Closing time
Counting the cost of alcoholattributable hospital admissions in
London
Technical report
Peninah Murage, John Hamm
London Regional Public Health Group (Department of Health)
Robel Feleke
London Health Observatory
March 2012
About our organisations
The London Regional Public Health Group (RPHG) is part of the
Department of Health’s regional presence. Together with colleagues working
in social care, we are responsible for ensuring that implementation of DH
national policy reflects and harnesses regional and local needs in order to
improve the health and wellbeing of all Londoners. The RPHG works with a
wide range of organisations to promote sustainable improvements in
Londoners’ health and wellbeing.
The London Health Observatory (LHO) is one of 12 Public Health
Observatories (PHOs) working across the five nations of England, Scotland,
Wales, Northern Ireland and the Republic of Ireland. The Public Health
Observatories in England work together through a national work programme
which contains both national and local elements. We produce information,
data and intelligence on people's health and health care for practitioners,
policy makers and the wider community. Our expertise lies in turning
information and data into meaningful health intelligence to support decisionmakers.
The London Health Observatory works in partnership with the NHS, local
authorities, researchers, the Mayor of London, the Greater London Authority
and other local and national agencies. The LHO’s national lead areas are
health inequalities, ethnic health and tobacco. The LHO is currently hosted by
London Health Programmes.
For more information on the LHO see www.lho.org.uk, and for more
information on London Health Programmes please see www.londonhp.nhs.uk.
1
Key messages
(Taken from the summary report Closing time: counting the cost of
alcohol-attributable hospital admissions in London)
Alcohol misuse imposes a major preventable burden on hospital
services in London

In 2008/09, it is estimated that there were just under 111,000 hospital
admissions in London attributable to alcohol, representing about 6% of
total hospital admissions in the capital.

Of these admissions, 28,000 were for “alcohol-specific” conditions in
which alcohol is a factor in all cases. The remaining 83,000 admissions
were “alcohol-related” – admissions in which alcohol is implicated in a
proportion of, but not all, cases.

67% of all alcohol-attributable admissions were emergency
admissions, but the proportion was higher for alcohol-specific
conditions (89%) than alcohol-related conditions (59%).
Alcohol-attributable admissions impose high costs on London’s health
services

Hospital admissions attributed to alcohol in 2008/09 cost the NHS in
London an estimated £264 million, or £34 for every London resident.

Of this total, £51 million was estimated to be the cost of alcohol-specific
hospital admissions. The biggest component of this cost was for
admissions classed as mental and behavioural disorders (£30 million).

The remaining £213 million was estimated to be for alcohol-related
admissions. The biggest component of this was £103 million for
diseases caused by high blood pressure.
The costs of alcohol alcohol-attributable admissions fall unequally
within London

In 2008/09, costs of alcohol-attributable hospital admissions varied
across London boroughs, ranging from £5 million in Kingston to £14.7
million in Ealing, nearly a three-fold difference.

Costs per resident across London boroughs ranged from £25 in Tower
Hamlets to £47 in Ealing.
1

The pattern of inequality emerging is different from that more
commonly seen in the capital and probably reflects the very distinctive
and different drinking behaviours among London’s diverse
communities.
Alcohol-attributable admissions used an estimated 1,600 beds in
London in 2008/09

Just over 585,000 hospital bed days were estimated to have been used
for alcohol-attributable admissions in London in 2008/09 - equivalent to
1,600 beds.

Of the total bed days used, 29% were for alcohol-specific conditions
and 71% for alcohol-related conditions.

