diseases made up 48.3% of these;



other conditions with the leading number of zero bed days were cardiac arrhythmias (12.6%) and malignant neoplasm of breast (9.7%);



across the South West, Devon had the highest number of zero bed days, 25,890 (14.5%), while Poole had the lowest number, 2,965 (1.7%).

Discussion and conclusions This report has provided detailed evidence about the rate and complexity of alcohol attributable hospital admissions in the South West. It has shown that despite lower rates than England as whole, local areas in the South West have substantial and serious issues to address regarding admissions to hospital which are wholly or partially attributable to alcohol.

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It has shown that considerable inequality exists in alcohol attributable hospital admission rates in the South West. These inequalities exist by geography, age, sex, deprivation and geodemographic segmentation groups. Analysis of alcohol attributable hospital admissions by cause, age and sex provides essential evidence to support the targeting of particular interventions and services. The Department of Health has identified a number of high impact changes (Department of Health, 2009b) that can be employed to achieve a reduction in admissions. These include employing Alcohol Health Workers and Alcohol Liaison Nurses in all acute hospitals to manage patients with alcohol problems and to liaise with community services. This approach has been shown to prevent unnecessary admissions, encourage better patient education and improve clinical practice. These and other interventions should be considered within the context of local need, outcome priorities and existing service provision. A number of key points of interest have been identified and include:



significant levels of alcohol attributable harm exist in the South West and have increased in all areas between 2002 and 2009.



the greater burden of alcohol health harms are evident in the most deprived areas of the region and the association between deprivation and hospital admissions was stronger in alcohol specific conditions than alcohol attributable conditions;



the sub-groups „Hard to Let‟, „Impoverished Elders‟ and „Cramped Flats‟ had the highest rates of both alcohol specific and alcohol attributable admissions;



overall alcohol attributable hospital admissions are significantly more common among older age groups, particularly in females, suggesting that higher numbers of females being admitted, especially in older age is predominantly due to the age demographic of the South West (which has a higher than average older population and considerably higher numbers of women in the oldest age groups);



there are notable exceptions where alcohol attributable hospital admissions among young people are high;



more men than women are admitted to hospital due to alcohol misuse, with some notable exceptions for certain alcohol specific conditions, including ethanol poisoning, where more women are admitted than men.



For ethanol poisoning in particular of important note is the considerably higher numbers of young females aged 15-24 than males in any age group, being admitted for this cause.

Understanding these and other variations is a key step in enabling those responsible for designing and implementing alcohol services and interventions to target resources appropriately to achieve good outcomes and best value. As health and other public services move through a period of significant change, particularly in relation to the commissioning of services, it is vital that intelligence and evidence such as that presented in this report is used to enhance efforts to reduce alcohol attributable hospital admissions and significant health harms caused by alcohol misuse.

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Glossary Alcohol attributable hospital admission: a hospital admission for which alcohol has been identified as a contributory factor. It could either be an alcohol related hospital admission or alcohol specific hospital admission. Alcohol specific hospital admission: a hospital admission for which the cause of admission is classified as wholly related or specifically related to alcohol, such as ethanol poisoning and alcoholic liver disease. Also, the alcohol-attributable fraction is 1. Alcohol related hospital admission: a hospital admission for which the cause of admission is related to alcohol use, among other factors, e.g. hypertensive disease and cardiac arrhythmias. The alcohol-attributable fraction here is less than 1. Alcohol attributable fractions (AAF): values ranging from -0.26 to 1, used to show how much alcohol contributes to a health outcome. They are calculated for conditions for which there is a known causal association with alcohol. People and Places Segmentation Tool: a geodemographic tool that uses income data to classify people into clusters. Crude rates: a measure of overall frequency which has not been adjusted for factors which might have influenced the rate. It is normally calculated by dividing the number of observations/events by the appropriate population. It normally refers to a specific period of time. Standardised rates: the rate for which its calculation took into consideration the particular underlying characteristics of the population, such as age and sex. This makes it suitable to be used to compare with other populations of differing structure. Deprivation quintile: a division of an area into five parts using deprivation measures such as income, crime, housing etc. Confidence intervals: a range of values round a point estimate that shows where the true value is likely to lie. Hospital Episode Statistics (HES): the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. Each HES record is classified using the International Classification of Disease, 10th Revision (ICD10). This enables each record to be identified according to the type of disease or other health condition. Each record may have more than one ICD10 code. For example, when treating someone for heart disease who also has diabetes, diabetes should be recorded as, although it is not the main reason for the current period of care, it is an important factor in managing the heart condition. International Classification of Disease, 10th Revision (ICD10): the international standard diagnostic classification for all general epidemiological and clinical use, and many health management purposes. For further details on the ICD10 classification visit http://www.who.int/classifications/icd/en/.

