Hospitals miss chances to cut deaths from alcohol related liver disease, report says

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f3781
  1. Susan Mayor
  1. 1London

A third of people admitted to hospitals in England, Wales, and Northern Ireland with known alcohol related liver disease are not referred for support to stop drinking as part of their care, warns a new report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).1 It recommends that all patients with a history of potentially harmful drinking be referred to alcohol support services.

“Many people with alcohol related liver disease have multiple admissions with this condition,” said Mark Juniper, consultant physician at the Great Western Hospitals NHS Foundation Trust, Swindon, and clinical coordinator for the report. “This gives clinicians an ideal opportunity to offer appropriate treatment and advice to patients to help them stop drinking and improve their future health. Unfortunately, this isn’t happening.”

For the report a multidisciplinary group of clinical advisers reviewed case notes of 385 patients who died in hospital with a diagnosis of alcohol related liver disease in the six months from 1 January to 30 June 2011. These represented samples of three patients from each of the 218 hospitals taking part in the study. The advisers also analysed questionnaires on clinical and organisational information concerning 512 patients against criteria that they considered represented good care.

The NCEPOD advisers found that less than half of patients (172/363 (47%)) received what they judged to be good care and identified 32 deaths that might have been avoided.

“This was a study of missed opportunities,” they said.

Most of the patients had been to hospital at least once in the two years before the admission during which they had died. But many patients had not been screened adequately for harmful use of alcohol. Even when harmful drinking was identified, more than a third of these patients (47/138) were not referred for support to stop drinking, despite most hospitals reporting to have alcohol liaison services.

Juniper said, “We know that abstinence works and that when simple advice is offered to patients one in eight will reduce their harmful drinking levels. That’s better than the results from stop smoking support services.”

The audit of questionnaires also showed that opportunities to carry out simple measures such as optimising fluid management and screening for or treating sepsis were often missed. “In a complex group of patients, specialist review would generally have been of benefit,” the authors suggested. But a quarter of patients (117/467) were never seen by a gastroenterologist or hepatologist during their admission.

To improve the prevention of alcohol related liver disease, the authors recommend that all patients who present to hospital services should be screened for their alcohol history. Patients presenting to acute services with a history of potentially harmful drinking should be referred to alcohol support services.

Each hospital should have a seven day alcohol specialist nurse service, with a skill mix of liver specialist and psychiatry liaison nurses to provide comprehensive physical and mental assessments, they suggest. This would enable each patient to receive brief interventions and access to services within 24 hours of admission for alcohol related liver disease.


Cite this as: BMJ 2013;346:f3781