We validate that the 28 days
after hospital-discharge are high-risk for drugs-related death (DRD) among drug
users in Scotland and investigate key risk-factors for DRDs soon after
hospital-discharge.
Using data from an anonymous linkage of hospitalisation and
death records to the Scottish Drugs Misuse Database (SDMD), including over
98,000 individuals registered for drug treatment during 1 April 1996 to 31
March 2010 with 705,538 person-years, 173,107 hospital-stays, and 2,523 DRDs.
Time-at-risk of DRD was categorised as: during hospitalization, within 28 days,
29–90 days, 91 days–1 year, >1 year since most recent hospital discharge
versus ‘never admitted’.
Factors of interest were: having ever injected, misuse
of alcohol, length of hospital-stay (0–1 versus 2+ days), and main
discharge-diagnosis. We confirm SDMD clients’ high DRD-rate soon after
hospital-discharge in 2006–2010. DRD-rate in the 28 days after
hospital-discharge did not vary by length of hospital-stay but was
significantly higher for clients who had ever-injected versus otherwise.
Three
leading discharge-diagnoses accounted for only 150/290 DRDs in the 28 days after
hospital-discharge, but ever-injectors for 222/290. Hospital-discharge remains
a period of increased DRD-vulnerability in 2006–2010, as in 1996–2006,
especially for those with a history of injecting.
...Our key confirmatory finding is that DRD-rates by time since
most recent hospitalization remained significantly higher in the 28 days after
hospital-discharge than at subsequent times post-discharge (with and without
covariate adjustment). The SDMD cohort’s DRD-rate while hospitalized had
decreased in 2006–2010, but absolute DRD-risks soon after hospital-discharge
remained similar across both periods.
New SDMD registrations in the validation period of
2006–2010 were different from those in the earlier registration period in
important respects: a higher proportion of 2006–2010 registered clients were 35
years of age or older at registration than among clients whose first SDMD
registration was in 1996–2006, and a higher proportion reported never having
injected. This suggests that Scottish drug users are not only ageing but that
newer clients are less likely to have been initiated into injecting.
The study disputed our hypothesis that individuals who
are hospitalized for a longer time (at least overnight) may be at greater
DRD-risk post-discharge due to loss of tolerance. However, the duration of
hospital-stay was a highly skewed variable; with a few individuals experiencing
very long (several months) periods. There was insufficient statistical power to
properly investigate the effect of short versus long stay lengths. A further
subdivision of duration of hospital-stay as 0–1 day, 2–6 days and 7+ days
(results not shown) also showed no difference between stays of less than versus
greater than one week.
The influence of main discharge-diagnosis on subsequent
DRD-risk was also analyzed by grouping the codes into pre-specified categories
as used previously by Merrall et al. [4]. We needed to consider the
entire SDMD cohort in order to have sufficient power per discharge-category
and, even so, only two main discharge-diagnoses exceeded 30 DRDs within 28 days
after hospital-discharge. These two discharge-categories were drug-related
morbidity and mental and behavioral disorders excluding psychoactive substance
misuse. Even together with diseases of the respiratory system, these top three
DRD-risk discharge-categories accounted for only 52% (150/290) DRDs in the 28
days after hospital-discharge.
By contrast, behavioral risk-factors were far more
discriminatory with ever injecting drug use accounting for the vast majority
(77%: 222/290) of DRDs in the 28 days after discharge. This finding gives added
focus to Scotland’s public health policy to make take-home naloxone (opiate
antagonist) readily available, as well as training in its administration, not
only in prisons and at drug treatment agencies but also at discharge from
hospital, see [22] and [23]. Moreover, our new results
suggest how hospital doctors can best target their harm reduction response [24]–not ineffectually according to
patients’ length of hospital-stay, nor too narrowly by concentrating on a few
main discharge-diagnoses, but highly efficiently by focusing on those who have
ever injected. For ever injecting drug users, we note that one DRD in the 28
days after hospital-discharge per 400 discharges is about half their estimated
DRD-risk in the 28 days after prison-release [25].
For the SDMD cohort of over 98,000 drug treatment clients
in Scotland, we have confirmed that a high DRD risk soon after
hospital-discharge applies in 2006–2010 as it did in 1996–2006 [14]. Length of hospital-stay had
no effect on DRD-rate, discharge-diagnosis had an effect (as did reported
misuse of alcohol) but neither was as discriminatory as the behavioral
risk-factor of having ever injected.
Full article at: http://goo.gl/zRYOtN
By:
Simon R. White, Sheila M. Bird
Medical Research Council
Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, United
Kingdom
Elizabeth L. C. Merrall
Novartis Pharam BV, Novartis
Vaccines & Diagnostics, Hullenbergweg 83–85, 1101 CL Amsterdam, Netherlands
Sharon J. Hutchinson
Health Protection Scotland,
Glasgow, G3 7LN, Scotland, United Kingdom
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