For all alcohol-attributable admissions, 78% of bed days were used by
patients who had an emergency admission.
2
Contents
1. Introduction ........................................................................................................... 4
1.1. About the data ................................................................................................ 4
2. Use of resources ................................................................................................... 6
2.1 Introduction ...................................................................................................... 6
2.2 Estimating the cost of alcohol attributable hospital admissions ........................ 6
2.3 Analysis of bed day use and mean length of stay .......................................... 10
2.4 Analysis of hospital admissions with zero bed days ....................................... 10
2.5 Analysis of hospital provider spell bed day use .............................................. 11
2.6 Mean length of stay of the hospital provider spell ........................................... 17
2.7. Clinical coding............................................................................................... 21
3. Reducing readmissions ....................................................................................... 24
3.1 What might this mean for London? ................................................................ 25
4. Alcohol attributable hospital admissions arriving via Accident and Emergency
departments ......................................................................................................... 27
4.1 Introduction .................................................................................................... 27
4.2 Source of referral and mode of arrival ............................................................ 27
4.3 Day and month of arrival in A&E .................................................................... 28
4.5 Time of arrival ................................................................................................ 30
Annexe 1 :List of ICD10 codes for diagnoses relating to alcohol and their attributable
fractions. ............................................................................................................. 33
References.............................................................................................................. 35
3
1. Introduction
This report arose from suggested further analysis of resource use arising from
a previous London Health Observatory report on alcohol attributable hospital
admissions1. The earlier report presented summary data on numbers and
rates of alcohol attributable hospital admissions in London by sex, diagnosis,
admission type and ethnicity. Accompanying the report was a data pack for
each local authority in London.
Hospital admissions for alcohol attributable conditions are a combination of
those conditions that are wholly attributable to alcohol (alcohol-specific
conditions) and those conditions that are partially attributable to alcohol
(alcohol-related conditions). The distinction between alcohol-specific and
alcohol-related hospital admissions is important in the subsequent analysis as
only alcohol-specific hospital admissions represent unique individuals.
The objective of this report is to compliment the earlier report by providing an
estimate of resource use in terms of the hospital cost and length of stay for
alcohol attributable hospital admissions. A summary report derived from
analysis shown in here is also available
To illustrate the potential of linked data, linked Accident and Emergency data
and hospital admissions data, were analysed by month, day of the week and
hour of the day of the alcohol attributable hospital admissions.
1.1. About the data
The analyses in this report were based on Hospital Episode Statistics (HES)
data. HES data was accessed in two ways, using the online interrogation
service and by using an HES data extract specifically for alcohol attributable
hospital admissions for the financial year 2008/09 provided to Public Health
Observatories.
Hospital data consists of episodes and hospital provider spells. A consultant
episode is defined as a single period of care under one consultant. A hospital
provider spell is the period between admission and discharge and may
contain one or more consultant episodes. The first consultant episode in the
hospital provider spell is termed the admission episode, illustrated by the
diagram below taken from HESonline.2
4
Alcohol attributable hospital admissions have been identified in HES data by
the NHS Information Centre for Health and Social Care using a standard
definition developed for the NHS and Local Authority indicators VSC 23 and
the National Indicator NI 39. This is based on a set of diagnoses and
associated alcohol attributable fractions (AAFs).3 Annexe 1 contains a list of
diagnosis and attributable fractions.
The attributable fraction represents the proportion of admissions for each
diagnosis that are estimated to be due to harm caused by alcohol. For
example, it is estimated that 32% of admissions for hypertension in men aged
35-44 are attributable to alcohol. Therefore, the attributable fraction for
admissions for hypertension in this age and sex group is 0.32. For alcoholspecific conditions such as alcoholic liver disease, the attributable fraction is
one. For alcohol-related conditions, the attributable fraction is less than one.
To assign the attributable fraction all diagnoses of the hospital admission
episode (up to 20) are compared with the list of alcohol attributable
diagnoses. If multiple diagnoses are matched, the diagnosis with the largest
attributable fraction is selected as defining the admission.
Alcohol attributable admissions are reported by applying the alcohol
attributable fractions to the measure (admissions or resource) in question.
For example, if 100 men aged between 35-44 were admitted with
hypertension, and the attributable fraction is 0.32 this would equate to 32
alcohol attributable hospital admissions.
The hospital provider spell was used to estimate resource use. Alcohol
attributable hospital admissions were linked to any subsequent consultant
episode to form a complete hospital provide spell.
HES data accessed via the HES interrogation service for 2009/10 onwards
contained a linked HES Accident and Emergency dataset.
5
2. Use of resources
2.1 Introduction
The London Health Observatory developed a methodology4 for costing
smoking attributable hospital admissions for use in the Local Tobacco Control
Profiles for England. This method was used to provide cost estimates for
alcohol attributable hospital admissions. The main difference was in the
method of identifying attributable factions, for alcohol this was based on all
diagnoses in the hospital admission episode, for smoking this was the primary
diagnosis on admission.
Alcohol attributable hospital admissions for 2008/09 were linked to any
subsequent consultant episode to form a complete hospital provider spell for
that admission. A Healthcare Resource Group (HRG) code was generated for
each consultant episode in the hospital provider spell and the most resource
intensive HRG identified.
A HRG based Department of Health Payment by Results national tariff for
2008/095 was applied to the hospital provider spells for 2008/09. Any
additional costs due to the use of specialist services, extended or shortened
length of stay, and market forces factor (MFF) were added to this cost.
A tariff could not be ascribed to 2.2 percent or 8,665 alcohol attributable
hospital admissions. The majority of these (7,544) were in the Mental Health
HRG chapter T and for which tariffs have not been developed, and 273,
predominantly Liver Transplants, were in a non-mandatory tariff category.
The remaining episodes without a tariff were really a function of the data
presented to the HRG grouping process; 649 were undefined HRG groups
and 169 had “Other” as a method of admission. The proportion of episodes
without a tariff varied from 0.8 percent in Havering to 4.4 percent in Lambeth.
2.2 Estimating the cost of alcohol attributable hospital admissions
In total, there were 110,596 hospital admissions in London attributable to
alcohol in 2008/09. Alcohol-specific hospital admissions accounted for a
quarter (27,942) and alcohol-related three quarters of alcohol attributable
hospital admissions. Two thirds of alcohol attributable hospital admissions
were classified as emergency admissions (73,669) and 30 percent (34,572)
as elective.
The overall number of hospital admissions in London 2008/09 was
