BACKGROUND/RATIONALE:
Severe alcohol misuse (drinking over 4 standard-sized US drinks) has been associated with 2- to 5-fold increases in adverse surgical outcomes, including post-operative (post-op) complications and mortality. Moreover, 4 weeks of preoperative abstinence from drinking decreased the risk of post-op complications in a Danish randomized controlled trial, but there is a need for a practical approach to identify patients at risk for alcohol-related post-op complications at least 4 weeks preoperatively.

OBJECTIVE(S):
The specific aims of this project were to: (1) to estimate the proportion of VA major non-cardiac surgery patients who screen positive for alcohol misuse in the year before surgery, and (2) to determine whether there is an association between the severity of alcohol misuse and the prevalence of post-op complications or (3) death in the 30 days post-op.

METHODS:
This retrospective cohort study included VA outpatients who completed the AUDIT-C alcohol screening questionnaire on the VA's mailed Survey of Health Experiences of Patients (SHEP) during fiscal years 2004-2006 and had major non-cardiac inpatient or outpatient surgery in the subsequent year assessed by the VA's National Surgical Quality Improvement Program (NSQIP). The study used secondary data from the SHEP, the NSQIP, and VA National Patient Care Databases. Descriptive analyses estimated gender-specific screening prevalence rates of alcohol misuse (AUDIT-C >= 5). To evaluate the association between AUDIT-C scores and surgical outcomes, random effects logistic regression was used to model the adjusted prevalence of alcohol-related surgical complications and death in the 30 post-op days, among patients who screened positive for mild, moderate, or severe alcohol misuse (AUDIT-C scores 5-8, 9-10, 11-12, respectively), compared to patients with low-level drinking (AUDIT-C scores 1-4), adjusting for demographics, smoking, time from screening to surgery and accounting for correlated data from surgeries at the same VA facility.

FINDINGS/RESULTS:
A total of 9,771 men and 513 women were eligible for prevalence analyses, with the prevalence of alcohol misuse 16% (95 % CI 16-17%) and 5% (3-7%) in men and women, respectively. Among men, rates of alcohol misuse were significantly increased in those who were young, unmarried, or who smoked, had previous alcohol or smoking-related diagnoses or underwent surgical procedures for smoking or alcohol-associated conditions (e.g. peripheral vascular disease and head and neck tumors). Among women, those who reported never marrying, and those who currently smoked or had diagnoses of cirrhosis, hepatitis or substance use disorders had significantly increased prevalence of alcohol misuse. Among men who drank, the adjusted prevalence of 30 day post-op complications increased as AUDIT-C scores increased: 5.5% (95% CI 4.8-6.6%); 7.9% (6.3-9.7%), 9.7% (6.6-14.1%) and 14.0% (8.9-21.3%) among patients with low-level drinking, and mild, moderate and severe alcohol misuse, respectively. The same general dose-response pattern was observed for three subtypes of complications: surgical site complications, non-surgical site infections, and cardiopulmonary complications. Mortality was not significantly increased among patients with alcohol misuse, but the number of deaths was small (N 84) and most patients who died (N 52) were nondrinkers.

IMPACT:
The VA screens 97% of outpatients annually for alcohol misuse with the AUDIT-C and this study showed that among men, results of AUDIT-C screening up to a year prior to surgery were associated with increased post-op complications. AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative assessment templates in CPRS, to alert clinicians to alcohol misuse at the time of referral to surgery. Further research is needed to identify the optimal approaches to supporting patients in decreasing their drinking and to determine whether such interventions decrease alcohol-related surgical risks in male VA patients. In the meantime, patients with AUDIT-C scores of 5 or more should have their drinking re-assessed at the time of referral for surgery, and those who screen positive can be advised that research suggests that drinkers who abstain for the 4 weeks before surgery lower their risk for surgical complications.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Harris AH, Frey MS, DeBenedetti A, Bradley KA. Alcohol Misuse and Related Post-Operative Complications in US Surgical Patients: A Review. Open Surgery Journal. 2008 Nov 8; 2(1):50-58. [view]
2. Bradley KA, Rubinsky AD, Sun H, Bryson CL, Bishop MJ, Blough DK, Henderson WG, Maynard C, Hawn MT, Tønnesen H, Hughes G, Beste LA, Harris AH, Hawkins EJ, Houston TK, Kivlahan DR. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. Journal of general internal medicine. 2011 Feb 1; 26(2):162-9. [view]
3. Rubinsky AD, Sun H, Blough DK, Maynard C, Bryson CL, Harris AH, Hawkins EJ, Beste LA, Henderson WG, Hawn MT, Hughes G, Bishop MJ, Etzioni R, Tønnesen H, Kivlahan DR, Bradley KA. AUDIT-C alcohol screening results and postoperative inpatient health care use. Journal of the American College of Surgeons. 2012 Mar 1; 214(3):296-305.e1. [view]
4. Harris AH, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. The Journal of Bone and Joint Surgery. 2011 Feb 16; 93(4):321-7. [view]
5. Bradley KA, Rubinsky AD, Sun H, Blough DK, Tønnesen H, Hughes G, Beste LA, Bishop MJ, Hawn MT, Maynard C, Harris AS, Hawkins EJ, Bryson CL, Houston TK, Henderson WG, Kivlahan DR. Prevalence of alcohol misuse among men and women undergoing major noncardiac surgery in the Veterans Affairs health care system. Surgery. 2012 Jul 1; 152(1):69-81. [view]

