High-Acuity Alcohol-Related Complications During the COVID-19 Pandemic (2024)

Key Points

Question Was the COVID-19 pandemic associated with increased rates of high-acuity alcohol-related complications?

Findings In this cohort study of a US national, commercially insured population, high-acuity alcohol-related complication episodes increased beyond what was expected in 4 of 18 pandemic months. Women aged 40 to 64 years experienced increases of 33.3% to 56.0% in high-acuity complication episodes in 10 of 18 pandemic months, a pattern associated with a large and sustained increase in high-acuity alcohol-related liver disease complications.

Meaning Findings underscore the need for increased attention to alcohol use disorder risk factors, alcohol use patterns, alcohol-related health effects, and alcohol regulations and policies, especially among women aged 40 to 64 years.

Importance Research has demonstrated an association between the COVID-19 pandemic and increased alcohol-related liver disease hospitalizations and deaths. However, trends in alcohol-related complications more broadly are unclear, especially among subgroups disproportionately affected by alcohol use.

Objective To assess trends in people with high-acuity alcohol-related complications admitted to the emergency department, observation unit, or hospital during the COVID-19 pandemic, focusing on demographic differences.

Design, Setting, and Participants This longitudinal interrupted time series cohort study analyzed US national insurance claims data using Optum’s deidentified Clinformatics Data Mart database from March 2017 to September 2021, before and after the March 2020 COVID-19 pandemic onset. A rolling cohort of people 15 years and older who had at least 6 months of continuous commercial or Medicare Advantage coverage were included. Subgroups of interest included males and females stratified by age group. Data were analyzed from April 2023 to January 2024.

Exposure COVID-19 pandemic environment from March 2020 to September 2021.

Main Outcomes and Measures Differences between monthly rates vs predicted rates of high-acuity alcohol-related complication episodes, determined using claims-based algorithms and alcohol-specific diagnosis codes. The secondary outcome was the subset of complication episodes due to alcohol-related liver disease.

Results Rates of high-acuity alcohol-related complications were statistically higher than expected in 4 of 18 pandemic months after March 2020 (range of absolute and relative increases: 0.4-0.8 episodes per 100 000 people and 8.3%-19.4%, respectively). Women aged 40 to 64 years experienced statistically significant increases in 10 of 18 pandemic months (range of absolute and relative increases: 1.3-2.1 episodes per 100 000 people and 33.3%-56.0%, respectively). In this same population, rates of complication episodes due to alcohol-related liver disease increased above expected in 16 of 18 pandemic months (range of absolute and relative increases: 0.8-2.1 episodes per 100 000 people and 34.1%-94.7%, respectively).

Conclusions and Relevance In this cohort study of a national, commercially insured population, high-acuity alcohol-related complication episodes increased beyond what was expected in 4 of 18 COVID-19 pandemic months. Women aged 40 to 64 years experienced 33.3% to 56.0% increases in complication episodes in 10 of 18 pandemic months, a pattern associated with large and sustained increases in high-acuity alcohol-related liver disease complications. Findings underscore the need for increased attention to alcohol use disorder risk factors, alcohol use patterns, alcohol-related health effects, and alcohol regulations and policies, especially among women aged 40 to 64 years.

Alcohol use and alcohol-related deaths increased over the past decade, with mortality rising faster among women than men.^1,2 Alcohol use complications are highest between the fourth and sixth decades of life, often due to alcohol-related liver disease (ALD) development.^3,4 The COVID-19 pandemic was associated with increased alcohol consumption, particularly among women, likely due to social isolation and stress.⁵ While several studies have examined differences in alcohol-related hepatitis hospitalizations or alcohol-related mortality in 2020 compared with prior years,^2,5-8 a rigorous analysis of the pandemic’s effect on a broader set of high-acuity alcohol-related complications is lacking. Such analyses could provide granular information about how socially disruptive phenomena such as the COVID-19 pandemic affect alcohol use–related presentations to the health system. We hypothesized that the pandemic would be associated with increased high-acuity alcohol-related complications caused by higher alcohol consumption and barriers to outpatient treatment services.

