By Coleen Curran

dm01.jpg (11209 bytes)Alcohol testing in ED patients can lead to better treatment, and in 36 states, denial of reimbursement
An expert panel of analytical toxicologists and emergency department physicians recently published its consensus recommendations for clinical laboratory testing of poisoned patients.

     Their report — National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Recommendations for the Use of Laboratory Tests to Support Poisoned Patients Who Present to the Emergency Department — discusses the importance of testing for numerous toxins in the emergency department including the most common, alcohol and drugs. In fact, it is a widely accepted statistic that about half of all emergency room visits are the result of the patient’s or someone else’s alcohol or drug use.

     The consensus document recognizes that the measurement of alcohol in body fluids and/or breath is an important test in the management of ED patients. It states, however, “A given ethanol concentration is difficult to interpret because clinical symptoms do not correlate well with any given serum or plasma concentration because of individual tolerance and possible co-ingestion or co-existing conditions. Nonetheless, an abnormally high result may be helpful in determining the cause of presenting signs and symptoms. A negative alcohol result may be even more important to the ED staff, because it directs their attention toward other possible etiologies and diagnostic procedures.”

     Alcohol testing is also important when a patient is being de-toxed from alcohol addiction, because ethanol is used as a therapeutic drug during the withdrawal period. Thus, frequent determinations are needed to ensure adequate dosing.

     While the legal limits that determine intoxication (0.08% or 0.1%) are firmly established by law, clinical intoxication is a much more difficult determination because “there is no concentration that consistently defines clinical intoxication” in all patients. This leaves the door open for the use of samples other than whole blood. Although there are subtle differences among serum, plasma, saliva and breath samples, the recommendations note, those differences are “clinically insignificant,” giving laboratories and EDs a wide choice of  specimen testing methods.

     Because most alcohol breath analyzers are accurate, precise and inexpensive, many EDs have adopted them for determining alcohol concentrations in intoxicated people. Even though they currently are not regulated by CLIA, the new guidelines recommend more laboratory oversight.

     “Nevertheless, because of the importance of alcohol measurement, the Committee feels that laboratory oversight is necessary,” the guidelines state. “The recommendations that follow were formulated by a Task Force of the AACC Therapeutic Drug Monitoring and Clinical Toxicology Division. The Task Force does not necessarily endorse the substitution of breath alcohol measurements for the serum or plasma alcohol test.

     Clinical breath alcohol testing is POC testing and must meet the same quality-assurance (QA)/quality control (QC) requirements as any POC test. As a part of the laboratory’s ongoing QA effort, a program must be in place to monitor and evaluate policy, protocols and the total testing process, so that breath alcohol results are accurate and reliable. The clinical laboratory should be involved in the design, implementation and monitoring of the quality assurance program.”

     The specifics of a QA program, as recommended by the expert panel, include monitoring and evaluating the overall quality of the total testing process (pre-analytic, analytic and post-analytic steps) as well as the evaluation of the effectiveness of policies and procedures; identification and correction of problems; assurance of accurate, reliable and prompt reporting of test results; and affirmation of the competency of operators. A standard operating procedure manual, operator training, evaluation of competency and a QC program are also recommended. They also advocate a daily accuracy checking of each device with a dry gas standard and an air blank.

     While these recommendations for clinical laboratory oversight of ED alcohol testing are designed to produce better processes and outcomes, they may have limited impact because many emergency department and trauma centers simply do not test patients for blood alcohol levels on a routine basis.

     It’s hard to believe that while almost half of all trauma care visits stem from alcohol- or  drug-related injuries, many emergency departments avoid screening seemingly intoxicated patients for alcohol and drug levels.

     Why test for hematocrit, electrolytes and CBC levels but not alcohol and drugs? Of course, that should be a clinical decision, but in some cases it depends on what state the trauma center calls home.

     In 40 states, there is a law that allows insurance companies to deny medical reimbursement to patients under the influence of alcohol (36 states) and narcotics (four states). This law, the UPPL or Uniform Accident and Sickness Policy Provision Law, was conceived as model legislation by the National Association of Insurance Commissioners (NIAC) and adopted by states in 1947.

     The way the UPPL is worded, a well-insured brides maid who dances at her friend’s wedding, breaks her leg and is taxied to the ER with too much champagne in her blood, may find herself saddled with a bill for the entire cost of her treatment. Notice there is no law broken in this scenario. However, even if she did drive herself to the hospital with an illegal blood-alcohol level, ED docs in states with these laws know enough to treat the broken leg and skip the test for drug and alcohol levels. Reimbursement is tough enough without asking for trouble. Not all insurance companies enforce the law, but doctors may err on the side of caution when they practice in a UPPL state.

     This practice goes against the recommendations of numerous expert panels on alcohol and emergency medicine, which describe optimal patient management as involving the measurement of patient blood alcohol level in an effort to diminish drunk driving and its repercussions.

     Among the 25 million or so injury-related visits to emergency departments each year, it is estimated that 20 to 40 percent of patients meet the criteria for an alcohol problem. When drugs are added to the mix, the percentage with a substance abuse problem goes even higher.

     When you add together the high cost of emergency medical care with the fact that few people are being tested and treated for their primary disease – alcoholism, the result is spiraling healthcare costs that seem to benefit no one.

     Fortunately, change is on the way if Larry Gentilello, M.D., has his way. Chief of trauma and surgical critical care at Boston’s Beth Israel Deaconess Hospital, Gentilello has worked for three years to repeal the laws that he believes are obstacles to improved patient outcomes and lowered healthcare costs.

