DRINKING PATTERNS AND PROBLEMS IN EMERGENCY SERVICES IN POLAND

Cheryl J. Cherpitel1,*, Jacek Moskalewicz2 and Grazyna Swiatkiewicz2

1 Public Health Institute, Alcohol Research Group, 2000 Hearst Avenue, Berkeley, CA 94709, USA and 2 Institute of Psychiatry and Neurology, Warsaw, Poland

* Author to whom correspondence should be addressed at: Public Health Institute, Alcohol Research Group, 2000 Hearst Avenue, Berkeley, CA 94709, USA. Tel.: 1 510 642 0164; Fax: 1 510 642 7175; E-mail: ccherpitel{at}arg.org

(Received 4 December 2003; first review notified 5 February 2004; in revised form 12 February 2004; accepted 13 February 2004)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To examine drinking patterns and problems in emergency services in Poland, where both alcohol consumption and the health care system have undergone enormous recent change. Methods: A probability sample of 734 emergency service patients was breathalyzed and interviewed in a large public hospital in Warsaw, Poland. Results: 2.5% of the sample was breathalyzer positive; all were male and injured. Injured males were significantly more likely to report heavy problem drinking than non-injured, but no differences were found for females. Among injured males who reported drinking prior to the event, close to 50% reported feeling drunk, and over 75% attributed a causal association of their drinking with injury. Conclusions: These data point to substantial alcohol-involvement on the part of injured males in this population, and suggest emergency services may be a productive venue for identifying those patients who would benefit from a brief intervention.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
A substantial literature exists internationally on the association of alcohol and injury (Roizen, 1989Go; Romelsjö, 1995Go), and much of this research has been conducted in emergency rooms (ERs) (Cherpitel, 1993Go). While ER studies have found injured patients compared to non-injured more likely to be positive for estimated blood alcohol concentration (BAC) at the time of the ER visit, and to report drinking prior to the event bringing them for treatment (Cherpitel, 1993Go), heterogeneity in these relationships has been found across multinational sites using similar methodologies with probability samples of ER patients (Cherpitel et al., 2003aGo,bGo). However, little research on alcohol and injury, using representative samples of patients, has been carried out in Central and Eastern European countries, where both alcohol consumption and the health care system have undergone enormous change. Since 1989 a substantial increase in alcohol consumption has been observed in Poland, together with changes in drinking patterns and alcohol-related health problems, and a visible liberalization of the State Alcohol Policy. While rates of immediate consequences of (binge) drinking are relatively high in Poland (as well as in other spirits drinking countries), the prevalence of heavy drinking patterns and related problems in ER caseloads and associations with injury are relatively unknown.

As a predominantly spirits drinking country, Poland is characterized by infrequent, but heavy, drinking with high levels of intoxication among males, leading to high rates of acute problems associated with alcohol consumption, and a lower prevalence of chronic problems (Moskalewicz, 1993Go). Estimates from the 1980s suggested that the number of problem drinkers may be as high as 1.5 million, or 6% of the adult population, and that 14.5% consumed more than 12 liters of pure alcohol annually, a figure confirmed by more recent general population data (Sieroslawski, 1996Go). Although between 9 and 23% of adults in Poland consider themselves abstainers (Zielinski, 1994Go), for some Poles an abstainer is someone who may consume beer or wine, but no vodka (Zielinski, 1987Go).

Per capita consumption in Poland averaged 7–8 liters between 1970 and 1989, rising to 10 liters after 1989 (60% of which were spirits), when free-market economy principles were introduced (Moskalewicz, 1991Go). Between the 1960s and the 1980s it is estimated that alcohol consumption rose to 300% among females and 75% among males in Poland (Moskalewicz and Zielinski, 1995Go). A study of brief intervention in primary care settings in Poland found, among nearly 4600 patients screened in 20 physician offices, nearly 25% met criteria for either at-risk, problem or dependent drinking (Fleming, 1999Go).

In Poland emergency care is delivered by both ambulance services and by emergency services offered by public hospitals. Emergency treatment is provided in a rotating system across a number of hospitals to assure access to services and to distribute the emergency service burden among all existing facilities. Each hospital in a given region provides a certain number of emergency days per month in general emergency treatment as well as in specialty areas. Patients obtain hospital-based emergency services by either ambulance transport or by referral from a doctor, with only a limited number of ‘walk-in’ patients.