1,876,298.6 This implies alcohol, to a greater or lesser extent is associated
with nearly 6 percent of all hospital admissions.
6
Table 2.1: Summary of hospital admissions in London 2008/09
Hospital Admissions
Alcohol-specific Alcohol-related
Total
Elective
2,734
31,838
34,572
Emergency
24,890
48,779
73,669
Other including maternity
318
2,038
2,356
Total
27,942
82,654
110,596
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory
Applying the methods described above it is estimated alcohol attributable
hospital admissions cost the NHS in London £264.1 million in 2008/09.
This varies by borough, from £14.7 million in Ealing to £5.0 million in
Kingston, nearly a three-fold difference.
Alcohol-specific hospital admissions were estimated to cost £51.2 million and
alcohol-related hospital admissions £212.9 million. Mental and behavioural
disorders due to use of alcohol (ICD diagnostic code F10) was the single
largest alcohol-specific hospital admissions group (£30.1 million).
Hypertensive diseases were the largest alcohol-related hospital admission
group (£103.3 million). Overall, 20 diagnostic groups were estimate to cost at
least £1 million.
Table 2.2 shows the breakdown of cost to the NHS by local authority of
residence and Table 2.3 shows this by diagnostic group.
7
Table 2.2: Estimated cost of alcohol attributable hospital admissions 2008/09
Local Authority
City of London
Barking & Dagenham
Barnet
Bexley
Brent
Bromley
Camden
Croydon
Ealing
Enfield
Greenwich
Hackney
Hammersmith & Fulham
Haringey
Harrow
Havering
Hillingdon
Hounslow
Islington
Kensington & Chelsea
Kingston-upon-Thames
Lambeth
Lewisham
Merton
Newham
Redbridge
Richmond upon Thames
Southwark
Sutton
Tower Hamlets
Waltham Forest
Wandsworth
Westminster
Total for London
Estimated cost of alcohol
attributable hospital admissions
Total Cost £000s
Per capita £s
210.8
£18.7
6,444.7
£37.6
10,413.0
£30.8
5,753.4
£25.6
10,367.2
£40.7
11,938.7
£38.8
7,435.7
£32.8
12,787.6
£37.5
14,718.8
£47.2
9,570.6
£33.1
6,443.3
£28.8
6,644.7
£31.2
7,040.5
£41.8
7,584.8
£33.7
7,676.2
£34.1
8,834.7
£38.0
10,149.5
£39.3
10,094.4
£43.9
7,429.9
£39.4
5,453.8
£31.9
5,001.3
£30.4
8,584.7
£30.5
9,243.5
£35.3
6,596.3
£32.5
8,388.3
£34.6
8,215.1
£31.1
5,934.3
£31.7
8,463.6
£29.9
6,569.5
£34.7
5,763.4
£25.4
7,434.5
£33.6
9,109.0
£32.1
7,782.8
£31.6
264,078.9
£34.4
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
Population denominator ONS mid year estimates 2008.
8
Table 2.3: Estimated cost of alcohol attributable hospital admissions 2008/09
by diagnostic group
Diagnostic group
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Ethanol poisoning
Alcoholic cardiomyopathy
Toxic effect of alcohol unspecified
Alcoholic gastritis
Degeneration of nervous system due to alcohol
Alcoholic polyneuropathy
Accidental poisioning by and exposure to alcohol
Alcoholic myopathy
Alcohol induced pseudo-Cushing's syndrome
Methanol poisoning
Total alcohol-specific diagnosis
Alcohol- Hypertensive diseases
related
Cardiac arrhythmias
AAF < 1 Epilepsy and Status epilepticus
Fall injuries
Fibrosis and cirrhosis of liver
Malignant neoplasm of lip oral cavity and pharynx
Assault
Malignant neoplasm of breast
Intentional self-harm
Haemorrhagic stroke
Spontaneous abortion
Oesophageal varices
Psoriasis
Malignant neoplasm of oesophagus
Road transport accidents
Acute and chronic pancreatitis
Pedestrian transport accident
Malignant neoplasm of larynx
Ischaemic stroke
Malignant neoplasm of colon
Other chronic pancreatitis
Malignant neoplasm of rectum
Work / machine injuries
Malignant neoplasm of liver and intrahepatic bile ducts
Fire injuries
Gastro-oesophageal laceration-haemorrhage syndrome
Inhalation and ingestion of food causing obstruction of respiratory tract
Event of undetermined intent
Sequelae of cerebrovascular disease
Chronic hepatitis not elsewhere classified
Firearm injuries
Inhalation of gastric contents
Exposure to excessive natural cold
Drowning
Water transport accidents
Air / space transport accidents
Total alcohol-related diagnosis
Overall Total
Alcoholspecific
AAF=1
Cost £000s
30,088.2
16,462.2
2,116.9
979.6
464.4
366.4
295.4
213.4
149.1
34.8
9.2
1.2
0.5
51,181.2
103,327.1
53,594.7
20,362.6
7,475.8
5,413.0
3,201.1
2,068.2
1,679.0
1,627.0
1,589.5
1,586.6
1,256.5
1,239.0
1,100.4
1,060.6
1,043.0
847.6
659.1
491.3
422.3
411.8
362.7
323.8
319.5
250.7
240.1
227.6
192.8
133.0
131.9
84.9
82.8
51.8
17.2
12.7
9.8
212,897.7
264,078.9
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
9
The estimate cost of alcohol attributable hospital admissions in London is
more than that estimated for smoking, £133.4 million in 2008/09.7 However,
smoking attributable fractions are based on the primary diagnosis whereas
alcohol attributable fractions search all of the available diagnoses on the
admission record. This results in more hospital admissions being identified as
alcohol attributable than smoking attributable, hence greater overall estimated
costs. In London of the 398,087 hospital admissions containing an alcohol
attributable diagnosis in 2008/09, 17 percent of these were identified based
on the primary diagnosis.
Other estimates of the NHS costs attributable to alcohol consumption in the
UK have placed this at £3 billion,8 compared to £5 billion for smoking.9
Different methods for estimation were used and were not based on the
national tariff.
2.3 Analysis of bed day use and mean length of stay
Another indicator of the resources used by alcohol attributable hospital
admissions is bed day use. To analyse bed days it is helpful to distinguish
over night stays (an overnight stay being one or more days) from those
admitted and discharged on the same day (zero bed days). To maintain
comparability with the costing analysis the duration of the hospital spell has
been reported. The mean length of stay is the mean for the hospital spell
containing the alcohol attributable admission. Hospital spells with a zero
duration of stay were excluded from the calculation of the mean length of stay.
2.4 Analysis of hospital admissions with zero bed days
A large proportion, (37 percent) of all hospital spells with an alcohol
attributable admission diagnosis were admitted and discharges on the same
day (zero bed days). There was some variation by local authority with
Lambeth reporting the lowest (24 percent) and Bromley the highest (45
percent). The majority of zero bed day hospital spells were elective
admissions, 65 percent.
Hospital admissions for hypertensive disease formed the single largest
diagnostic group 54 percent of zero bed day hospital spells. Table 2.3 shows
the distribution of zero day hospital spells for all and elective admissions
respectively. The majority of admissions classified as alcohol-specific were
emergency admissions, 85 percent, compared to 30 percent of alcohol-related
admissions.
In terms of the activity taking place within the elective hospital spells with zero
bed days the single largest procedure, 15.7 percent was for cataract
operations.i Hypertension, alcohol, diabetes and smoking are among a range
of factors that can increase the risk of developing cataracts.
i
OPCS code version 4, C751 Insertion of prosthetic replacement for lens
10
Table 2.4: Analysis of same day hospital bed day use by alcohol attributable
diagnosis, 2008/09
Diagnostic group
Alcohol- Mental and behavioural disorders due to use of alcohol
specific Alcoholic liver disease
AAF=1 Ethanol poisoning
Toxic effect of alcohol unspecified
Chronic pancreatitis (alcohol induced)
Alcoholic gastritis
Alcoholic cardiomyopathy
Accidental poisioning by and exposure to alcohol
Alcoholic polyneuropathy
Degeneration of nervous system due to alcohol
Alcohol induced pseudo-Cushing's syndrome
Total alcohol-specific
Alcohol- Hypertensive diseases
related
Cardiac arrhythmias
AAF<1
Malignant neoplasm of breast
Fall injuries
Epilepsy and Status epilepticus
Malignant neoplasm of colon
Spontaneous abortion
Intentional self-harm
Assault
Malignant neoplasm of rectum
Work / machine injuries
Malignant neoplasm of oesophagus
Oesophageal varices
Malignant neoplasm of lip oral cavity and pharynx
Fibrosis and cirrhosis of liver
Road transport accidents
Psoriasis
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of larynx
Other chronic pancreatitis
Pedestrian transport accident
Acute and chronic pancreatitis
Event of undetermined intent
Haemorrhagic stroke
Sequelae of cerebrovascular disease
Ischaemic stroke
Gastro-oesophageal laceration-haemorrhage syndrome
Chronic hepatitis not elsewhere classified
Fire injuries
Inhalation and ingestion of food causing obstruction of respiratory tract
Firearm injuries
Drowning
Exposure to excessive natural cold
Water transport accidents
Inhalation of gastric contents
