Alcohol Drinking Patterns and Health Care Utilization in a Managed Care Organization.

Alcohol Drinking Patterns and Health Care Utilization in a Managed Care Organization Gary A. Zarkin, Jeremy W. Bray, Thomas F. Babor, and John C. Higgins-Biddle Objective. To estimate the relationship between current drinking patterns and health care utilization over the previous two years in a managed care organization (MCO) among individuals who were screened for their alcohol use. Study Design. Three primary care clinics at a large western MCO administered a short health and lifestyle questionnaire to all adult patients on their first visit to the clinic from March 1998 through December 1998. Patients who exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for moderate drinking were given a more comprehensive alcohol screening using a modified version of the Alcohol Use Disorders Identification Test (AUDIT). Health care encounter data for two years preceding the screening visit were linked to the remaining individuals who responded to one or both instruments. Using both quantity­frequency and AUDIT- based drinking pattern variables, we estimated negative binomial models of the relationship between drinking patterns and days of health care use, controlling for demographic characteristics and other variables. Principal Findings. For both the quantity­frequency and AUDIT-based drinking pattern variables, current alcohol useisgenerally associatedwithless healthcare utilization relative to abstainers. This relationship holds even for heavier drinkers, although the differences are not always statistically significant. With some exceptions, the overall trend is that more extensive drinking patterns are associated with lower health care use. Conclusions. Basedonoursample,wefindlittleevidencethatalcoholuseisassociated with increased health care utilization. On the contrary, we find that alcohol use is generally associated with decreased health care utilization regardless of drinking pattern. Key Words. Alcohol, health care utilization, alcohol screening Alcoholism and alcohol abuse impose significant costs on society. One consequence that has received much attention is the possibility that alcohol abuse leads to increased health care utilization. Although the alcohol treatment cost offset literature (e.g., Holder and Blose 1991, 1992; Holder and Cunningham 1992; Holder, Lennox, and Blose 1992) has demonstrated that untreated alcoholics have greater health care utilization than nonalco- holics, it does not shed light on the relationship between the level and intensity of alcohol use (as opposed to abuse or dependence) and health care utilization. 553 Because the number of alcohol users is much greater than the number of dependent or abusive drinkers,1 understanding the relationship between alcohol use patterns and health care utilization is important to policymakers. Once this relationship is understood, policymakers need to understand the underlying reasons for the relationship and whether a screening intervention is warranted to detect and change these patterns. Our article contributes to the first part of this research by examining the relationship between alcohol drinking patterns and health care utilization. Several recent studies have examined the relationship between alcohol consumption and health care utilization. In general, the results appear counterintuitive in light of the cost offset literature. For example, Armstrong, Midanik, and Klatsky (1998) found in a survey of health maintenance organization (HMO) users that the heaviest drinkers (as measured by weekly consumption), after adjusting for age and race, had fewer hospital days, fewer hospitalizations, and fewer outpatient visits than abstainers. Rice et al. (2000) examined the relationship between health care use (outpatient visits and odds of hospital use) and alcohol use collected from a member survey at an HMO. Results indicate that current drinkers had lower rates of health care utilization than nondrinkers and that nondrinkers with a drinking history had substantially greater utilization than nondrinkers without a history. Polen et al. (2001) examined the relationship between alcohol consumption (based on a user survey at an HMO) and health care utilization (health care costs, outpatient visits, inpatient days, and emergency room visits). Several patterns of alcohol consumption were created from the AUDIT, including drinks per month. No strong, consistent relationship was found between the multiple drinking patterns and health care utilization cost and use. However, they found that nondrinkers had greater health care costs and utilization than drinkers. Cryer et al. (1999) examined the relationship between alcohol consumption and acute and preventive health care use for a random sample of adults in South East England. They found that although heavy drinkers used more acute care, they also used less preventative care. Interestingly, they This study was funded by a contract to RTI from the University of Connecticut Health Center as part of the Cutting Back s research study funded by the Robert Wood Johnson Foundation. Additional funding was provided by NIAAA (R01­AA 12788). Address correspondence to Gary A. Zarkin, Ph.D., RTI International, 3040 Cornwallis Rd., P.O. Box 12194, Research Triangle Park, NC 27709. Jeremy W. Bray, Ph.D., is also with RTI International. Thomas F. Babor, Ph.D., and John C. Higgins-Biddle, Ph.D., are with the University of Connecticut. 554 HSR: Health Services Research 39:3 (June 2004) found that abstainers were also overusers of acute care but underusers of preventative services. These findings of a negative relationship between alcohol use and health care utilization (with the exception of Cryer et al. 1999) are consistent with the possibility that moderate alcohol consumption may provide beneficial health effects, which in turn may lead to lower health care utilization. Numerous studies have found that moderate alcohol use is associated with reduced risk of coronary heart disease and with reduced overall mortality within certain populations (Doll 1998; Chick 1998; Klatsky 1999; Ashley et al. 1994). Indeed, Doll (1998) concluded that alcohol consumption in the range of one to four drinks per day is associated with reductions in the risk of premature death. Unfortunately, much of the previous literature on alcohol use and health care utilization has focused on measures of weekly or monthly alcohol consumption, and so we cannot determine if the beneficial health effect of regular, moderate drinking explains the results of this literature (an exception is Rice et al. 2000, which used drinks per day). Nor has previous health services research taken into account the quantity­frequency pattern of drinking as we do here. There is evidence, for example, that frequent binge drinking----which is a typical pattern in Russia, Poland, and the Baltic states----is associated with increased mortality and morbidity (Chenet et al. 1998). Further complicating the putative association between drinkers and abstainers is the issue that abstainers include never drinkers and former drinkers, and these two groups are very different. For example, Fillmore et al. (1998) found that former drinkers are more likely to have health risk factors such as cigarette smoking, depression, and obesity. Polen et al. (2001) found that former drinkers have higher health care costs than never drinkers and light drinkers. This study expands the previous literature on the relationship between alcohol use and health care utilization in an MCO by examining two different drinking pattern measures: quantity-frequency and alcohol problem severity measures. In addition, we have included covariates for two important health behaviors----smoking and exercising. Controls for exercise have not been available in the previous literature. We have also included more traditional demographic factors, such as age and gender. DATA AND METHODS Data Data for this analysis were collected as part of Cutting Back s , a six-year, five- site national research project evaluating the application of alcohol screening Drinking Patterns and Health Care Utilization 555 [ABSTRACT FROM AUTHOR]