Alcohol-related injury visits: Do we know the true prevalence in U.S. trauma centres?
Introduction
Injury is the leading cause of death and disability for men and women under the age of 45 in the United States.21 The financial cost to society is enormous with an estimated $80.2 billion dollars in medical costs alone for the 50 million Americans who sustained an injury that required medical attention in the year 2000.11 Globally, there are approximately 5 million deaths attributed to injury every year, with an annual death rate that varies by region from 51.1 to 131.5 deaths per 100,000 population.26 In 2002, there were more worldwide deaths due to injury than the total number of deaths due to AIDS, TB or malaria.17 Even more devastating, across all mechanisms except fire-related injuries, injury disproportionately affects young males, the productive component of a society. The World Health Organisation has referred to injury as a “hidden epidemic among young men” that requires a global response to address its risk factors and causes.38
Clinicians practicing in acute-care settings, such as trauma centres, recognise that alcohol misuse is frequently associated with an injury admission. Many authors identify alcohol consumption as a significant risk factor for injuries.20, 1, 19, 37, 14, 35 One trauma centre study showed that, compared to patients without an alcohol-related admission, patients with an alcohol-related admission had more than twice the risk for a future injury event.10 The importance of alcohol misuse as a precursor to serious injury is widely accepted enough that in 2006 the American College of Surgeons Committee on Trauma introduced screening for problem drinking as a requirement for designation as a level I or II trauma centre.7 Moreover, level I trauma centres must provide an intervention for identified problem drinkers. Recent studies have shown that brief interventions significantly reduced post-injury problem drinking as well as the incidence of associated recurrent injury.30, 12 Therefore, as interventions are employed at trauma centres, a valid estimate of the magnitude of the problem is appropriate.
The prevalence of alcohol-related visits to U.S. emergency departments (EDs) has been estimated at about 9%.18 In the 2005 National Alcohol Survey, among those surveyed who reported an ER visit in the past year, 24% were positive for risky drinking (14+ drinks weekly for men and 7+ for females and/or 5+/4+ in a day in the last 12 months) and 8% for problem drinking.6 Injuries are the most common reason for an alcohol-related ER visit.3 Therefore, the prevalence for ED patients who present for injuries can be much higher.5 Because surgeons at trauma centres assess and treat only injured patients, they also probably serve a patient population in which the prevalence of alcohol-related visits is considerably higher than 9%. A variety of studies have estimated the prevalence of alcohol-related visits to trauma centres, but no study estimates the prevalence for all alcohol-related visits to U.S. trauma centres, or even for level I trauma centres. Trauma centres are currently experiencing financial constraints that limit their capacity to respond to the myriad of problems they encounter. Thus, an accurate estimate of alcohol-related visits is crucial for the appropriate allocation of limited resources and prevention services. A valid national estimate would supply that evidence and would also provide a benchmark for trends on intervention impact and facilitate appropriate planning and resource allocation.
The goal of this review is to evaluate the extent to which the English-language literature provides or can be used to calculate a valid estimate of the prevalence of alcohol-related visits to U.S. trauma centres.
Section snippets
Materials and methods
We reviewed the literature for studies of all patients who presented at U.S. trauma centres and were tested for pre-injury alcohol intake. A Medline search from 1966 to 2007 was performed using a complex set of title/abstract words and subject headings for each of the two main study concepts. The first set included alcohol, alcohol drinking, alcoholism, and ethanol; and the second included wounds and injuries, trauma, injury, emergency, and accidents. We excluded articles having terms such as
Results
Fifteen studies met our inclusion criteria but focused on significantly different target populations.33, 29, 28, 27, 15, 4, 16, 36, 25, 32, 8, 34, 9, 2, 31 Two studies included only patients dead on the scene or dead at arrival. The remaining fourteen included only admitted trauma patients. Of these, four studies required patients to be hospitalised for 2 or more days, two of which included patients only if they had intact cognition. No studies included “all-comers”, that is an estimate that
Discussion
Our aggregate estimate of alcohol-related visits to trauma centres is 32.4%. Although this may be a reasonable initial estimate of alcohol-related visits to U.S. trauma centres, it is subject to a number of limitations, an understanding of which will inform an accurate interpretation. This estimate is subject to variability in three different domains: the population covered by the studies, the thresholds used to identify the “alcohol relatedness” of the visit, and the quality of study methods
Conclusion
The current literature does not yield a valid estimate for the prevalence of alcohol-related injury admissions to trauma centres in the U.S. For a variety of reasons, the aggregate prevalence estimate of 32.5% calculated from the reviewed studies could be a significantly large under- or over-estimate. None of the studies provided an estimate for the complete population of trauma centre patients. The lack of a methodologically valid prevalence estimate hinders efforts to devise appropriate
Conflict of interest
The authors would like to confirm that they have no conflict of interest, personal, financial or otherwise, that would inappropriately influence their work.
Acknowledgements
The authors would like to thanks Karl Woodworth MLn, Head Librarian of the Woodruff Health Sciences Library, Grady Campus, Emory University School of Medicine for his assistance in performing the literature search.
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