Air / space transport accidents
Total alcohol-related
Overall Total
All zero bed days
Elective only
Spells
Per cent Spells
Per cent
6,331
4.3%
529
0.5%
993
0.7%
674
0.7%
765
0.5%
1
0.0%
184
0.1%
91
0.1%
30
0.0%
70
0.0%
12
0.0%
45
0.0%
23
0.0%
14
0.0%
1
0.0%
13
0.0%
7
0.0%
5
0.0%
2
0.0%
2
0.0%
2
0.0%
8,513
5.8% 1,281
1.3%
79,284
53.6%
59,590
61.5%
13,524
9.1%
8,704
9.0%
10,517
7.1%
10,085
10.4%
6,540
4.4%
551
0.6%
4,821
3.3%
2,279
2.4%
4,566
3.1%
4,440
4.6%
4,262
2.9%
1,740
1.8%
2,692
1.8%
39
0.0%
2,358
1.6%
392
0.4%
2,044
1.4%
1,983
2.0%
1,384
0.9%
486
0.5%
1,305
0.9%
1,220
1.3%
952
0.6%
928
1.0%
858
0.6%
776
0.8%
814
0.6%
705
0.7%
746
0.5%
51
0.1%
724
0.5%
606
0.6%
273
0.2%
244
0.3%
236
0.2%
224
0.2%
229
0.2%
185
0.2%
191
0.1%
10
0.0%
176
0.1%
113
0.1%
161
0.1%
13
0.0%
156
0.1%
23
0.0%
122
0.1%
85
0.1%
105
0.1%
57
0.1%
76
0.1%
20
0.0%
73
0.0%
61
0.1%
71
0.0%
5
0.0%
58
0.0%
6
0.0%
32
0.0%
15
0.0%
6
0.0%
6
0.0%
6
0.0%
3
0.0%
1
0.0%
139,372
94.2%
95,636
98.7%
147,885 100.0%
96,917 100.0%
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
2.5 Analysis of hospital provider spell bed day use
The number of hospital bed days used provides an alternative way of looking
at resource use. Alcohol attributable fractions were applied to the duration of
stay and overnight stays only were included.
In total 585,513 hospital bed days were estimated to be attributable to alcohol
in London in 2008/09. This is equivalent to 1,600 beds. Of the total bed days
used 29 percent (167,684 bed days) were alcohol-specific and 71 percent
(417,829) were alcohol-related.
11
Emergency admissions were the largest proportion of hospital bed days, 78
percent (457,084 bed days). This was true for both alcohol-specific and
alcohol-related hospital admissions.
Mental and behavioural disorders due to use of alcohol and alcoholic liver
disease were the largest proportion of alcohol-specific hospital bed days, 93
percent (157,393 bed days). Hypertensive diseases and cardiac arrhythmias
were the largest proportion of alcohol-related hospital bed days, 72 percent.
This also corresponds with the distribution of estimated hospital costs by
diagnosis. Tables 2.5 to 2.9 show the distribution of hospital bed days by
method of admission, local authority and diagnosis.
Table 2.5: Analysis of alcohol attributable hospital bed days (overnight stay) by
method of admission, 2008/9
Alcohol-specific
Method of Admission
Hospital
spells
Alcohol-related
Total bed Hospital
days
spells
Total bed Hospital
days
spells
Total
Total bed
days
26,088 11,504
75,206 12,930
101,294
134,481 35,167
322,603 51,102
457,084
7,115
1,587
20,019
1,872
27,134
17,646
167,684 48,259
417,829 65,905
585,513
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
Elective
Emergency
Other including maternity
Total
1,426
15,935
285
12
Table 2.6: Alcohol attributable hospital bed days (overnight stay) by local
authority 2008/09
Alcohol-specific
AAF=1
Local Authority
City of London
Barking & Dagenham LB
Barnet LB
Bexley LB
Brent LB
Bromley LB
Camden LB
Croydon LB
Ealing LB
Enfield LB
Greenwich LB
Hackney LB
Hammersmith & Fulham LB
Haringey LB
Harrow LB
Havering LB
Hillingdon LB
Hounslow LB
Islington LB
Kensington & Chelsea LB
Kingston-upon-Thames LB
Lambeth LB
Lewisham LB
Merton LB
Newham LB
Redbridge LB
Richmond upon Thames LB
Southwark LB
Sutton LB
Tower Hamlets LB
Waltham Forest LB
Wandsworth LB
Westminster LB
Total
Hospital
spells
33
336
460
345
642
666
777
713
1,000
403
579
601
640
519
335
311
576
628
595
444
318
875
811
412
459
442
309
800
381
467
484
639
646
17,646
Alcohol-related
AAF <1
Total bed Hospital
days
spells
310
29
2,837
1,270
4,219
1,963
4,181
1,248
6,118
1,811
6,241
2,193
7,925
1,060
8,199
2,461
8,570
2,640
4,997
1,927
6,277
1,304
6,520
1,151
4,680
1,086
5,705
1,294
3,949
1,463
1,979
1,822
4,652
2,085
5,729
1,575
5,703
1,185
5,232
858
2,802
882
9,074
1,456
7,517
1,792
4,096
1,272
4,083
1,328
3,283
1,666
3,100
986
8,235
1,430
3,190
1,397
4,553
1,067
2,625
1,566
5,242
1,742
5,861
1,252
167,684
48,259
Total
Total bed Hospital
days
spells
245
62
10,896
1,606
15,721
2,423
12,730
1,593
14,074
2,453
20,470
2,859
8,678
1,837
21,441
3,174
22,267
3,640
18,247
2,330
12,369
1,883
11,625
1,752
8,963
1,726
12,056
1,813
11,487
1,798
15,284
2,133
16,115
2,661
13,475
2,203
10,288
1,780
7,195
1,302
7,805
1,200
13,462
2,331
14,500
2,603
11,482
1,684
10,799
1,787
14,318
2,108
9,429
1,295
12,601
2,230
11,233
1,778
9,097
1,534
12,803
2,050
16,107
2,381
10,566
1,898
417,829
65,905
Total bed
days
555
13,733
19,940
16,911
20,192
26,711
16,603
29,640
30,837
23,244
18,646
18,145
13,643
17,761
15,436
17,263
20,767
19,204
15,991
12,427
10,607
22,536
22,017
15,578
14,882
17,601
12,529
20,836
14,423
13,650
15,428
21,349
16,427
585,513
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
13
Table 2.7: Analysis of hospital bed days (overnight stay) by alcohol attributable
diagnosis, elective admissions 2008/09
Diagnostic group
Alcohol
specific
AAF=1
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Alcoholic cardiomyopathy
Alcoholic polyneuropathy
Degeneration of nervous system due to alcohol
Ethanol poisoning
Toxic effect of alcohol unspecified
Alcoholic gastritis
Total alcohol specific diagnosis
Alcohol
related
AAF<1
Hypertensive diseases
Cardiac arrhythmias
Epilepsy and Status epilepticus
Malignant neoplasm of lip oral cavity and pharynx
Fibrosis and cirrhosis of liver
Intentional self-harm
Malignant neoplasm of breast
Malignant neoplasm of oesophagus
Malignant neoplasm of larynx
Haemorrhagic stroke
Psoriasis
Fall injuries
Malignant neoplasm of rectum
Malignant neoplasm of colon
Oesophageal varices
Ischaemic stroke
Malignant neoplasm of liver and intrahepatic bile ducts
Other chronic pancreatitis
Sequelae of cerebrovascular disease
Acute and chronic pancreatitis
Assault
Spontaneous abortion
Gastro-oesophageal laceration-haemorrhage syndrome
Road transport accidents
Pedestrian transport accident
Inhalation of gastric contents
Fire injuries
Inhalation and ingestion of food causing obstruction of respiratory tract
Work / machine injuries
Chronic hepatitis not elsewhere classified
Firearm injuries
Event of undetermined intent
Water transport accidents
Total alcohol-related diagnosis
Total
Hospital
spells
999
347
57
14
4
2
1
1
1
1,426
6,658
2,078
999
533
268
26
259
93
65
21
66
98
38
35
36
11
25
24
8
20
55
43
3
15
6
1
5
1
5
5
2
2
1
11,504
12,930
Total bed
days
22,920
2,678
348
106
24
4
4
3
1
26,088
36,834
15,884
9,810
3,679
1,986
1,165
973
682
563
535
483
478
336
293
276
235
162
154
139
138
90
63
58
52
42
23
19
16
13
11
7
5
1
75,206
101,294
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
14
Table 2.8: Analysis of hospital bed days (overnight stay) by alcohol attributable
diagnosis, emergency admissions 2008/09
Diagnostic group
Alcohol
specific
AAF=1
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Ethanol poisoning
Alcoholic cardiomyopathy
Toxic effect of alcohol unspecified
Degeneration of nervous system due to alcohol
Alcoholic polyneuropathy
Alcoholic gastritis
Accidental poisioning by and exposure to alcohol
Alcoholic myopathy
Methanol poisoning
Total alcohol specific diagnosis
Alcohol
related
AAF<1
Hypertensive diseases
Cardiac arrhythmias
Epilepsy and Status epilepticus
Fall injuries
Fibrosis and cirrhosis of liver
Intentional self-harm
Malignant neoplasm of lip oral cavity and pharynx
Haemorrhagic stroke
Psoriasis
Acute and chronic pancreatitis
Assault
Malignant neoplasm of oesophagus
Pedestrian transport accident
Oesophageal varices
Road transport accidents
Ischaemic stroke
Spontaneous abortion
Malignant neoplasm of breast
Inhalation and ingestion of food causing obstruction of respiratory tract
Malignant neoplasm of larynx
Other chronic pancreatitis
Malignant neoplasm of liver and intrahepatic bile ducts
Gastro-oesophageal laceration-haemorrhage syndrome
Malignant neoplasm of colon
Inhalation of gastric contents
Fire injuries
Malignant neoplasm of rectum
Event of undetermined intent
Sequelae of cerebrovascular disease
Chronic hepatitis not elsewhere classified
Exposure to excessive natural cold
Work / machine injuries
Firearm injuries
Drowning
Air / space transport accidents
Water transport accidents
Total alcohol-related diagnosis
Total
Hospital
spells
11,319
2,950
501
678
98
184
48
27
115
11
3
1
15,935
15,049
9,123
4,199
1,557
697
930
272
167
185
245
549
159
173
146
284
67
661
129
43
55
64
38
76
33
16
30
25
62
24
17
11
56
16
4
3
4
35,167
51,102
Total bed
days
90,612
34,549
4,179
1,451
1,103
932
731
450
392
51
29
2
134,481
130,277
104,716
36,916
13,688
7,937
3,552
2,988
2,505
1,833
1,821
1,730
1,714
1,686
1,664
1,480
1,058
1,040
983
708
692
516
401
384
369
271
267
261
248
202
188
155
142
112
60
23
16
322,603
457,084
