Abstract
Alcohol withdrawal syndrome (AWS) is a common inpatient diagnosis managed primarily with benzodiazepines. Concerns about the adverse effects associated with benzodiazepines have spurred interest in using benzodiazepine-sparing treatments. To evaluate changes in outcomes after implementation of a benzodiazepine-sparing AWS inpatient order set that included adjunctive therapies (eg, gabapentin, valproic acid, clonidine, and dexmedetomidine). This difference-in-differences quality improvement study was conducted among 22 899 AWS adult hospitalizations from October 1, 2014, to September 30, 2019, in the Kaiser Permanente Northern California integrated health care delivery system. Data were analyzed from September 2020 through November 2021. Implementation of the benzodiazepine-sparing AWS order set on October 1, 2018. Adjusted rate ratios for medication use, inpatient mortality, length of stay, intensive care unit admission, and nonelective readmission within 30 days were calculated comparing postimplementation and preimplementation periods among hospitals with and without order set use. Among 904 540 hospitalizations in the integrated health care delivery system during the study period, AWS was present in 22 899 hospitalizations (2.5%), occurring among 16 323 unique patients (mean [SD] age, 57.1 [14.8] years; 15 764 [68.8%] men). Of these hospitalizations, 12 889 (56.3%) used an order set for alcohol withdrawal. Among hospitalizations with order set use, any benzodiazepine use decreased after implementation from 6431 hospitalizations (78.1%) to 2823 hospitalizations (60.7%) (P < .001), with concomitant decreases in the mean (SD) total dosage of lorazepam before vs after implementation (19.7 [38.3] mg vs 6.0 [9.1] mg; P < .001). There were also significant changes from before to after implementation in the use of adjunctive medications, including gabapentin (2413 hospitalizations [29.3%] vs 2814 hospitalizations [60.5%]; P < .001), clonidine (1476 hospitalizations [17.9%] vs 2208 hospitalizations [47.5%]; P < .001), thiamine (6298 hospitalizations [76.5%] vs 4047 hospitalizations [87.0%]; P < .001), valproic acid (109 hospitalizations [1.3%] vs 256 hospitalizations [5.5%]; P < .001), and phenobarbital (412 hospitalizations [5.0%] vs 292 hospitalizations [6.3%]; P = .003). Compared with AWS hospitalizations without order set use, use of the benzodiazepine-sparing order set was associated with decreases in intensive care unit use (adjusted rate ratio [ARR], 0.71; 95% CI, 0.56-0.89; P = .003) and hospital length of stay (ARR, 0.71; 95% CI, 0.58-0.86; P < .001). This study found that implementation of a benzodiazepine-sparing AWS order set was associated with decreased use of benzodiazepines and favorable trends in outcomes. These findings suggest that further prospective research is needed to identify the most effective treatments regimens for patients hospitalized with alcohol withdrawal.
Highlights
Alcohol use disorders account for more than 400 000 hospitalizations each year with a total estimated cost of $3.5 billion in the US.[1]
Among 904 540 hospitalizations in the integrated health care delivery system during the study period, alcohol withdrawal syndrome (AWS) was present in 22 899 hospitalizations (2.5%), occurring among 16 323 unique patients
Compared with AWS hospitalizations without order set use, use of the benzodiazepine-sparing order set was associated with decreases in intensive care unit use and hospital length of stay (ARR, 0.71; 95% CI, 0.58-0.86; P < .001)
Summary
Alcohol use disorders account for more than 400 000 hospitalizations each year with a total estimated cost of $3.5 billion in the US.[1]. Among inpatients with alcohol use disorders, alcohol withdrawal syndrome (AWS) occurs with an incidence between 2% and 7%.2,3. Up to 20% of individuals with AWS can develop severe complications, including autonomic instability, seizures, hallucinations, and delirium tremens, with mortality rates between 3% and 15%.2,4,5. While benzodiazepines (BZDs) are the mainstay of treatment,[5-8] with symptom-triggered treatment recommended to decrease overall BZD exposure,[8-12] it is unclear what protocols most hospitals use to treat AWS. While BZDs are associated with effective reductions in AWS symptoms, they are associated with adverse effects, including excessive sedation, falls, respiratory depression, aspiration, delirium, and even mortality.[10,13-18]. Alternate AWS treatments have been suggested, including anticonvulsants and α-2 adrenergic agonists.[19-25]. Significant uncertainty remains about the optimal approach to AWS
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