BACKGROUND AND PURPOSE: Since stroke is a principal cause of death in elderly people, we analyzed the association between alcohol and stroke mortality in a cohort of 15,077 middle-aged and older men and women. METHODS: Data on alcohol habits were obtained from a questionnaire in 1967. The subsequent 20 years yielded 769 deaths from stroke, of which 574 were ischemic. Relative mortality risks (RR) were estimated from logistic regression analyses with lifelong alcohol abstainers as a reference group. Adjustments were made for age and smoking. RESULTS: No association was found between alcohol intake and hemorrhagic stroke. An elevated risk of ischemic stroke was found for men who drank infrequently, that is, a few times a year or less often (RR, 2.0; 95% confidence interval [CI], 1.3 to 3.2), for those who were intoxicated now and then (RR, 1.8; 95% CI, 1.1 to 2.8), and for those who reported "binge" drinking a few times in the year or less often (RR, 1.6; 95% CI, 1.1 to 2.5). Among women only ex-drinkers had an elevated risk of dying of ischemic stroke (RR, 3.3; 95% CI, 1.5 to 7.2). The risk was reduced for women who had an estimated average consumption of 0 to 5 g pure alcohol per day (RR, 0.6; 95% CI, 0.5 to 0.8); for those who did not drink every day (RR, 0.7; 95% CI, 0.5 to 0.9); and for those who never "went on a binge" (RR, 0.6; 95% CI, 0.5 to 0.8) or became intoxicated (RR, 0.7; 95% CI, 0.5 to 0.9). CONCLUSIONS: Drinking habits were associated only with deaths from ischemic stroke, and the risk patterns were different for men and women. In analyses, ex-drinkers should not be included with lifelong abstainers, since the former tend to run high health risk.
A small subgroup of patients accounts for a substantial proportion of emergency room (ER) consultations. Of the 479,956 consultations at ER facilities at Stockholm hospitals in 1996, a quarter were accounted for by six per cent of the patients, a subgroup characterised by at least four ER consultations during the year. Some 1,500 patients consulted 12-233 times. Analysis of the care-seeking habits of five extremely heavy ER-facility consumers showed them also to be heavy consumers of other health care services such as primary and tertiary facilities. Since previous studies have shown heavy ER-facility consumers to be a vulnerable subgroup both medically and socially, co-ordination and planning of their care might well be beneficial.
Heavy users of the services of emergency departments (EDs) have in previous studies been found to have psychological, social, economic and other difficulties besides their more or less acute medical problems. In order to establish whether mortality is associated with high ED use, a nine-year follow-up study was conducted of a 10 per cent population sample (n = 17,000), selected from the catchment area of Huddinge Hospital, Sweden. ED visits were found to predict nine-year mortality in the cohort. The group of individuals who had made four or more ED visits during a period of 15 months prior to follow-up (heavy ED users) had a two-fold excess mortality (95 per cent confidence interval (CI) = 1.9-2.1), those who had made one to three ED visits (moderate ED users) had a slightly elevated mortality (standardized mortality ratio SMR = 1.1, 95 per cent CI = 1.0-1.3), while the SMR of the non-users was 0.9 (95 per cent CI = 0.8-1.0). The three predominant causes of death in the cohort were diseases in the circulatory system, tumours and violent death. Heavy ED users had elevated mortality in all diagnoses, the most important excess mortality being from violent death, comprising suicide, probable suicide and alcohol/drug abuse, with an SMR of 6.3 (95 per cent CI = 6.0-6.7). The excess mortality from these causes of the heavy ED users accounted for more than one-third of their total excess mortality.(ABSTRACT TRUNCATED AT 250 WORDS)
STUDY OBJECTIVE: We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites. METHODS: A computerized patient database covering all ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period. RESULTS: Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care for 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [CI] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) for 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55; 95% CI 1.26 to 1.90). CONCLUSION: High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category.
Comment In: Ann Emerg Med. 2001 Jun;37(6):627-911385331
Comment In: Ann Emerg Med. 2002 Jun;39(6):693-512023721
In a trial, patients who came to a hospital Emergency Department (ED) with non-urgent complaints were advised and referred to primary health care outside the hospital. The effect of this was assessed by measuring health care utilization one year before and one year after the referral, using the Stockholm County computerized medical information system and ED medical records. The proportion of the 189 referred patients who visited the ED decreased from 48% to 42%, whereas in a control group of 107 patients the proportion increased from 41% to 51%. A small proportion, 7%, of the referred patients with four or more ED visits accounted for 45% of the total number of ED visits the year before the trial. These frequent ED users did not reduce their ED utilization more than frequent ED users in the control group. The use of health care centres increased in the referred group and was practically unchanged in the control group. However, those referred patients who continued to use the ED still quite often did so for non-urgent complaints.
Patients with non-urgent complaints and/or who attend frequently account for a substantial portion of the visits to emergency units. These patients usually require other types of care than that provided by a highly specialized emergency department (ED). In this paper we describe the development of ED utilization in the catchment area of Huddinge University Hospital, and the attempts made to improve the quality of care for high consumers of ED care. In a trial, nurse's advice and referral proved to be a feasible means of referring patients with non-urgent complaints from the hospital emergency department to more appropriate care sources, such as primary health care centres. A long-term follow-up showed that without any intervention, frequent ED users are a high-risk group as regards morbidity and mortality, especially with respect to suicide. Prevention with comprehensive and continuous treatment programmes should therefore be planned when a tendency is noted for patients to attend the ED frequently.