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
15
Table 2.9: Analysis of hospital bed days (overnight stay) by alcohol attributable
diagnosis, all other admissions including maternity 2008/09
Diagnostic group
Alcohol
specific
AAF=1
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Alcoholic polyneuropathy
Alcoholic cardiomyopathy
Ethanol poisoning
Total alcohol specific diagnosis
Alcohol
related
AAF<1
Hypertensive diseases
Cardiac arrhythmias
Epilepsy and Status epilepticus
Haemorrhagic stroke
Fibrosis and cirrhosis of liver
Fall injuries
Intentional self-harm
Spontaneous abortion
Ischaemic stroke
Malignant neoplasm of lip oral cavity and pharynx
Fire injuries
Assault
Acute and chronic pancreatitis
Malignant neoplasm of larynx
Oesophageal varices
Road transport accidents
Pedestrian transport accident
Psoriasis
Sequelae of cerebrovascular disease
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of oesophagus
Malignant neoplasm of breast
Malignant neoplasm of rectum
Other chronic pancreatitis
Work / machine injuries
Event of undetermined intent
Malignant neoplasm of colon
Chronic hepatitis not elsewhere classified
Inhalation and ingestion of food causing obstruction of respiratory tract
Inhalation of gastric contents
Firearm injuries
Gastro-oesophageal laceration-haemorrhage syndrome
Water transport accidents
Total alcohol-related diagnosis
Total
Hospital
spells
195
71
10
3
2
4
285
589
349
320
51
36
36
17
74
9
10
8
18
6
3
9
8
6
10
2
3
4
4
1
2
9
1
1
1
2
1
1
1
0
1,587
1,872
Total bed
days
4,908
1,726
255
118
77
31
7,115
7,899
5,487
2,569
1,065
678
398
286
236
221
191
108
107
94
88
86
85
85
64
49
43
35
30
22
22
20
18
18
6
3
2
2
1
0
20,019
27,134
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London and London Health Observatory.
16
2.6 Mean length of stay of the hospital provider spell
The mean length of stay provides another way of looking at resource use. In
the calculation of length of stay only overnight stays have been included. To
provide a more robust estimate of the mean length of stay the geometric
mean has been calculated. As the distribution of the mean length of stay is
both non-negative and skewed to the right, calculating the geometric mean
helps to reduce this impact. Alcohol attributable fractions have not been
applied to the mean length of stay; rather these represent the mean stay for
those admissions identified with an alcohol attributable diagnosis.
Overall, elective hospital admissions had the shortest mean length of stay, 3.3
days compared with 4.7 days for emergency admissions. There was nearly a
two-day variation in mean length of stay by local authority from 5.6 days in
Bexley to 3.8 days in Hammersmith and Fulham.
For alcohol-specific hospital admissions mental and behavioural diagnoses
formed both the largest number of elective admissions and had the longest
mean length of stay, 9.4 days. Mental and behavioural diagnoses were also
the largest number of alcohol-specific emergency admissions with a mean
length of stay of 3.6 days.
Tables 2.10 to 2.14 show the average spell duration of hospital stay by local
authority of residence, method of admission and broad diagnostic group.
17
Table 2.10: Average duration of hospital stay, alcohol attributable hospital
admissions by local authority 2008/09
95% Confidence interval
Mean
Hospital
duration of
Spells
stay (Days) Lower limit Upper Limit
Local Authority
City of London
174
4.3
3.6
5.1
Barking & Dagenham LB
5,982
4.5
4.4
4.7
Barnet LB
9,435
4.4
4.3
4.5
Bexley LB
6,101
5.6
5.4
5.8
Brent LB
8,494
4.1
4.0
4.2
Bromley LB
10,675
4.6
4.5
4.7
Camden LB
5,238
4.2
4.0
4.3
Croydon LB
11,360
4.5
4.4
4.6
Ealing LB
12,368
4.2
4.1
4.3
Enfield LB
9,069
4.8
4.6
4.9
Greenwich LB
6,278
5.0
4.9
5.2
Hackney LB
5,658
4.7
4.5
4.8
Hammersmith & Fulham LB
5,424
3.8
3.7
3.9
Haringey LB
6,179
4.4
4.3
4.5
Harrow LB
6,910
4.0
3.9
4.1
Havering LB
8,670
4.5
4.4
4.6
Hillingdon LB
9,722
3.9
3.8
4.0
Hounslow LB
7,533
3.9
3.8
4.0
Islington LB
5,688
4.2
4.0
4.3
Kensington & Chelsea LB
4,302
4.2
4.0
4.3
Kingston-upon-Thames LB
4,293
5.0
4.8
5.2
Lambeth LB
7,125
4.7
4.5
4.8
Lewisham LB
8,549
4.4
4.3
4.5
Merton LB
6,096
4.7
4.5
4.8
Newham LB
5,948
3.9
3.8
4.0
Redbridge LB
7,950
4.5
4.4
4.6
Richmond upon Thames LB
4,827
4.6
4.4
4.7
Southwark LB
6,840
4.6
4.4
4.7
Sutton LB
6,623
4.3
4.2
4.4
Tower Hamlets LB
4,998
4.8
4.6
4.9
Waltham Forest LB
7,298
4.1
4.0
4.2
Wandsworth LB
8,217
4.7
4.6
4.8
Westminster LB
6,003
4.3
4.2
4.5
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
18
Table 2.11: Average duration of hospital stay, alcohol attributable hospital
admissions, method of admission 2008/09
Mean
Hospital
duration of
Method of Admission
Spells
stay (Days)
Elective
51,838
3.3
Emergency
171,849
4.7
Other including maternity
6,340
6.6
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
Table 2.12: Average duration of hospital stay of alcohol attributable diagnosis,
elective hospital admissions 2008/09
95% Confidence interval
Alcoholspecific
AAF=1
Alcoholrelated
AAF<1
Hospital
Spells
999
347
57
14
4
2
1
1
1
Diagnostic group
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Alcoholic cardiomyopathy
Alcoholic polyneuropathy
Degeneration of nervous system due to alcohol
Alcoholic gastritis
Ethanol poisoning
Toxic effect of alcohol unspecified
Hypertensive diseases
Cardiac arrhythmias
Malignant neoplasm of breast
Epilepsy and Status epilepticus
Malignant neoplasm of lip oral cavity and pharynx
Malignant neoplasm of colon
Fall injuries
Malignant neoplasm of rectum
Fibrosis and cirrhosis of liver
Malignant neoplasm of oesophagus
Malignant neoplasm of larynx
Psoriasis
Assault
Spontaneous abortion
Malignant neoplasm of liver and intrahepatic bile ducts
Acute and chronic pancreatitis
Haemorrhagic stroke
Other chronic pancreatitis
Ischaemic stroke
Intentional self-harm
Work / machine injuries
Road transport accidents
Sequelae of cerebrovascular disease
Oesophageal varices
Pedestrian transport accident
Fire injuries
Chronic hepatitis not elsewhere classified
Event of undetermined intent
Firearm injuries
Gastro-oesophageal laceration-haemorrhage syndrome
Inhalation and ingestion of food causing obstruction of respiratory tract
Inhalation of gastric contents
Water transport accidents
* Confidence intervals for 2 or fewer admissions not calculated
32,033
6,857
3,414
1,785
1,228
1,123
651
644
411
395
230
208
203
200
196
110
109
109
108
78
68
66
57
54
23
13
8
7
6
6
4
4
4
Mean
duration of
stay
(Days)
9.4
3.8
3.3
4.0
5.5
1.7
1.0
4.0
3.0
3.1
3.7
2.7
3.5
3.6
4.8
2.4
5.3
3.9
3.7
3.8
3.6
1.3
1.3
3.9
3.2
10.9
2.9
5.3
9.5
1.7
1.8
4.0
3.3
3.1
2.6
1.8
2.0
2.9
5.8
14.2
13.4
1.4
Lower limit
Upper Limit
8.7
3.3
2.5
2.1
2.5
*
*
*
*
10.2
4.2
4.3
8.0
12.1
*
*
*
*
3.1
3.6
2.6
3.3
3.4
4.6
2.2
4.9
3.5
3.3
3.2
3.1
1.2
1.2
3.3
2.6
8.4
2.4
4.0
6.5
1.5
1.4
2.7
2.5
1.8
1.5
1.0
1.0
1.0
0.9
5.7
1.4
0.5
3.1
3.8
2.8
3.7
3.8
5.1
2.6
5.7
4.4
4.2
4.5
4.2
1.4
1.3
4.4
3.9
14.1
3.6
7.0
14.0
2.1
2.3
6.0
4.3
5.3
4.4
3.5
4.2
8.7
38.2
35.7
130.7
4.3
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London
19
Table 2.13: Average duration of hospital stay of alcohol attributable diagnosis
for emergency hospital admissions 2008/09
95% Confidence interval
Alcoholspecific
AAF=1
Alcoholrelated
AAF<1
Hospital
Spells
11,319
2,950
678
501
184
115
98
48
27
11
3
1
Diagnostic group
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Ethanol poisoning
Chronic pancreatitis (alcohol induced)
Toxic effect of alcohol unspecified
Alcoholic gastritis
Alcoholic cardiomyopathy
Degeneration of nervous system due to alcohol
Alcoholic polyneuropathy
Accidental poisioning by and exposure to alcohol
Alcoholic myopathy
Methanol poisoning
Hypertensive diseases
Cardiac arrhythmias
Fall injuries
Epilepsy and Status epilepticus
Spontaneous abortion
Intentional self-harm
Assault
Malignant neoplasm of breast
Road transport accidents
Acute and chronic pancreatitis
Fibrosis and cirrhosis of liver
Malignant neoplasm of colon
Haemorrhagic stroke
Work / machine injuries
Malignant neoplasm of oesophagus
Ischaemic stroke
Malignant neoplasm of lip oral cavity and pharynx
Pedestrian transport accident
Psoriasis
Malignant neoplasm of rectum
Malignant neoplasm of liver and intrahepatic bile ducts
Other chronic pancreatitis
Oesophageal varices
Sequelae of cerebrovascular disease
Malignant neoplasm of larynx
Event of undetermined intent
Inhalation and ingestion of food causing obstruction of respiratory tract
Gastro-oesophageal laceration-haemorrhage syndrome
Fire injuries
Inhalation of gastric contents
Firearm injuries
Exposure to excessive natural cold
Chronic hepatitis not elsewhere classified
Water transport accidents
Air / space transport accidents
Drowning
