Emergency services utilization by patients with alcohol-associated hepatitis: An analysis of national trends

Abstract

Background: Hospitalization and mortality in patients with alcohol-associated hepatitis (AH), a severe form of liver disease, continue to increase over time. Given the severity of the illness, most hospitalized patients with AH are admitted from the emergency department (ED). However, there are no data on ED utilization by patients with AH. Thus, the Nationwide Emergency Department Sample (NEDS) dataset was analyzed to determine the ED utilization for AH.

Methods: Temporal trends (2016-2019) and outcomes of ED visits for AH were determined. Primary or secondary AH diagnoses were based on coding priority. Numbers of patients evaluated in the ED, severity of disease, complications of liver disease, and discharge disposition were analyzed. Crude and adjusted rates were examined, and temporal trends evaluated using logistic regression with orthogonal polynomial contrasts for each year.

Results: There were 466,014,370 ED visits during 2016-2019, of which 448,984 (0.096%) were for AH, 85.0% of which required hospitalization. The rate of visits for AH (primary and secondary) between 2016 and 2019 increased from 85 to 106.8/100,000 ED visits. The rate of secondary AH increased more than the rate of primary AH (from 68.6 to 86.5 vs. from 16.4 to 20.3/100,000 ED visits). Patients aged 45-64 years had the highest rate of ED visits for AH, which decreased during the study period, while the rate of ED visits for AH increased in those aged 25-44 years (from 38.5% to 42.9%). The severity of disease (ascites, hepatic encephalopathy, and acute kidney injury) also increased over time. Medicaid and private insurance were the most common payors for patients seeking care in the ED for AH.

Conclusions: Temporal trends show an overall increase in ED utilization rates for AH, more patients requiring hospitalization, and an increase in the proportion of younger patients presenting to the ED with AH.

Keywords: Nationwide Emergency Department Sample; alcohol use disorder; alcohol-associated liver disease; emergency department; outcomes.

Fig 1.. Consort flow diagram of patient selection.

Frequencies presented are unweighted. AH: Alcohol-associated hepatitis; ED: Emergency department

Fig 2.. Yearly prevalence rate of all alcohol-associated hepatitis (AH)-related emergency department (ED) visits increased from 2016–2019.

A. Unadjusted and adjusted linear trend of all ED visits coded as AH from 2016–2019. p-value < 0.001 from 2016–2019. Circles represent unadjusted values. Line represents age and sex adjusted values which was performed using direct standardization with 2010 census data as the standard population with the age groups 18–24, 25–44, 45–64, and 65 years and older. Grey shading represents 95% confidence interval. AH: alcohol associated hepatitis. CI: confidence interval. B. Prevalence of primary and secondary AH-related ED visits increased from 2016–2019. A greater increase was seen in secondary AH. Linear trend p-value < 0.001 for both groups from 2016–2019. Singular shapes (circles and squares) represent crude rates, lines represent age and sex-adjusted rates with adjustments performed using direct standardization with 2010 census data as the standard population and the age groups of 18–24, 25–44, 45–64, and 65 years and older. Shaded area represents 95% CI.

Fig 3.. Greater rate of increase and yearly prevalence rates were seen in males with alcohol-associated hepatitis (AH)-related emergency department (ED) visits.

Line graph showing AH visits per 100,000 sex-specific ED-visits. Circles and squares represent crude rates, lines represent age and sex-adjusted rates generated using direct standardization with 2010 census data as the standard population with the following age groups: 18–24, 25–44, 45–64, and 65 years and older. Shaded area represents 95% confidence interval (CI).

Fig 4.. Metropolitan teaching hospitals had the highest yearly prevalence rate of alcohol-associated hepatitis (AH)-related emergency department (ED) visits.

Circles and squares represent crude rates, lines represent age and sex-adjusted rates performed using direct standardization with 2010 census data as the standard population with the age groups 18–24, 25–44, 45–64, and 65 years and older. Shaded area represents 95% confidence interval (CI).

Fig 5.. Yearly prevalence rate of emergency department (ED) visits for alcohol-associated hepatitis (AH) increased in every region with the highest rate of increase in the West.

Circles and squares represent crude rates, lines represent age and sex-adjusted rates performed using 2010 census data as the standard population with the age groups 18–24, 25–44, 45–64, and 65 years and older.