Given the apparent large increase in alcohol consumption and related problems in Poland over the last decade, and the limited amount of epidemiologic data on alcohol and injury in the emergency room setting, this paper reports data on drinking patterns, alcohol-related problems and drinking-in-the-event variables from a probability sample of both injured and non-injured emergency patients treated in a large public-funded hospital. The purpose of this paper is to compare the prevalence of alcohol involvement between injured and non-injured patients seeking emergency services, and to compare these data with similar data from other countries. Data reported here are important for determining the extent and nature of problem drinking among emergency patients treated in a hospital facility in this population, the role of alcohol in injury, and the potential of emergency services as a site for identifying those who could benefit from a brief intervention for problem drinking.


    SUBJECTS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Sample
Data were collected over a seven-month period (2002) at Public Hospital No. 1 in Warsaw, located in the central district of the city. This facility has 1000 beds, and provides various types of emergency services to approximately 25,000 emergency patients per year. Given the rotating system in which emergency patients are treated in a given emergency facility, patients are therefore representative of the larger region in which they reside. Probability samples of both injured and non-injured emergency patients treated in general surgery, orthopedic surgery and ophthalmology were obtained according to the representation of the specialty area in a given month in terms of hours of the day and days of the week the specialty area treated patients. Patients were sampled from admission forms that reflected consecutive arrival to the emergency service. Completed interviews were obtained from 734 of the 1089 patients sampled, representing a 68% completion rate. Reasons for non-interview were due to refusal (20%), the patient's condition (5%), failure to locate the patient (5%), and for other reasons including failure of the patient to complete the interview (3%). Table 1 presents demographic characteristics by injury status for those interviewed and for those not interviewed. The non-interviewed were no different on gender than those interviewed, but were older (a smaller proportion were under 30 and a larger proportion over 70), suggesting that non-response was likely not caused by problems associated with alcohol intoxication. Injured patients were more likely to be male and younger, and less likely to have used the ER during the previous year compared to non-injured patients. Mean age among injured was 41 compared to 53 among the non-injured (P = .00). Among the injured, 38% were treated for injuries relating to falls, while only 7% were treated for motor vehicular injuries and 5% reported injuries relating to violence (not shown).


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Table 1. Demographic Characteristics for Interviewed by Injury Status and for Non-interviewed, in percent (n's )

 
Data Collection
A cadre of 10 interviewers was trained by the authors and supervised by survey research staff at the Polish Institute of Psychiatry and Neurology. Patients were approached for their informed consent to be breathalyzed and interviewed as soon as possible after registering for care. Interviews were conducted in a private area of the waiting room or in an adjacent office to ensure confidentiality of responses while allowing for the patient's being called for care during the interview. Breath analysis and interviews were generally carried out prior to the patient's examination. If time did not permit, or if the patient was called for treatment, the interview was completed after the examination. Patients who were too severely injured or ill to be interviewed at that time, but who were hospitalized, were interviewed at a later time after their condition had stabilized.

Instruments
General description Data were collected using a 25 min interviewer-administered questionnaire and the Alco-Sensor III breathalyzer which has been found to provide estimates of blood alcohol concentration (BAC) which are highly correlated (.96) with chemical analysis of blood (Gibb et al., 1984Go). The interview questionnaire was similar to that used in a number of other countries (Cherpitel et al., 2003aGo,bGo), and was translated from that used in the Santa Clara ER study in the US (Cherpitel, 1998Go). The questionnaire obtained data, among other items, on the condition which brought the patient to treatment, quantity and frequency of usual drinking and higher consumption times, frequency of drunkenness (with each patient defining for himself what the term ‘drunk’ meant), social consequences of drinking and alcohol dependence (all during the last year), previous alcohol-related accidents, ever having had treatment for an alcohol problem and demographic characteristics. Patients were also asked whether they had been drinking within 6 h prior to the event. For those who reported drinking during this time, additional data were obtained on the number of drinks consumed, the time lapsed between the last drink and the event, whether the patient was feeling drunk at the time and whether he believed the event would have happened if he had not been drinking.