* Confidence intervals for 2 or fewer admissions not calculated
78,854
32,880
14,271
7,988
3,048
2,752
2,033
1,761
1,376
1,223
1,117
1,085
934
793
730
645
639
614
602
437
337
297
227
218
206
186
172
161
80
64
63
45
29
18
17
12
Mean
duration of
stay
(Days)
3.6
6.6
1.5
4.5
1.6
2.2
5.9
8.8
12.2
3.1
3.0
2.0
4.8
6.2
5.0
4.2
1.4
1.9
2.0
4.9
2.9
5.2
6.7
6.8
7.1
1.9
6.6
7.6
6.5
4.8
5.4
6.3
6.4
4.8
7.2
5.2
6.5
2.2
5.5
3.1
4.5
9.1
2.7
7.4
5.9
3.1
6.0
6.7
Lower limit
Upper Limit
3.5
6.4
1.5
4.1
1.4
1.9
4.7
6.3
8.5
1.6
0.0
*
3.7
6.9
1.6
4.9
1.8
2.5
7.4
12.3
17.6
5.8
338.9
*
4.8
6.1
4.9
4.1
1.3
1.8
1.9
4.7
2.7
4.9
6.3
6.4
6.6
1.8
6.1
6.9
5.9
4.3
5.0
5.7
5.7
4.2
6.4
4.5
5.5
1.9
4.4
2.7
3.5
6.7
2.0
5.1
3.5
2.0
3.8
2.7
4.9
6.3
5.2
4.3
1.4
1.9
2.0
5.2
3.1
5.4
7.2
7.3
7.8
2.0
7.1
8.3
7.1
5.2
5.9
7.0
7.2
5.4
8.2
6.0
7.6
2.5
6.9
3.6
5.9
12.3
3.5
10.7
9.7
4.7
9.4
16.7
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
20
Table 2.14: Average duration of hospital stay of alcohol attributable diagnosis
for all other hospital admissions including maternity 2008/09
95% Confidence interval
Alcoholspecific
AAF=1
Alcoholrelated
AAF<1
Hospital
Spells
195
71
10
4
3
2
Diagnostic group
Mental and behavioural disorders due to use of alcohol
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Ethanol poisoning
Alcoholic polyneuropathy
Alcoholic cardiomyopathy
Hypertensive diseases
Cardiac arrhythmias
Epilepsy and Status epilepticus
Spontaneous abortion
Fall injuries
Haemorrhagic stroke
Work / machine injuries
Ischaemic stroke
Assault
Fibrosis and cirrhosis of liver
Intentional self-harm
Malignant neoplasm of breast
Road transport accidents
Psoriasis
Acute and chronic pancreatitis
Malignant neoplasm of lip oral cavity and pharynx
Malignant neoplasm of colon
Fire injuries
Malignant neoplasm of liver and intrahepatic bile ducts
Pedestrian transport accident
Malignant neoplasm of oesophagus
Oesophageal varices
Malignant neoplasm of larynx
Malignant neoplasm of rectum
Sequelae of cerebrovascular disease
Other chronic pancreatitis
Inhalation and ingestion of food causing obstruction of respiratory tract
Event of undetermined intent
Firearm injuries
Gastro-oesophageal laceration-haemorrhage syndrome
Inhalation of gastric contents
Chronic hepatitis not elsewhere classified
Water transport accidents
* Confidence intervals for 2 or fewer admissions not calculated
2,697
1,172
546
341
286
275
129
82
65
55
50
49
40
32
31
24
23
22
21
17
16
14
13
13
13
11
6
4
2
2
2
1
1
Mean
duration of
stay
(Days)
7.8
14.5
11.7
4.4
30.4
33.2
7.1
8.6
3.9
2.3
6.1
12.3
1.7
16.1
3.1
11.6
7.4
5.5
6.2
4.3
8.7
10.4
10.5
5.5
12.6
9.2
8.0
7.0
14.6
13.2
14.5
8.8
1.5
Lower limit
*
9.4
18.2
27.6
33.6
278.7
*
6.7
8.1
3.6
2.1
5.2
10.8
1.5
12.6
2.4
9.0
5.1
4.1
4.2
3.1
5.9
6.1
5.8
3.0
8.8
4.9
4.5
3.6
7.2
5.8
7.1
7.4
0.9
1.0
7.28
2.2
1.0
3.7
11.0
2.0
Upper Limit
6.4
11.5
5.0
0.6
3.3
*
*
*
*
*
7.4
9.2
4.3
2.5
7.1
13.9
1.9
20.4
4.0
15.0
10.7
7.5
9.0
6.0
13.0
17.9
18.7
10.1
17.9
17.0
13.9
13.3
29.9
30.4
29.6
10.5
2.5
51.8
*
*
*
*
*
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London
2.7. Clinical coding
As described the algorithm that identifies an alcohol attributable hospital
admission inspects up to 20 ICD 10 diagnostic codes contained on the
hospital admission episode. If the number of diagnostic codes per admission
episode systematically varied this may influence the likelihood of identifying
an alcohol attributable admission. The average number of diagnoses per FCE
is referred to as the depth of coding.
Table 2.15 shows the depth of coding expressed as the mean, median and
90th percentile by local authority in London 2008/09. Overall the average
depth of coding was 4.7 codes per hospital admission episode, ranging from
3.8 in Bexley and Greenwich to 5.2 in Ealing.
There is some suggestion of an association between the standardised rate of
alcohol attributable hospital admissions and the depth of coding. Ealing had
the highest standardised rate of alcohol attributable admissions and the
highest depth of coding, 5.2 per hospital admission episode. Conversely
21
Bexley had relatively low standardised rates of alcohol attributable hospital
admissions and admissions and low depth of coding 3.8 codes per hospital
admission record. However, the majority of local authorities had a depth of
coding of between 4.4 and 5.0 diagnostic codes per hospital admission
episode.
Table 2.15: Depth of clinical coding 2008/09 HES data
Number of diagnostic codes
Rate of alcohol
including
attributable
primary diagnosis
hospital
90th
admissions
Local Authority
Mean Median percentile
2008/09 (2)
Ealing LB
5.2
5
9
2,140.9
Islington LB
4.5
4
8
1,990.6
Newham LB
4.7
4
8
1,981.3
Hammersmith & Fulham LB
4.9
4
9
1,978.0
Hounslow LB
5.1
5
9
1,932.9
Barking & Dagenham LB
4.5
4
7
1,841.0
Hillingdon LB
5.0
5
9
1,802.8
Lewisham LB
4.5
4
8
1,705.2
Waltham Forest LB
4.7
4
8
1,670.0
Brent LB
4.8
4
8
1,662.1
Haringey LB
4.5
4
8
1,633.0
Camden LB
4.9
4
9
1,607.8
Hackney LB
4.5
4
8
1,592.1
Croydon LB
5.1
5
9
1,515.1
Wandsworth LB
5.0
5
9
1,474.7
Lambeth LB
4.7
4
8
1,459.0
Tower Hamlets LB
4.5
4
8
1,440.3
Redbridge LB
4.4
4
7
1,440.2
Bromley LB
4.5
4
8
1,437.5
Havering LB
4.6
4
8
1,400.6
Enfield LB
4.6
4
8
1,350.5
Greenwich LB
3.8
3
7
1,327.8
Southwark LB
4.6
4
8
1,312.2
Harrow LB
4.9
4
8
1,282.3
Sutton LB
4.9
5
9
1,279.6
Westminster LB
4.6
4
8
1,272.3
Barnet LB
4.5
4
8
1,220.0
Merton LB
5.1
5
9
1,200.0
Richmond upon Thames LB
4.8
4
8
1,102.1
Kingston-upon-Thames LB
4.6
4
8
1,101.8
Kensington & Chelsea LB
4.7
4
8
1,081.6
Bexley LB
3.8
3
6
911.2
City of London
4.5
4
8
851.5
London
4.7
4
8
1,483.0
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
(2) Local Alcohol Profiles for England. Alcohol attributable hospital admissions per 100,000
2008/09
The depth of coding gives an indication of the quality of diagnostic coding but
not the accuracy of coding. The Audit Commission have conducted annual
22
national clinical coding audits linked to Payment by Results. The audit for
2008/0910 indicated the overall national coding error rate was 12.8 percent,
an improvement from 2007/08 when the error rate was 16.5 percent. The
audit indicated there was little evidence to suggest over or under-coding of
activity. However, the audit concluded the level of error continues to be a
concern given the wider use and application of clinical coding data within the
NHS.
Clinical coding of alcohol use is dependent on clinicians interpreting both the
consumption and effect on the patient’s health and documenting this in case
notes. The inclusion of alcohol abuse in the list of mandatory co-morbidities to
be recorded for admitted patient care data from April 2010, gives additional
weight to auditing the clinical recording and subsequent clinical coding of
alcohol use.
It should be recognised clinical coding is subject to error and this will carry
through to the identification of alcohol attributable hospital admissions.
Therefore the use of resources presented here are estimates based on the
available 2008/09 hospital admissions data.
23
3. Reducing readmissions
Patients with repeated alcohol-specific admissions present a significant
burden on hospital resources.11 Below are examples of initiatives that have
been adopted in London and elsewhere to aid in the reduction of alcoholattributable readmissions.
I. Salford data sharing model
A report produced by the Royal College of Physicians called for a cultural
shift from merely treating the disease to tackling the underlying alcohol
problem. One way of doing this is by improving liaison between acute
hospitals and mental health trusts.11
Salford Royal NHS Foundation Trust working in conjunction with Salford
PCT initiated a ‘Healthy Hospitals’ data sharing project, a partnership that
has managed to integrate hospital and community treatment in order to
improve the management of patients with co-morbidities. Robust data
collection and analysis of hospital data, alongside collaboration with DAAT
(Drugs & Alcohol Action Team) facilitated the identification of 100 patients
who had the highest frequent use of services.
Subsequent data sharing between the acute medical management,
community alcohol, mental health, psychiatric, housing and probation
services hopes to achieve a reduction by 225 admissions, with an annual
cost saving of £340,000.11
II. Alcohol Intensive Case Management- Wandsworth project12
This initiative is run by Westminster Drug Project; a charity that provides
advice, support and treatment to those affected by drug and alcohol
misuse. The project targets severely dependant adults (those with high
levels of contact with acute health services and have a poor history of
engaging with alcohol treatment services). The project aims to;



