Background: Alcohol use disorders (AUDs) are common among hospitalized patients. Naltrexone has been proved to assist patients with AUDs in maintenance of sobriety. The initiation of naltrexone has been studied in outpatient and inpatient settings. Our hospitalist program lacked a process for initiation of naltrexone for maintenance of sobriety among inpatients with AUDs.
We created an algorithm for evaluating hospitalized patients with AUDs for naltrexone, including medication dosage and contraindications. We targeted patients who were admitted specifically for detoxification or withdrawal from alcohol. The algorithm was disseminated to the group via email, posting of paper versions at computer work stations, presentation at a monthly group meeting and the creation of “smart phrases” in the electronic medical record.
Patients hospitalized for alcohol-related indications were identified using Diagnosis Related Groupings (DRGs) 896 and 897, which are “alcohol/drug abuse or dependence without rehabilitation therapy,” with and without major co-morbidity or complication, respectively. Repeat hospitalizations and admissions primarily for other reasons than withdrawal (i.e., pancreatitis) were excluded. Discharge summaries were reviewed for documentation of counseling about and/or initiation of naltrexone.
Process measures included the percentage of patients hospitalized for alcohol withdrawal or detoxification who were counseled about naltrexone, before and after intervention. Consecutive samples of ten patients were plotted sequentially on a control chart. Pharmacies for patients prescribed naltrexone were contacted to measure compliance. Outcome measures included 30-day emergency department (ED) revisit rate and 30-day readmission rate. Analysis included comparison of pre- vs. post-intervention patients and comparison of those counseled vs. not counseled on naltrexone before discharge.
There were 128 patients identified before and 82 after implementation of the new process. After implementation, the percentage of patients hospitalized for alcohol detoxification or withdrawal counseled about naltrexone before discharge rose from 1.5% to 64.6% (p<.001, Table 1). The increase also met control chart rules for special cause variation (Figure 1). Of those prescribed naltrexone, 73.1% filled at least one prescription.
The 30-day ED revisit and re-hospitalization rates declined, though did not achieve statistical significance (Table 1). In multivariate analysis, those counseled vs. not counseled were significantly less likely to return to the ED within 30 days of discharge (OR 0.29, 95%CI 0.10-0.72).
Conclusions: Our hospital medicine group demonstrated the successful creation and implementation of an algorithm for evaluating patients for naltrexone during hospitalization for alcohol detoxification or withdrawal. Implementation of the new process correlated with trends toward decrease in 30-day ED revisit and re-hospitalization rates. Patients prescribed naltrexone had good adherence with filling the prescriptions. Those counseled about naltrexone were significantly less likely to return to ED within 30 days compared with those not counseled.