Drinking patterns Quantity and frequency (Q–F) of drinking were obtained from a series of questions used in previous US National Alcohol Surveys (Clark and Hilton, 1991Go), as well as ER studies conducted in the US and elsewhere (Cherpitel et al., 2003aGo). These questions elicited data on the frequency of any drinking (ranging from ‘everyday’ to ‘not during the last 12 months’), and the frequency (using the same range) with which 12 or more drinks and 5–11 drinks were consumed during the last year. Frequency of drinking was categorized as: low (<once a month), moderate (≥once a month but <three times a week), high (≥three times per week). Quantity was defined as low: (never five drinks at one time), moderate (≥five but <12 drinks at one time), high (≥12 drinks at one time). A ‘time’ was defined by each respondent, but generally referred to a drinking occasion that was not separated by more than 2 h from the next occasion. A drink was defined as 250 ml of beer (half of a half-liter bottle or can of beer), a glass of wine (100 ml) or 40 ml of spirits, each of which contains ~0.5 ounce of absolute alcohol. A Q–F typology, developed in prior ER studies based on these categories, defined five levels of drinking as follows: (1) abstainer (no drinking during the last year); (2) infrequent (low frequency/any quantity); (3) light (moderate or high frequency/low quantity); (4) moderate (moderate or high frequency/moderate quantity or moderate frequency/high quantity); (5) heavy (high frequency/ high quantity).

Alcohol-related problems Social consequences of drinking were measured by five items that have also been used in previous US general population surveys (Clark and Hilton, 1991Go) and ER studies (Cherpitel et al., 2003aGo). These items asked questions related to whether respondents' drinking ever caused them difficulties with: personal relationships, work, the police or other authorities, physical health, and psychological health or mental well-being. Alcohol dependence was derived from a positive response in three or more domains, and harmful drinking/ abuse from a positive response in one or more domains, on either ICD-10 (International Classification of Diseases, 10th Revision; World Health Organization, 1992Go) or DSM-IV (Diagnostic and Statistical Manual, 4th edition; American Psychiatric Association, 2000Go) diagnostic criteria adapted (Cherpitel, 1998Go) from the Alcohol Section of the CIDI core (Composite International Diagnostic Interview; World Health Organization, 1993Go).

Data Analysis
Data were analyzed comparing equality of sample proportions between injured and non-injured patients separately for males and females, and by comparing sample proportions between injured males and injured females, and between non-injured males and non-injured females on breathalyzer readings (Table 2), drinking patterns (Table 3), alcohol-related problems (Table 4) and drinking in the event (Table 5). SPSS (1999)Go was used for analysis.


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Table 2. Breathalyzer Reading by Gender & Injury Status, in percent (n's)

 

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Table 3. Quantity and Frequency of Drinking and Frequency of Drunkenness Among Drinkers by Gender and Injury Status, in percent (n's)

 

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Table 4. Alcohol Related Problems by Gender and Injury Status, in percent (n's)

 

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Table 5. Self-Reported Consumption by Gender and Injury Status and Drinking-in-the-Event Variables for Those Who Reported Drinking, in percent (n's)

 

    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Drinking patterns and problems
About 80% of respondents were breathalyzed. Failure to obtain a breathalyzer test was largely due to the patient's condition, including difficulty breathing. Table 2 shows breathalyzer readings at the time of emergency treatment. None of the female patients were found to be positive on the breathalyzer, while 4.4% of the males were positive and these were exclusively among the injured patients.

Table 3 shows the quantity and frequency of drinking during the last year and frequency of drunkenness among drinkers. Injured males were significantly less likely to be abstainers and significantly more likely to be heavier drinkers than non-injured, while again, no differences were found for females by injury status. Both injured male and female drinkers were significantly more likely to report being drunk during the last year compared to non-injured, although among females, there was no significant difference for reporting drunkenness as often as monthly.

Table 4 shows alcohol-related problems during the last year, ever having had an alcohol-related accident and treatment for an alcohol problem. Again, only among males are significant differences found by injury status, with injured patients more likely to report all of these measures than non-injured, except for problems at work relating to drinking and prior alcohol treatment.

Self-reported consumption and drinking-in-the-event
Table 5 shows variables related to drinking prior to the injury or illness event. Injured males were twice as likely to report drinking within 6 h prior to the event than non-injured, while no significant difference was found by injury status among females. Among injured males, 35% reported seven or more drinks during the 6 h prior to injury compared to only 12% of the females; however, females were significantly more likely to report their drinking in closer proximity to the injury, with 75% reporting <1 h lapse between the last drink and the injury compared to 31% of the males.