Journal Other

1. DeBenedetti AF, Maynard C, Bishop MJ, Schifftner TL, Hughes G, Todd-Stenberg J, Sun H, Henderson WG, Beste LA, Harris AH, Hawkins EJ, Kivlahan DR. Prevalence of alcohol misuse among VA patients undergoing major surgery. [Abstract]. Alcoholism, clinical and experimental research. 2008 Jul 15; 32(1S):200A. [view]
2. Beste LA, Sun H, Maynard CC, Bishop MJ, Henderson W, Schiftner T, Hughes G, Todd-Stenberg J, Kivlahan DR, Hawkins EJ, Harris A, DeBeneditti A, Bradley KA. Prevalence of alcohol misuse in patients undergoing common surgeries in VA. [Abstract]. Journal of general internal medicine. 2008 Jul 15; 15(23):177. [view]

Conference Presentations

1. Bradley KA, Lapham GT, Johnson L, Williams EC, Rubinsky AD, Hawkins EJ, Achtmeyer CE, Kivlahan DR. A Majority of Brief Alcohol Interventions Documented in the Medical Record are Reported by VA Patients. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2011 Jun 27; Atlanta, GA. [view]
2. Bishop MJ, Rubinsky AF, Sun H, Bradley KA. Alcohol Misuse Screening Predicts Post-operative Complications: A Cohort Study of Surgery in the VA. Poster session presented at: American Society of Anesthesiologists Annual Meeting; 2009 Oct 20; New Orleans, LA. [view]
3. Bradley KA. Alcohol Screening and Post-operative Complications: A Cohort Study of Men Undergoing Major Surgery in VA and Review of Trials of Medical Management Findings. Presented at: Scandin-Alc Project Expert Annual Workshop and Course; 2009 May 26; Stavanger, Norway. [view]
4. Bradley KA, Sun H, Kivlahan DR, Henderson B, Hawn M, Bishop M, Harris A, Hawkins E. AUDIT-C Alcohol Misuse Screening and Post-Operative Complications: A Cohort Study of Men Undergoing Major Surgery in VA. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
5. Rubinsky AF, Sun H, Kivlahan DR, Hawn MT, Bryson CL, Bishop MJ, Maynard CC, Hawkins EJ, Tonnesen H, Hughes G, Bradley KA. AUDIT-C Alcohol Screening Results are Associated with Length of Hospital Stay among VA Men Undergoing Major Surgery. Poster session presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA. [view]
6. Bradley KA, Rubinsky AF, Sun H, Kivlahan DR, Henderson W, Hawn M, Bishop MJ, Harris A. AUDIT-C Misuse Screening and Post-operative Complications: A Cohort Study of Men Undergoing Major Surgery in VA. Poster session presented at: VA Leadership Board Annual Meeting; 2009 Feb 4; Baltimore, MD. [view]
7. Bradley KA, Lapham GT, Kivlahan DR. Implications of Varying Alcohol Screening Instruments and Thresholds for a Performance Measure of Brief Alcohol Counseling. Presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA. [view]
8. Rubinsky AF, Lapham GT, Kivlahan DR, Williams EC, Hawkins EJ, Bradley KA. Prevalence of Previously Recognized Alcohol and Other Substance Use Disorders among VA Patients who Screen Positive for Alcohol Misuse. Presented at: AcademyHealth Annual Fall Seminar; 2010 Sep 27; Boston, MA. [view]
9. DeBenedetti AF, Volk RJ, Kivlahan DR, Bradley KA. Using Zones rather than Dichotomous Thresholds on the AUDIT and AUDIT-C to Assess the Probability of Alcohol Dependence. Presented at: Research Society on Alcoholism Annual Scientific Meeting; 2007 Jul 15; Chicago, IL. [view]

DRA: Substance Use Disorders
DRE: Treatment - Observational, Prevention
Keywords: Addictive behaviors, Addictive Disorders, Surgery
MeSH Terms: none