We studied commercial claims data from Optum’s deidentified Clinformatics Data Mart database from March 2017 to September 2021. We conducted a longitudinal interrupted time series study of a rolling cohort aged 15 years and older with at least 6 months of continuous insurance enrollment. We measured presentations to the emergency department, observation unit, or hospital using claims-based algorithms and alcohol-specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes (eAppendix in Supplement 1). We defined high-acuity alcohol-related complication episodes as conditions representing acute decompensation of chronic alcohol-related diseases that necessitated urgent or emergent management by a medical professional (eAppendix and eTable 1 in Supplement 1).

The Duke University and Harvard Pilgrim Health Care Institute institutional review boards approved this study and waived need for informed consent because deidentified data were used. This report adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

We ran regression models with generalized estimating equations, an identity link, and robust standard errors to compare observed monthly rates after March 2020 to rates predicted by the trajectory of the March 2017 to February 2020 baseline fitted trend (eAppendix in Supplement 1). Models adjusted for age group (15-39, 40-64, 65-74, and ≥75 years), sex, US division (9 divisions), poverty level of residence, and seasonality using quarterly indicators (eAppendix in Supplement 1). Additional analyses were stratified by age group and sex. We also separately analyzed rates of high-acuity ALD episodes over time. We describe COVID-19 pandemic era trends (April 2020 to September 2021) and present estimates of differences between monthly rates of high-acuity alcohol-related complication episodes vs predicted rates.

The statistical analysis was performed using Stata, version 16 (StataCorp), and SAS Studio software, release 3.7, enterprise edition (SAS Institute). Results are reported based on 2-sided tests of statistical significance, defined as P < .05.

Study characteristics in April 2017, April 2020, and April 2021 are summarized in eTable 2 in Supplement 1. Among high-acuity diagnoses, 54% to 66% were ALD related, 29% to 39% were alcohol withdrawal or alcohol-related mood disorders, 3% to 5% were alcohol-related cardiomyopathy, and 1% to 3% were alcohol-related gastritis with bleeding (eTable 3 in Supplement 1). Other than a transient decrease in April 2020 and a reduction that was not statistically significant in February 2021, monthly rates of high-acuity alcohol-related complication episodes were higher than predicted in all follow-up months (Figure 1 and the Table), though only 4 of 18 reached statistical significance. The range of absolute and relative increases in these 4 months was 0.4 to 0.8 episodes per 100 000 people and 8.3% to 19.4%, respectively.

The subgroup of members aged 40 to 64 years had a similar but more pronounced pattern of pandemic-era increases. The magnitude of all monthly estimates after April 2020 was higher than predicted, with 9 reaching statistical significance. The range of absolute and relative increases in these 9 months was 1.1 to 2.1 episodes per 100 000 people and 16.9% to 35.9%, respectively. Women in this age group experienced statistically significant increases in 10 of 18 pandemic months, with a range of absolute and relative increases of 1.3 to 2.1 episodes per 100 000 people and 33.3% to 56.0%, respectively. Men in this age group did not experience statistically significant changes, though most pandemic-era estimates were positive in magnitude. Additional subgroup analyses by age group and sex revealed no consistent pandemic-era patterns and few statistically significant changes (eTable 4 in Supplement 1).

The overall pattern of high-acuity ALD-related episode rates was similar to that of the broad complication outcome among the overall sample, the subgroups of members aged 40 to 64 years, and women and men in this age group (Figure 2). However, women aged 40 to 64 years experienced statistically significant increases in 16 of 18 pandemic months, with a range of absolute and relative increases of 0.8 to 2.1 episodes per 100 000 people and 34.1% to 94.7%, respectively. Additional subgroup analyses of high-acuity ALD-related episodes by age group and sex revealed no consistent pandemic-era patterns among subgroups and few statistically significant changes (eTable 5 in Supplement 1).

The COVID-19 pandemic was associated with increases in high-acuity alcohol-related complication episodes in half of follow-up months among members aged 40 to 64 years in a national, commercially insured population. Women in this age group experienced increases in 10 of 18 follow-up months, which appeared to be associated with major relative increases in high-acuity ALD-related presentations in 16 of 18 pandemic months.