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Lower Super Output Area (LSOA): area that has a minimum population of 1,000, with an overall mean of 1,500. There are 34,000 LSOAs in England and Wales. Middle Super Output Area (MSOA): area with a minimum population of 5,000 and overall mean of 7,200. Built from groups of LSOAs and constrained by the Local Authority boundaries of 2003, there are 7,000 MSOAs in England and Wales.

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References Royal College of Psychiatrists (AL 49). (2009, April 23). Retrieved September 09, 2010, from www.parliament.uk: Memorandum by the Royal College of Psychiatrists (AL 49): http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/368/368we 50.htm Crawford, M. E. (2004). Screening and referral for brief intervention of alcohol misusing patients in an Emergency Department: a pragmatic randomised controlled trial. The Lancet , 364:1334-1339. Department of Health. (2008a, November 04). Retrieved October 12, 2010, from The Cost of Alcohol Harm to the NHS in England: http://www.alcohollearningcentre.org.uk/Topics/Browse/Policy/?parent=4441&child =4652 Department of Health. (2008b). Retrieved from Hospital admissions for alcohol related harm,Technical Information and Definition for Vital Signs: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitala sset/dh_086417.pdf Department of Health. (2009a, December). Retrieved December 2010, from Local Routes: Guidance for Developing Alcohol Treatment Pathways: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitala sset/dh_110422.pdf Department of Health. (2009b, July). Retrieved December 2010, from Signs for improvement – Commissioning Interventions to Reduce Alcohol Related Harm: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitala sset/dh_104854.pdf Harris R, S. P. (2005). Geodemographics, GIS and Neighbourhood Targeting. London: Wiley. Jones L, B. M. (2008). Alcohol attributable fractions for England: Alcohol attributable mortality and hospital admissions. Centre for Public Health, Liverpool John Moores University. NHS Connecting for Health. (2010). Retrieved December 2010, from Elective Admission Type/ Admission Method: http://www.connectingforhealth.nhs.uk/systemsandservices/data/nhsdmds/faqs/cds /admitpat/eltype The Health and Social Care Information Centre. (2010, May 26). Retrieved September 09, 2010, from Statistics on Alcohol: England: http://www.ic.nhs.uk/webfiles/publications/alcohol10/Statistics_on_Alcohol_Englan d_2010.pdf

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Appendix: Additional tables Table A1: Alcohol attributable fractions (AAFs) for hospital admissions

Source: Hospital Admissions for alcohol-related harm: Technical Information and Definition, December 2008

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Table A2: People and Places branch definitions People and Places branch name A01. Worldly Horizons:

A02. Provincial Haves: A05. Established Prosperity: A06. Ripened Success: B04.Rural Comfort: B09. Harder Pastures: C03.Thriving Families: C07.Contented Families: C12. Developing Families:

D11. Matrimonial Homes: D13. Established Couples: D14. Multicultural Families:

Definitions Older adults and pensioners, wealthy and married from a diverse mix of ethnic backgrounds. Older adults, mostly married couples and highly qualified. They include pensioners below the age of 74. Older adults and pensioners, mostly married and well qualified and maybe employers or self-employed. Older adults of a non-pensionable age and well qualified. Affluent older adults married and may be self-employed. Older adults and skilled manual workers who may be working in agriculture. Predominantly married couples with children, well qualified, with many working in utility industries. Older adults with children, mostly aged between 35 and 54, mostly professionals. Families made up of young couples and young children. They are qualified and work as professionals. Middle-aged married couples, aged between 35 and 54 and may be working as skilled manual workers particularly in the manufacturing industry. Older adults and pensioners, living as couples, may be retired or working in utilities industry. Families from a diverse mix of ethnic backgrounds, well qualified and work in the utility industries. Consist of adults aged between 25 and 54, may be married or co-habiting and work mainly as skilled manual workers.

D15. Skilled Workers: E08. Urban Professionals: E18.Capital Apartments:

Young adults aged between 16 and 34, with no children, highly qualified and work in well paid occupations. Young adults who live in flats in the capital and are highly qualified. Mainly consists of pensioners, aged 75 and over, some living alone.

F10.Richer Retired Pensioners, particularly those with assets, and may be living alone. F16. Asseted Greys: Mainly pensioners (may include adults aged between 55 and 65) and may be living alone. F20. Mature Mobility: Young adults aged between 25 and 34, from a variety of occupations. G17. Aspiring Streets: G19. Co-habiting Suburbs: G21.Mature Satisfaction:

Mainly adults, aged between 25 and 34, co-habiting, and probably employed in utility and manufacturing industries. Pensioners, 75 and over and may be alone. Families made up of young adults (aged between 16 and 34 and maybe 35 to 54) with no qualifications and working as unskilled, semi-skilled and skilled manual labour

G23. Routine Families: H22.Students in the Community:

Students living within a community of a city and mostly young people. Young adults aged between 16 and 34, well qualified and working in professional or managerial roles.

H25. Working Singles: H26. Student Life:

Young adults aged between 16 and 34 and may be working in white collar

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occupations.

I24. Cultural Enterprise: I33: Multicultural Key Workers:

Rich, ethnically diverse, well qualified, working in higher managerial or professional positions. Less affluent than Cultural Enterprise, with no qualifications and tend to work as semi-skilled and unskilled labour Young adults aged between 16 and 34, with no qualifications and many working as semi-skilled manual and unskilled labour.

J27. Limited Labour: J28. Manufacturing Pride:

Young families (with parents aged 16 and 34) with many working as semiskilled or unskilled labour. Young adults aged between 16 and 32, with no qualifications living in council terraces. Unemployment exists within this group.

J30. Council Terraces: Families where parents are young adults with no qualifications. Unemployment is high within this group. J34. Young Parents: K29. Blue Collar Elders:

K31. Struggling Single Parents:

K36. Sheltered Singles:

Elders, aged 75 and above, living alone, employed as blue collar workers. Single parent families (parents may be aged between 16 and 24), in council accommodation, with no qualification and working in routine and semi-routing occupations. Single households, mostly lone pensioners, aged over 70 and maybe working in routine and semi-routine occupations and have no qualifications. Parents aged between 16 and 34, with children, and no qualifications. May be working in routine and semi routine occupations.

L32. Assisted families: Young parents aged between 25 and 34, have no qualifications and work in routine and semi-routine occupations. Unemployment is high here. L39. Rootless families: M35. Impoverished Elders:

Pensioners, 75 and above, poor and renting accommodation from the council. Mix of young adults, aged 16 to 24, with children and no qualification and working in semi-skilled and unskilled jobs.