     In the late 1990s, while at the Department of Surgery, University of Washington School of Medicine, The Harborview Injury Prevention and Research Center in Seattle, Gentilello and several colleagues conducted a three-year study to see if providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and decrease the rate of trauma recidivism.

     In the randomized, prospective controlled study at the level 1 trauma center, 2,524 patients were tested for blood alcohol concentration using gamma glutamyl transpeptidase level and short Michigan Alcoholism Screening Test (SMAST). The 1,153 patients with positive results were divided into an intervention group (366) and a control group (396). Re-injury was detected by a computerized search of emergency department and statewide hospital discharge records. Six-month and 12-month follow-up interviews were conducted to assess alcohol use.

     At 12 months, the intervention group had decreased its alcohol consumption in comparison with the control group. The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score of 3 to 8). Most importantly, there was a 47 percent reduction in injuries requiring either emergency department or trauma center admission and a 48 percent reduction in injuries requiring hospital admission at three years follow up. The authors concluded that interventions are associated with a reduction in alcohol intake and a reduced risk of trauma center recidivism, and given the prevalence of alcohol-related problems in trauma centers, screening, intervention and counseling for alcohol problems should be routine.

     Armed with this evidence, Gentilello enlisted the help of the American Society of Addiction Medicine, where he is a member, Mothers Against Drunk Driving (MADD) and the National Association of Insurance Commissioners (NAIC) to help repeal the laws. Ironically, the NAIC – the association that drew up the original model legislation in 1947 – now supports its repeal.

     “The prevalence of alcohol problems is higher in trauma patients than in any other medical setting,” Gentilello said. “The leading cause of death for substance abusers is injury, not cirrhosis or pancreatitis. Trauma patients with alcohol problems have very high re-injury rates and deaths due to re-injury. Opportunistic screening and intervention in healthcare settings where there is a high proportion of patients with alcohol problems is perhaps the most promising means of closing the gap between the number of patients who might benefit from treatment and the number who receive it.”

     To date, only three states – Maryland, North Carolina and Vermont – have repealed their laws. Both North Carolina and Vermont repealed their UPPLs in 2001 with almost no opposition.

     However, it’s not a smooth road to change in all states. A bill, recently introduced to repeal the Texas UPPL, is still underway. Similar legislation proposed in Washington did not make it out of the Insurance and Finance Committee because of concerns about increased insurance costs. Despite this claim, in hearings before the National Association of Insurance Commissioners, the insurance lobby was unable to demonstrate any savings as a result of the UPPL. So why the opposition?

     Those who believe in UPPL repeal believe that doctors who work in jurisdictions where this law is enforced have stopped testing patients for blood alcohol in order to maintain their and their hospital’s financial viability. Insurance companies still pay for the treatment of alcohol-related injuries, but doctors are denied the opportunity for a teachable moment that could result in patients diminishing or even eliminating destructive behaviors such as drinking and driving. Many believe the net effect of the law is to sweep the alcohol problems under the rug rather than confront them head-on with intervention and treatment.

     “When this law was put in place, we didn’t have the ability to screen people for drugs and alcohol the way we do today,” said Carol McNamee, MADD’s vice president for public policy. “Alcoholism wasn’t even recognized as a disease. The attitude back then was very short-sighted compared to today.”

     In Vermont, the legislation to repeal the law was sponsored by Kathleen Keenan, R.N., a representative in the Vermont General Assembly who also works in the emergency department at Northwestern Medical Center, a 70-bed, private, not-for-profit community hospital in St. Albans, Vt. “It wasn’t a practice in our hospital to not test for drug and alcohol levels, but it didn’t seem like the kind of law that was doing anyone any good,” she said.

     The only organization that testified against repealing the law in Vermont was Cigna Healthcare. “The employer-sponsored health plans that the Cigna companies administer generally cover all medically necessary care subject to the “prudent lay person’s test,” said Cigna spokesperson Lindsay Shearer. “As a consequence, coverage is unaffected by the fact that a person may be impaired by alcohol or drugs. Most states have laws requiring that insurance companies and HMOs provide coverage for emergency care at an in-network level under circumstances where a prudent lay person seeks emergency care because he or she reasonably believes that his or her life or serious physical impairment would otherwise result if treatment was not received immediately. So we’re already doing it.”

     Generally speaking, insurance companies oppose any and all mandates for coverage.

     Betsey Costle, who was the Vermont Insurance Commissioner when the repeal bill passed, recalled that the UPPL repeal was opposed but not very strenuously. “There was pretty much unanimous support for it, so they didn’t fight very hard,” Costle said.

     Keenan notes that Northwestern’s clinical laboratory has not felt any significant increase in workload. “We’re just adding a few drug and alcohol tests to the usual emergency panel. It’s all done on the same tube of blood,” Keenan said.

     States with laws that give insurers the option to deny medical reimbursement to patients under the influence of alcohol are: Alabama, Alaska, Arizona, Arkansas, California, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, North Dakota, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wyoming.

     States with laws that give insurers the option to deny medical reimburement to patients under the influence of narcotics are: Minnesota, New York, Oklahoma, South Dakota.

     “Exactly whom does this law serve?” Gentilello asks. “It certainly doesn’t serve the patients, who don’t get tested or treated and end up back in the trauma center. It adds to the overall cost of healthcare. Insurance companies don’t save any money because in states that have the law, physicians are aware of it and don’t order the alcohol and drug tests. I see nothing beneficial that it does. Why not repeal it?”

Coleen Curran, based in Charlotte, N.C., is a writer, healthcare consultant and former editor of CLP.