A larger proportion of injured males compared to females reported feeling drunk at the time of the event, although this difference was not significant (most likely due to the small number of females who reported drinking prior to injury), and a significantly larger proportion attributed a causal association of drinking and the event. Over 75% of the males believed the injury would not have happened if they had not been drinking compared to only 25% of the females. When causal attribution was analyzed by whether or not the patient reported feeling drunk (not shown), 88% of the males who reported feeling drunk attributed a causal association of drinking and the event compared to 67% who reported not feeling drunk, while neither of the two females who reported feeling drunk attributed a causal association of drinking and the event.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
This study of alcohol and injury in the emergency service of a large public hospital in Warsaw found large differences in drinking patterns and problems between injured and non-injured patients for males but not for females. Positive breathalyzer readings were found exclusively among injured male patients. Sixteen percent of the injured males reported heavy drinking during the last year, in which 12 or more drinks were consumed on at least one occasion, 20% reported at least monthly drunkenness, and 26% met diagnostic criteria for either alcohol dependence or for harmful drinking/alcohol abuse. This figure was similar to the prevalence of at-risk, problem or dependent drinking previously reported in primary care settings in Poland (Fleming, 1999Go), however, the cross-cultural applicability of diagnostic criteria has been found to be problematic (Room et al., 1996Go; Schmidt and Room, 1999Go). Despite higher rates of alcohol use disorders among injured compared to non-injured, no significant difference was found for reporting prior alcohol treatment. Twice as many injured as non-injured reported a previous alcohol-related injury. Among females, no differences were found between injured and non-injured patients except for reported drunkenness, and female emergency service patients reported a low prevalence of other indicators of heavy or problem-related drinking.

These data are similar to findings from ER studies reported elsewhere of a greater prevalence of alcohol involvement among injured compared to non-injured patients, and among males compared to females. An international review of ER studies using probability sampling designs found positive BAC estimates among injured patients (including both males and females) to range from 6 to 32%, while self-reported consumption within 6 h prior to the event ranged from 8 to 39% (Cherpitel, 1993Go). While BAC and self-report estimates from this study remain comparatively low, a high prevalence of heavy and problem-related drinking was found among injured male patients. Since no previous data from Poland are available for comparison with findings reported here, we do not know whether this may be a permanent feature of drinking in Poland, whether it is related to changing drinking patterns associated with liberalization of the State Alcohol Policy, or whether it may be due to changes in the health care system in relation to who is actually seeking care in hospital-based emergency services. These data pertain only to those admitted to a hospital-based emergency service, and do not include those treated by the ambulance team but not subsequently admitted to the hospital emergency service. Additionally, no comparative data on alcohol involvement in hospital-based emergency facilities from other Central or Eastern European countries are available at present. It is important to note that multiple comparisons were carried out on analyses of these data, which increases the likelihood that some significant differences may have occurred by chance alone.

As found in other ER studies, a considerably larger proportion reported drinking within 6 h prior to the event than were positive on the breathalyzer. Although patients were breathalyzed as soon as possible after seeking emergency treatment, the concordance of breathalyzer reading and self-reported consumption has not been found to be high in ER studies in other countries (Cherpitel et al., 1992Go), since these two measure do not necessarily cover the same period of time, due to the time lapsed between injury occurrence and treatment seeking. This may be especially true in Poland where access to emergency services is governed, in part, by the specialty service offered by a particular emergency service on a particular day.

Among those males who reported drinking prior to injury, close to half reported feeling drunk at the time of injury, and over three-quarters reported believing the event would not have happened if they had not been drinking at the time. Attribution of injury to alcohol has been found to be predictive of the patients' degree of readiness to change their drinking behavior (Miller et al., 1993Go), with closer attributional links between alcohol and injury associated with higher motivation to change. The perceived role of alcohol in the injury event, then, may be important for tailoring effective intervention strategies. Given the high proportion of injured male patients in this sample and the high prevalence of heavy problem drinking and of causal attribution of drinking with the injury event among these patients, as well as data from prior studies suggesting relatively high recidivism rates for alcohol-related injuries among those meeting criteria for alcohol dependence at the time of the initial injury visit (Rivara et al., 1993Go), hospital-based emergency services in Poland may be an important potential site for identifying those who could benefit from a brief intervention for problem drinking, with a subsequent reduction in alcohol-related injuries, especially among injured male patients.


    ACKNOWLEDGEMENTS
 
This study was supported by a grant (R21 AA12889-02) from the National Institute of Alcohol Abuse and Alcoholism.


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 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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