M38: Hard to Let: Occupied by young adults between 16 and 24. Working as single workers or single parents, in semi skilled, manual and unskilled jobs. Unemployment may be high as are incidences of long term sickness. M40. Cramped Flats: Source: P2 People & Places © Beacon Dodsworth 2004–2009 www.p2peopleandplaces.co.uk

87

SWPHO


Table A3: Overall contribution to alcohol attributable hospital admissions (NI39), South West, 2008/09 Males by age Total Percentage Number of number of Number of of all NI39 Age group admissions Individuals Individuals admissions 0-14

Percentage of all NI39 admissions

72

71

0.0

72

0.1

15-19

2,628

2,288

1.0

1,128

1.1

20-24

3,463

2,862

1.3

1,617

1.6

25-29

3,086

2,414

1.1

1,544

1.6

30-34

3,015

2,198

1.0

1,628

1.7

35-39

4,292

3,016

1.3

2,306

2.3

40-44

5,748

3,701

1.6

3,059

3.1

45-49

7,265

4,569

2.0

3,753

3.8

50-54

8,742

5,313

2.3

4,114

4.2

55-59

12,733

7,388

3.3

5,272

5.4

60-64

19,466

11,055

4.9

7,255

7.4

65-69

21,157

11,494

5.1

6,366

6.5

70-74

24,182

13,305

5.9

7,125

7.2

75-79

24,153

13,749

6.1

5,763

5.9

80-84

20,883

12,065

5.3

4,980

5.1

85+

19,499

11,684

5.1

4,582

4.7

All ages 180,384 107,172 47.2 60,566 61.5 Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

Table A4: Overall contribution to alcohol attributable hospital admissions (NI39), South West, 2008/09 Females by age Total Percentage Number of Percentage number of of all NI39 of all NI39 Age Band admissions Individuals Individuals admissions admissions 0-14

122

120

0.1

122

0.1

15-19

2,513

1,969

0.9

1,199

1.2

20-24

2,915

2,304

1.0

1,208

1.2

25-29

2,905

2,189

1.0

1,081

1.1

30-34

3,529

2,374

1.0

1,222

1.2

35-39

5,044

3,002

1.3

1,705

1.7

40-44

6,860

3,568

1.6

2,166

2.2

45-49

9,019

4,053

1.8

2,415

2.5

50-54

10,308

4,967

2.2

2,555

2.6

55-59

12,809

6,464

2.8

2,662

2.7

60-64

17,627

9,292

4.1

3,575

3.6

65-69

17,989

10,254

4.5

2,861

2.9

70-74

21,113

12,472

5.5

3,407

3.5

75-79

26,041

15,653

6.9

3,277

3.3

80-84

27,076

16,788

7.4

3,431

3.5

85+

38,596

24,433

10.8

5,009

5.1

204,466

119,902

52.8

37,894

38.5

All ages


88

SWPHO


Table A5: Top ten causes of alcohol attributable admissions for males, South West, 2008/09

Cause of Admission

NI39 Admissions

Percentage of Percentage all NI39 of all All Admissions Individuals Individuals Admissions


22,479

22.8

50,681

22.3

84,313

Cardiac Arrrhythmias

11,777

12.0

22,507

9.9

36,463


10,123

10.3

7,030

3.1

10,123


3,475

3.5

3,944

1.7

6,460


2,655

2.7

1,217

0.5

2,655

Fall injuries

1,596

1.6

7,085

3.1

9,990


1,311

1.3

1,021

0.4

1,311

Malignant neoplasm of oesophagus

823

0.8

656

0.3

3,134


771

0.8

1,645

0.7

2,242

Malignant neoplasm of lip, oral cavity and pharynx

765

0.8

499

0.2

1,589


Table A6: Top ten causes of alcohol attributable admissions for females, South West, 2008/09 Percentage Percentage NI39 of all NI39 of all All Admissions Admissions Individuals Individuals Admissions