Reduce the severity and longer term consequences of severe
alcohol dependency
Reduce the level of utilisation of acute health care services
including a reduction in non-planned admissions
Increase levels of engagement with both primary health care and
specialist alcohol treatment services.
These objectives are delivered via the following;




A comprehensive assessment of needs
Community case management and care assessment
Referal to other specialist service and facilitation of multi-agency
intervenetion
Psychosial interventions such as Cognitive Behavioural Therapy
(CBT)
24

Direct support/assistance in engaging with services e.g.
arranging and escorting clients to appointments
III. Alcohol Screening and Brief Intervention
Alcohol screening, also commonly referred to as IBA (Identification and
Brief Advice) is different from other medical screening programs because
it does not involve recalling patients for periodic screening over the
years. Rather, alcohol screening encourages opportunistic screening and
brief advice when patients attend an emergency department13.
The use of an alcohol screening and intervention toolkit (SBIRT) piloted
in emergency departments across USA showed an 8.7 percent total
reduction in return visits due to alcohol-related injuries. The use of a
screening toolkit also led to a 10 percent reduction in alcohol
consumption14.
SBIRT is a particularly effective toolkit because it combines the following
three components of intervention; screening, brief intervention and
referral to treatment.14
In the UK, the Department of Health views IBA as one of the most costeffective intervention that can be implemented among the range of
available interventions.13
Routine use of screening tools also has the added benefit of shifting the
focus from alcoholism as a clinical entity to a public health perspective
that emphasises the early detection of hazardous drinking before the
onset of significant harm.15
3.1 What might this mean for London?
Results from a randomised control trial conducted at St Mary’s hospital in
London recorded a 50 percent drop in A&E re-attendance among patients
referred for brief interventions. To avoid one visit to the emergency
department, nine people needed to be screened and two people referred for a
brief intervention.16
The Regional Public Health Group London used the above trial to illustrate the
cost saving potential of prevention. This of course has a number of caveats
not least the assumption that the characteristics of patients admitted to
hospital are the same as those arriving in A&E. It is likely those admitted with
alcohol-specific conditions may be less amenable to IBA. Nevertheless, this
indicates an area for further analysis and modelling.
Using HES A&E and APC (Admitted Patient Care) linked data; we know that
about 22% percent of all A&E attendances are eventually admitted.17 Using
the findings from the St Mary’s hospital study, if an IBA was offered for every
two A&E attendances, the hypothetical 50 percent drop in re-attendances,
also gives an average drop of 50 percent in alcohol-specific hospital
readmissions admitted as an emergency, as shown on Table 3.1.
25
In monetary terms, based on the cost of emergency readmissions previously
calculated this would result in a reduction of approximately £26 million in
hospital costs across London.
Table 3.1: Potential reduction in hospital readmissions in London as a result of
IBA
Alcohol-specific A&E Attendances
Total in year Attendances
Single A& E Attendances
205,774
105,529
Multiple A&E Attendances
After 50% drop in
reattendances (post IBA)
100,245
All Attendances
Single Attendances
155,652
105,529
Multiple Attendances
50,123
Alcohol-specific A&E Admissions
Total in year A&E admissions
Single A&E Admissions
Multiple A&E Admissions
After 50% drop in reattendances
All admissions
44,511
22,827
21,684
33,621
Single A&E Admissions
22,827
Multiple A&E Admissions
10,794
Total drop
Single A&E Admissions
0
Multiple Admissions
Percentage drop (multiple
admissions)
Cost of emergency multiple
admissions £000s
Cost of emergency multiple
admissions (post IBA) £000s
10,890
Predicted cost reduction £000s
26
50.22%
52,284.5
26,258.5
26,026.0
4. Alcohol attributable hospital admissions arriving via Accident and
Emergency departments
4.1 Introduction
The Health and Social Care Information Centre (The Information Centre) 18
published a second experimental statistics report on accident and emergency
(A&E) attendances for 2009/10. The report drew attention to the provision of
A&E HES data linked to admitted patient care data for 2009/10.
An initial analysis of HES A&E data for London NHS hospital providers19
showed reasonably good coverage20 of the number of A&E attendances when
compare to the Quarterly Monitoring of Accident and Emergency (QMAE)
return. This increased to 88 percent if A&E attendances at PCT providers,
which do not appear in HES, were excluded.
The analysis showed the recording of the diagnosis on attending A&E was
low, only 34 percent of attendances have a diagnosis with any discriminatory
value. This is lower than the national figure of 48 percent. Ten of the 27 NHS
hospital providers in London A&E HES dataset in London had zero valid
primary A&E diagnosis codes. A similar picture of was found for the reason
for A&E attendance. A high proportion 79 percent were recorded as “Other”
or “Not known” and a further 17 percent were coded as “other accident”. In
London a slightly greater proportion were as classified as “Not known” than
nationally; both indicate that for at least 80 percent of the data the reason for
A&E attendance is not well described.
In contrast, time and duration of A&E attendance were largely complete; for
London NHS hospital providers and all date fields complete only 0.8 percent
of A&E arrival times were incomplete.
By linking A&E and admitted patient datasets those records with an alcohol
attributable condition and admitted via A&E can be determined, thereby
enriching both datasets. The analysis reported illustrates the possibilities for
analysis arising from linked records. It is included to encourage the use of
linked data and to stimulate improvements in data quality by showing the
values of such data.
4.2 Source of referral and mode of arrival
As previously discussed alcohol attributable hospital admissions may be
alcohol-specific or alcohol-related. The analysis of alcohol-related hospital
admissions linked analysis is of limited value as individual episodes are not
identified. It is assumed, and that assumption may be incorrect, that in any
sub analysis of alcohol-related hospital admissions the distribution of a factor
is the same, whether alcohol-related or not. Secondly, as diagnostic coding
is poorly completed on the A&E dataset it is not possible to complement the
admission episode AAF with additional diagnostic information. Tables 4.1 and
4.2 show the mode of arrival and source of referral. The majority (70 percent)
27
of alcohol attributable admissions arriving from A&E were brought in by
ambulance.
Table 4.1 Alcohol attributable hospital admissions: A&E arrival mode 2009/10
Brought in by ambulance
Other
Not known
Total
Alcohol-related
Alcohol- specific
Total
Number Percent Number Percent Number Percent
15,220
73.0% 121,325
68.6% 136,545
69.1%
5,412
26.0%
53,184
30.1%
58,596
29.6%
207
1.0%
2,320
1.3%
2,527
1.3%
20,839 100.0% 176,829 100.0% 197,668 100.0%
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
Table 4.2 Alcohol attributable hospital admissions: A&E source of referral
2009/10
General medical practitioner
Self referral
Local authority social services
Emergency services
Work
Educational establishment
Police
Health care provider: same or other
All other
Not known
Total
Alcohol-related
Alcohol-specific
Total
Number Percent Number Percent Number Percent
1,003
4.8%
17,930
10.1%
18,933
9.6%
9,364
44.9%
76,194
43.1%
85,558
43.3%
81
0.4%
692
0.4%
773
0.4%
1,955
9.4%
18,777
10.6%
20,732
10.5%
13
0.1%
229
0.1%
242
0.1%
11
0.1%
64
0.0%
75
0.0%
743
3.6%
2,044
1.2%
2,787
1.4%
254
1.2%
3,750
2.1%
4,004
2.0%
7,320
35.1%
55,913
31.6%
63,233
32.0%
95
0.5%
1,236
0.7%
1,331
0.7%
20,839 100.0% 176,829 100.0% 197,668 100.0%
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
4.3 Day and month of arrival in A&E
There is an indication of a higher proportion of alcohol-related hospital
admissions occurring in December and January. Computing the average
number of hospital admissions, corrected for the number of days in the month
shows this more clearly. Alcohol-related hospital admissions are highest in
the winter period, whereas alcohol-specific hospital admissions are lower
during this period. It is unlikely that this is simply a compensating process as
the average daily number of alcohol-related hospital admissions, 484 is far
larger than alcohol-specific hospital admissions, 57. Figures 4.1 and 4.2
show the average number of daily hospital admissions by month.
The day of week of arrival for alcohol-related and alcohol-specific hospital
admissions are shown on Figure 4.3. Alcohol-related hospital admissions are
lower at the weekend. There is much less day of week variation in alcoholspecific hospital admissions.
28
