Treatment of alcohol use disorder at discharge reduces risk for hospital return

Key takeaways:

• MAUD initiation at discharge reduced the incidence of all-cause mortality or return to hospital by 42%.
• There is a need to expand ongoing interventions and facilitate outpatient follow-up, an expert said.

The initiation of medications for alcohol use disorder, or AUD, at discharge reduced the incidence of several outcomes like hospital readmissions and ED visits, a study showed.

“We know from randomized trials that medications like naltrexone and acamprosate are effective treatments for AUD, but most of these trials are based in outpatient settings,” Eden Y. Bernstein, MD, a general internal medicine fellow at Massachusetts General Hospital, told Healio. “Health vulnerability experienced during acute illness may motivate behavior change, but these medications are rarely started during hospitalizations.”

Healio previously reported on a study that Bernstein and colleagues did last year that showed that only about 2% of patients start medications for AUD (MAUD) within 2 days of discharge.

“We wanted to know whether patients who start these medications on hospital discharge experience better clinical outcomes compared to those who do not,” Bernstein said.

The researchers assessed the effectiveness of MAUD at discharge by examining data from Medicare Part D enrollees who were hospitalized for AUD and discharged in 2016.

The study’s primary outcome was a composite of all-cause mortality or return to hospital within 30 days of discharge (this included hospital readmissions and ED visits).

The secondary outcomes were those outcomes examined separately, along with alcohol-related returns to the hospital and whether patients followed up with a primary care or mental health care provider within 30 days of discharge.

The cohort comprised 6,794 individuals (mean age, 54 years; 32.6% women), representing 9,834 alcohol-related hospitalizations.

Bernstein and colleagues found that the primary outcome occurred in 25.5% of hospitalizations that involved MAUD initiation at discharge and in 49.7% that did not.

Overall, MAUD initiation at discharge was associated with a 42% decreased incidence of the primary outcome (incident rate ratio [IRR] = 0.58; 95% CI, 0.45-0.76), for an absolute risk difference of –18% (95% CI, 0.26 to 0.11).

Initiation of MAUD at discharge was also associated with a reduced incidence of:

• all-cause ED visits (IRR = 0.57; 95% CI, 0.41-0.8);
• all-cause readmissions (IRR = 0.42; 95% CI, 0.27-0.63);
• all-cause return to hospital (IRR = 0.56; 95% CI, 0.43-0.73); and
• alcohol-related return to hospital (IRR = 0.49; 95% CI, 0.34-0.71).

According to the researchers, MAUD initiation increased the incidence of a primary care or mental health follow-up within 30 days of discharge (IRR = 1.22; 95% CI, 1.04-1.44). This outcome occurred in 43.6% of hospitalizations.

“The finding that less than half of patients in our study had a primary care or mental health follow-up within 30 days of discharge likely reflects the fact that these patients experience social and systemic barriers to health care access,” Bernstein explained. “Further research is needed to better understand these barriers and develop interventions to address them in this population.”

She added that she was surprised at the reductions in both ED visits and readmissions associated with MAUD initiation.

“When caring for hospitalized patients with AUD, physicians should consider initiating medication treatment, which may lead to meaningful improvements in short-term clinical outcomes after discharge,” she said.

According to the researchers, barriers to MAUD prescribing can include gaps in clinician knowledge, AUD stigma and concern about discharge follow-up, although past implementation efforts centered on AUD hospitalizations “have shown success.”

“We need to expand ongoing interventions and quality improvement efforts to increase prescribing on hospital discharge,” Bernstein explained.

The study had several limitations. For example, the results may not be generalizable to younger patients and those without disabilities, and “associations between medication receipt and outcomes should not be interpreted as causal” because of the study design, Bernstein said.

Still, the findings “highlight the importance of increased prescribing on hospital discharge,” she said.