The increase in ALD-related complication episodes that we detected is consistent with recent analyses that have demonstrated increases in ALD-related hospitalizations and deaths, as well as alcohol-related deaths during the pandemic era.^2,6-10 Moreover, we add the key findings that the pandemic was associated with increases in a broader measure of alcohol-related complications and that changes primarily occurred among women aged 40 to 64 years. Rates of alcohol-related complications in this group remained elevated into late 2021, suggesting potentially sustained increases in alcohol-related harms. Although estimates among men aged 40 to 64 years did not reach statistical significance, they were consistently higher than predicted after April 2020, warranting further investigation with additional data sources.

Recent epidemiological patterns in alcohol use might help explain these results. Over the past decade, the 2-week prevalence of having 5 or more drinks in a row increased twice as quickly among women aged 35 to 50 years compared with men.¹ Unlike men, women had considerably more heavy drinking days (≥4 drinks within a few hours) in 2020 compared with 2019.⁵ Thus, longer-term increases in alcohol consumption might have increased the risk of ALD among women aged 40 to 64 years prior to the pandemic, then pandemic-related increases in alcohol consumption may have contributed to new or worsening ALD complications.

These findings imply a need for increased attention to alcohol use disorder (AUD) risk factors, alcohol use patterns, alcohol-related health effects, and related interventions, especially among women aged 40 to 64 years. Clinicians and population health managers should consider increasing screening efforts in this population. Policymakers should consider enhancing access to interventions including AUD treatment early in the disease process and closer collaboration with addiction clinicians and hepatologists. Evidence-based policies to reduce the aforementioned harms include increasing alcohol taxes, setting minimum alcohol prices, and limiting alcohol advertising.¹¹ The persistent elevations in alcohol-related complications we detected in a relatively small population subgroup suggest a need for more granular public health monitoring. This study adds a novel, broad measure of acute decompensation of chronic alcohol-related diseases that might reflect alcohol consumption levels in the community, access to AUD treatment, and access to specialists such as hepatologists. Monitoring this measure could complement monitoring less common outcomes such as alcohol-related mortality, allowing identification of smaller, at-risk patient subgroups that require urgent and early interventions.

Study limitations include underestimating high-acuity alcohol-related complications due to use of alcohol-specific billing codes, and potential changes in insurance enrollment patterns from before to after the pandemic. Further research is needed to determine whether the increases we observed persist several years after the pandemic onset.

In this cohort study, high-acuity alcohol-related complications, especially those associated with ALD, increased during the COVID-19 pandemic period among adults aged 40 to 64 years, particularly women. Findings underscore the need for increased attention to alcohol use disorder risk factors, alcohol use patterns, alcohol-related health effects, and alcohol regulations and policies, especially among women aged 40 to 64 years.

Accepted for Publication: February 15, 2024.

Published: April 12, 2024. doi:10.1001/jamahealthforum.2024.0501

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Shuey B et al. JAMA Health Forum.

Corresponding Author: Bryant Shuey, MD, MPH, Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, 200 Meyran Ave, Pittsburgh, PA 15201 (bryant.shuey@pitt.edu).

Author Contributions: Dr Wharam had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Shuey, Williams, Druss, Wen, Wharam.

Acquisition, analysis, or interpretation of data: Shuey, Halbisen, Lakoma, Zhang, Argetsinger, Wen, Wharam.

Drafting of the manuscript: Shuey.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Shuey, Lakoma, Zhang, Wharam.

Obtained funding: Williams, Wen, Wharam.

Administrative, technical, or material support: Halbisen, Argetsinger, Wharam.

Supervision: Williams, Wen, Wharam.

Conflict of Interest Disclosures: Dr Zhang reported receiving postmarket safety study stipends from Pfizer and GlaxoSmithKline outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01AA029819 to Dr Wharam, Dr Wen, Dr Zhang, Dr Druss, Mr Lakoma, and Ms Argetsinger). Dr Shuey was supported for this work by the Department of Population Medicine in the Harvard Pilgrim Health Care Institute, which is connected to the Institutional National Research Service Awards T32HP32715 and T32HP42013. Dr Shuey was also supported for this work by a grant from the National Institute on Drug Abuse (K12DA050607).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.