Cause of Admission Hypertensive diseases

11,796

12.0

60,131

26.5

94,762

Cardiac Arrrhythmias

8,025

8.2

21,503

9.5

33,473


4,023

4.1

2,868

1.3

4,023


3,776

3.8

4,397

1.9

7,296


1,716

1.7

4,736

2.1

21,969


1,681

1.7

1,372

0.6

1,681


1,344

1.4

613

0.3

1,344


1,310

1.3

2,694

1.2

3,924

Fall injuries

1,121

1.1

12,210

5.4

17,887

Spontaneous abortion 734 0.7 2,981 Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

1.3

3,372

89

SWPHO


Table A7: Overall contribution to alcohol specific conditions, South West, 2008/09 Males by age

Total Age group admissions

Individuals

Number of Percentage alcohol Percentage of all of all specific alcohol specific individuals admissions admissions

0-4

Suppressed Suppressed Suppressed Suppressed

Suppressed

05-09


Suppressed

10-14

67

66

0.4

67

0.3

15-19

518

481

3.3

518

2.3

20-24

835

704

4.8

835

3.7

25-29

843

654

4.4

843

3.8

30-34

972

665

4.5

972

4.4

35-39

1,378

924

6.2

1,378

6.2

40-44

1,791

1,057

7.1

1,791

8.0

45-49

1,745

1,035

7.0

1,745

7.8

50-54

1,494

888

6.0

1,494

6.7

55-59

1,592

927

6.3

1,592

7.1

60-64

1,401

843

5.7

1,401

6.3

65-69

911

592

4.0

911

4.1

70-74

676

392

2.7

676

3.0

75-79

390

263

1.8

390

1.7

80-84

235

153

1.0

235

1.1

85+

118

95

0.6

118

0.5

All ages 14,971 9,744 65.9 14,971 67.1 Note: Small numbers have been suppressed in line with ONS guidelines. Therefore, the numbers in the columns, when added may not equal the totals shown. Source: Data: NI39 HES, 2008/09; Department of Health. Analysed by: SWPHO

90

SWPHO


Table A8: Overall contribution to alcohol specific conditions, South West, 2008/09 Females by age

Total Age group admissions

Individuals

Number of Percentage of Percentage alcohol all alcohol of all specific specific individuals admissions admissions

0-4


Suppressed

05-09


Suppressed

10-14

119

117

0.8

119

0.5

15-19

516

464

3.1

516

2.3

20-24

447

401

2.7

447

2.0

25-29

408

313

2.1

408

1.8

30-34

487

347

2.3

487

2.2

35-39

690

478

3.2

690

3.1

40-44

965

606

4.1

965

4.3

45-49

923

549

3.7

923

4.1

50-54

714

436

2.9

714

3.2

55-59

532

343

2.3

532

2.4

60-64

497

307

2.1

497

2.2

65-69

353

214

1.4

353

1.6

70-74

256

171

1.2

256

1.1

75-79

213

137

0.9

213

1.0

80-84

114

85

0.6

114

0.5

85+

103

70

0.5

103

0.5

7,340

5,041

34.1

7,340

32.9

All ages


91

About the South West Public Health Observatory The South West Public Health Observatory (SWPHO) is part of a network of regional public health observatories in the UK and Ireland. These were established in 2000 as outlined in the Government White Paper Saving lives: our healthier nation. Key tasks include: monitoring health and disease trends; identifying gaps in health information; advising on methods for health and health impact assessment; drawing together information from different sources; and carrying out projects on particular health issues. The SWPHO incorporates the National Drug Treatment Monitoring System South West (NDTMS-SW), and in April 2005 merged with the South West Cancer Intelligence Service (SWCIS). The SWPHO works in partnership with a wide range of agencies, networks and organisations regionally and nationally to provide ‘a seamless public health intelligence service’ for the South West. For more information about the SWPHO and its partner organisations, please visit www.swpho.nhs.uk Photograph on cover taken by: Ryan Gageler, Perth, Australia SWPHO is part of the UK & Ireland Association of Public Health Observatories.