Figure 4.1: Average daily arrivals in A&E, by month. Alcohol-related hospital
admissions 2009/10
600
Monthly average per day
Annual average per day
Average per day
500
400
300
200
100
0
Apr09
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan10
Feb
Mar10
Month (2009/10 data year)
Data source: Hospital Episode Statistics (HES), The Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
Figure 4.2: Average daily arrivals in A&E, by month. Alcohol-specific hospital
admissions 2009/10
70
Monthly average per day
Annual average per day
Average per day
60
50
40
30
20
10
0
Apr09
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan10
Feb
Mar10
Month (2009/10 data year)
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
29
Figure 4.3: Day of week of arrival in A&E, alcohol attributable hospital
admissions 2009/10
Alcohol-related
Alcohol-specific
18
16
14
Percent
12
10
8
6
4
2
Day of week
y
Su
nd
a
Sa
tu
rd
ay
Fr
id
ay
Th
ur
sd
ay
da
y
W
ed
ne
s
Tu
es
da
y
M
on
da
y
0
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
4.5 Time of arrival
Combining A&E data with that of admitted care patients enhances both
datasets. Diagnostic information from the hospital admission episode can be
used in conjunction with time information from the A&E arrival episode, both
of which were not available on individual datasets.
The following three diagnoses represent 95 percent of alcohol-specific
hospital admissions arriving via A&E:
 Mental and behavioural disorders due to use of alcohol
 Alcoholic Liver Disease
 Ethanol poisoning
Radar charts have been used to illustrate the 24-hour pattern of A&E arrivals
for these three alcohol-specific diagnoses. These are shown in Figures 5.5 to
5.7.
Hospital admissions for mental and behavioural disorders due to use of
alcohol represent the largest group with over 15,000 hospital admissions. The
majority of these arrive in A&E between midday and midnight, over 60
percent.
30
Figure 4.4: 24-hour pattern of A&E arrivals subsequently admitted to hospital
with mental and behavioural diagnoses 2009/10
0 Midnight
23
Mental and behavioural
n= 15,308
1
6.0
22
2
5.0
21
3
4.0
20
4
3.0
2.0
19
5
1.0
18
6
.0
17
7
16
8
15
9
14
10
13
11
12 Midday
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
In contrast A&E arrivals subsequently admitted for ethanol poisoning are very
much a feature of the night, 67 percent arrive between 6 pm and 6 am with a
particular peaks between 10 pm and 2 am when more than a third of A&E
arrivals occurred.
Figure 4.5: 24-hour pattern of A&E arrivals subsequently admitted to hospital
with ethanol poisoning 2009/10
0 Midnight
23
22
9.0
1
Ethanol poisioning
n= 1,432
2
8.0
7.0
21
3
6.0
5.0
20
4
4.0
3.0
19
5
2.0
1.0
18
6
0.0
17
7
16
8
15
9
14
10
13
11
12 Midday
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
31
A&E arrivals subsequently admitted and diagnosed with alcoholic liver
disease (ALD) are again a feature of the day with 70 percent arriving between
6 am and 6 pm and nearly 50 percent between 10 am and 4 pm.
Figure 4.6: 24- hour pattern of A&E arrivals subsequently admitted to hospital
with alcoholic liver disease 2009/10
0 Midnight
23
22
1
8.0
6.0
21
Alcoholic liver disease
n= 2,831
2
7.0
3
5.0
20
4
4.0
3.0
19
5
2.0
1.0
18
6
.0
17
7
16
8
15
9
14
10
13
11
12 Midday
Data source: Hospital Episode Statistics (HES), NHS Information Centre for Health & Social
Care. Analysed by Regional Public Health Group London.
The above illustrates the potential of linked HES data. Date and time fields
have a high level of completeness on HES A&E data. Other fields, in
particular diagnostic ones are under recorded on HES A&E data and therefore
limit its usefulness.
It would for example be useful to analyse diagnostic data on HES A&E for
those hospital admissions flagged as alcohol-related using alcohol attributable
fractions. This may help identify or refined individual episodes potentially
associated with alcohol.
32
ANNEXE 1 :List of ICD10 codes for diagnoses relating to alcohol and their attributable fractions.
Category
Alcohol-specific
(Chronic)
ICD code
ICD name
0-15
M
F
1.00 1.00
1.00 1.00
16-24
M
F
1.00 1.00
1.00 1.00
25-34
M
F
1.00 1.00
1.00 1.00
Alcohol Attributable Fraction
35-44
45-54
55-64
M
F
M
F
M
F
1.00 1.00 1.00 1.00 1.00 1.00
1.00 1.00 1.00 1.00 1.00 1.00
65-74
M
F
1.00 1.00
1.00 1.00
75+
M
F
1.00 1.00
1.00 1.00
E24.4
G31.2
Alcohol-induced pseudo-Cushing's syndrome
Degeneration of nervous system due to alcohol
G62.1
G72.1
I42.6
K29.2
K70
K86.0
F10
Alcoholic polyneuropathy
Alcoholic myopathy
Alcoholic cardiomyopathy
Alcoholic gastritis
Alcoholic liver disease
Chronic pancreatitis (alcohol induced)
Mental and behavioural disorders due to use of
alcohol
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
Alcohol-specific
(Acute)
T51.0
T51.1
T51.9
X45
Ethanol poisoning
Methanol poisoning
Toxic effect of alcohol, unspecified
Accidental poisoning by and exposure to
alcohol
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
Accidents &
Injury (Acute)
W00-W19
W24-W31
W32-W34
W65-W74
W78-W79
Fall injuries
Work/machine injuries
Firearm injuries
Drowning
Inhalation of gastric contents/Inhalation and
ingestion of food causing obstruction of the
respiratory tract
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.22
0.07
0.25
0.34
0.25
0.14
0.07
0.25
0.34
0.25
0.22
0.07
0.25
0.34
0.25
0.14
0.07
0.25
0.34
0.25
0.22
0.07
0.25
0.34
0.25
0.14
0.07
0.25
0.34
0.25
0.22
0.07
0.25
0.34
0.25
0.14
0.07
0.25
0.34
0.25
0.22
0.07
0.25
0.34
0.25
0.14
0.07
0.25
0.34
0.25
0.12
0.07
0.25
0.34
0.25
0.04
0.07
0.25
0.34
0.25
0.12
0.07
0.25
0.34
0.25
0.04
0.07
0.25
0.34
0.25
X00-X09
X31
X60-X84,
Y10-Y33
Fire injuries
Accidental excessive cold
Intentional self-harm/Event of undetermined
intent
0.00
0.00
0.00
0.00
0.00
0.00
0.38
0.25
0.34
0.38
0.25
0.35
0.38
0.25
0.34
0.38
0.25
0.33
0.38
0.25
0.35
0.38
0.25
0.34
0.38
0.25
0.37
0.38
0.25
0.34
0.38
0.25
0.36
0.38
0.25
0.32
0.38
0.25
0.31
0.38
0.25
0.25
0.38
0.25
0.27
0.38
0.25
0.20
X85-Y09
§§
§
Assault
Pedestrian traffic accidents
Road traffic accidents (driver/rider)
0.00
0.00
0.00
0.00
0.00
0.00
0.27
0.35
0.21
0.27
0.16
0.09
0.27
0.45
0.33
0.27
0.19
0.15
0.27
0.46
0.24
0.27
0.21
0.12
0.27
0.46
0.24
0.27
0.21
0.12
0.27
0.23
0.09
0.27
0.03
0.03
0.27
0.23
0.09
0.27
0.03
0.03
0.27
0.23
0.09
0.27
0.03
0.03
Alcohol-specific
(Mental/Beh)
Violence (Acute)
Transport
accidents (Acute)
33
Spontaneous
abortion (Acute)
Digestive
(Chronic)
Cancer (Chronic)
Other chronic
diseases (low
AF)
V90-V94
V95-V97
Water transport accidents
Air/space transport accidents
0.00
0.00
0.00
0.00
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
0.20
0.16
O03
Spontaneous abortion
0.00
0.00
0.00
0.23
0.00
0.21
0.00
0.22
0.00
0.21
0.00
0.20
0.00
0.15
0.00
0.12
K22.6
Gastro-oesophageal laceration-haemorrhage
syndrome
0.00
0.00
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
0.47
K73, K74
Chronic hepatitis, not elsewhere classified and
Fibrosis and cirrhosis of liver
0.00
0.00
0.77
0.67
0.76
0.59
0.74
0.60
0.79
0.59
0.77
0.57
0.71
0.48
0.61
0.38
K85, K86.1
I85
C00-C14
Acute and chronic pancreatitis
Oesophageal varices
Malignant neoplasm of lip, oral cavity and
pharynx
0.00
0.00
0.00
0.00
0.00
0.00
0.27
0.77
0.50
0.19
0.67
0.40
0.27
0.76
0.50
0.16
0.59
0.35
0.26
0.74
0.49
0.16
0.60
0.36
0.30
0.79
0.53
0.16
0.59
0.35
0.27
0.77
0.50
0.14
0.57
0.33
0.22
0.71
0.44
0.10
0.48
0.26
0.16
0.61
0.36
0.07
0.38
0.20
C15
C32
C16
C18
C20
C22
Malignant neoplasm of oesophagus
Malignant neoplasm of larynx
Malignant neoplasm of stomach
Malignant neoplasm of colon
Malignant neoplasm of rectum
Malignant neoplasm of liver and intrahepatic
bile ducts
0.00
0.00
0.00
0.00
0.32
0.34
0.23
0.25
0.31
0.33
0.20
0.21
0.30
0.32
0.20
0.22
0.34
0.36
0.20
0.21
0.32
0.34
0.18
0.20
0.26
0.28
0.14
0.15
0.20
0.22
0.10
0.11
0.00
0.00
0.00
0.00
0.00
0.00
0.05
0.08
0.16
0.03
0.06
0.11
0.05
0.08
0.15
0.03
0.05
0.10
0.04
0.08
0.15
0.03
0.05
0.10
0.05
0.09
0.17
0.03
0.05
0.10
0.05
0.08
0.16
0.03
0.05
0.09
0.04
0.07
0.13
0.02
0.03
0.07
0.03
0.05
0.10
0.01
0.03
0.05
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.34
0.35
0.00
0.56
0.31
0.09
0.24
0.36
0.00
0.64
0.20
0.00
0.33
0.36
0.00
0.58
0.30
0.08
0.19
0.35
0.00
0.59
0.15
0.00
0.32
0.37
0.00
0.58
0.27
0.09
0.20
0.35
0.00
0.61
0.15
0.00
0.37
0.38
0.00
0.61
0.34
0.09
0.20
0.35
0.00
0.61
0.15
0.00
0.34
0.37
0.00
0.61
0.30
0.08
0.18
0.33
0.00
0.57
0.13
0.00
0.27
0.34
0.00
0.51
0.24
0.06
0.13
0.27
0.00
0.45
0.10
0.00
0.20
0.30
0.00
0.42
0.16
0.04
0.09
0.22
0.00
0.35
0.06
0.00
0.00
0.16
0.03
0.13
0.00
0.08
0.00
0.18
0.00
0.12
0.00
0.06
0.00
0.00
0.00
0.00
0.00
0.34
0.33
0.34
0.33
0.35
0.33
0.36
0.32
0.35
0.31
0.33
0.26
0.30
0.22
C50
Malignant neoplasm of breast
I10-I15
Hypertensive diseases
I47-I48
Cardiac arrhythmias
I50-I51
Heart failure
Other diseases
G40-G41
Epilepsy and Status epilepticus
(low AF)
I60-I62,
Haemorrhagic stroke
I69.0-I69.2
I63-I66,
Ischaemic stroke
I69.3, I69.4
L40
Psoriasis
excluding
cirrhosis
L40.5
§ V12-V14 (.3 -.9), V19.4-V19.6, V19.9, V20-V28 (.3 -.9), V29-V79 (.4 -.9), V80.3V80.5, V81.1, V82.1, V82.9, V83.0-V86 (.0 -.3), V87.0-V87.9, V89.2, V89.3, V89.9
§§ V02-V04 (.1, .9), V06.1, V09.2, V09.3
Source: Reproduced from Alcohol Attributable Admissions in London. LHO 2010.
34
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35