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Alcohol Misuse and the Risk of Post-Surgical Complications and Mortality
Katharine A. Bradley, MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Funding Period: September 2006 - November 2009
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.
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.
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.
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.
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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DRA: Substance Use Disorders
DRE: Treatment - Observational, Prevention
Keywords: Addictive behaviors, Addictive Disorders, Surgery
MeSH Terms: none