Publication today in the Lancet ‘Deaths from alcohol-related liver disease: an escalating tragedy’ highlights the need for urgent action to reduce unnecessary and avoidable deaths from alcohol-related liver disease.
The Lancet article follows a report published this week by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) that shows little progress has been made since the original recommendations were made by NCEPOD in 2013.
Dr Michael Allison, hepatologist at Cambridge University Hospitals NHS Foundation Trust and lead author of the report said, ““The report published in 2013 highlighted the huge burden of alcohol related liver disease and the avoidable deaths. It also made clear recommendations for action. Sadly, this new report published this week shows that there is still widespread failure to implement these recommendations. The findings come at a time when new figures from the Office for National Statistics reveal that the number of people dying from alcohol-related problems reached a new high in 2021 - up 27% from 2019 and 7% since 2020. 78% (7,518) of these deaths were due from alcohol-related liver disease.”
Between March 2020 and March 2021, almost six out of ten people (58.6%) reported that they were drinking either at a risky level - more than 14 units a week – the equivalent of a bottle and half of wine a week or at higher-risk levels (more than 50 units per week for men, and more than 35 units per week for women).
Vanessa Hebditch, Director of Policy at the British Liver Trust, said “This report shows that deaths from alcohol related liver disease remain unacceptably high. The NHS must systematically address this by adopting the recommendations in this report. The publication also coincides with the Government announcement that it intends to freeze alcohol duty at a time when urgent action is needed to address the UK’s drinking culture.
This is a difficult message to get across at Christmas when many of us will want to enjoy a drink. However, since the start of 2020, there has been a big shift in the UK’s drinking culture with millions of us drinking more regularly and at home – pouring much larger measures than if drinking when out. Adults who drink mainly at home report that they are aware that they run a risk of higher overall alcohol consumption but tend to play down the possibility that increased consumption may lead to longer-term harm. Alcohol is the leading cause of liver disease in the UK and a common myth is that it’s only ‘alcoholics’ who have liver damage. More than one in five of us are currently drinking alcohol in way that could harm their liver. If you are concerned about your drinking, try to start cutting down by having at least three alcohol-free days per week."
The number of deaths from alcohol-related liver disease highlights the urgent need to prioritise care pathways for patients with alcohol-related liver disease. In 2013, the original NCEPOD report ‘Measuring the units’ examined the care of patients who died in hospital from alcohol related liver disease. It found that admission with decompensated cirrhosis was a common medical presentation, with high (10-20%) in-hospital mortality. ‘Measuring the units’ described a series of missed opportunities in relation to such care including not enough being done about patients’ harmful drinking while they were in hospital, not referring them for support and delayed specialist reviews.
28 recommendations were made to improve the reliability of care delivery and the organisation of hospital services for patients with ARLD. The report this week found that some progress has been made in the care of alcohol dependent patients including more alcohol care teams having been established and the development of a chronic liver disease care bundle (endorsed by national specialist societies) to look after people with the most advanced liver disease.
However, the latest report also found that there was a serious failure to implement the recommendations from 2013 and that was regional variation in hospital admissions which predated the COVID-19 pandemic.
Liver disease was, overall, the fourth most common cause of Years of Life Lost in those aged 75 years old and younger. ‘Measuring the units’ also found that the majority (58.6%) of patients were not assessed for risk of alcohol withdrawal. It recommended that alcohol withdrawal scales should be used to guide treatment decisions.
Among the recommendations in Remeasuring the Units are
- specific focus on reducing variations in care, for example, which predated the COVID-19 pandemic
- A multidisciplinary Alcohol Care Team should be established in each acute hospital and integrated across primary and secondary care
- The development of a toolkit to aid the non-specialist healthcare professional in the management of these patients
- Once patients are discharged from hospital, measures to improve abstinence, and to reduce morbidity and mortality from harmful alcohol use by ensuring contact is made with community alcohol services.
- Escalation of care should be actively pursued for ARLD patients, who deteriorate acutely and whose background functional status is good. There should be close liaison between the medical and critical care teams when making escalation decisions
- Hospitals without specialist liver care on-site should be in a clinical network so transfer of care to a liver unit or a liver transplant centre can occur if needed.
- Increased and improved palliative care
- More widespread mortality reviews to learn from deaths and to improve services.
