Alcoholic liver disease is a major cause of illness, death and economic burden across the world. A catch-all for conditions including cirrhosis, alcoholic hepatitis and liver fibrosis, it results in around a half a million deaths each year.
While other liver diseases like hepatitis B and C are expected to become less prevalent in years to come, people drink so much that alcoholic liver disease (ALD) is unlikely to move in the same direction. The UK has one of the highest rates in western Europe (albeit lower than much of eastern Europe), and Scotland drinks more and suffers more alcohol-related harms than the rest of the country. Worse, it is the poorest in society who suffer the most alcohol-related harm.
There has been some cause for optimism in recent years in Scotland – but only at first glance. The incidence of ALD hospitalisations for new patients fell between 2008/09 and 2012/13 – or may have started to drop a couple of years earlier, according to different figures. It has since been rising again, however – and still is, according to the new figures.
Total ALD patients admitted over time
And even at their lowest recent level in 2012/13, the rates were still high compared to the rest of the UK and western Europe. The most recent figure for 2015/16 of 3,788 hospitalisations is higher than all years except 2006-09 and the figures also mask the fact that chronic ALD rates caused by heavy alcohol consumption – cirrhosis, fatty liver and hepatic failure – have been rising all along.
Chronic ALD patients admitted over time
Explaining why Scots drink more than those in many countries is not easy. But the reason for the sharp rise and then the slight fall in the ALD rates is arguably because excessive drinking got worse in the 1970s and 1980s. These people continued to drink large amounts over time and were then dying in the 2000s in greater numbers for the first time.
Cirrhosis incidence by country
We have published a new study into the prevalence and costs of alcoholic liver disease in Scotland between 1991 and 2011. We found that almost one in five of these patients died during their first hospitalisation. Of the people discharged alive, more than 50% died within five years. These risks are markedly increased if patients present with severe symptoms such as liver or heart failure.
When we compared with a group from the general population who had healthy livers but were similar in terms of sex, age and where they came from, the ALD patients are much more likely to spend time in hospital (for any reason) both before and after their first ALD diagnosis.
The average annual hospital cost per person was meanwhile over twice as high for ALD patients than the other group before diagnosis (approximately £1,400 vs £570). After diagnosis it went up to ten times as high (approximately £14,000 vs £1,200).
A first admission to hospital with ALD often indicates a very poor outcome with a high risk of dying during that hospitalisation or afterwards. Those discharged alive are often readmitted, frequently multiple times, which helps explain the high costs to the NHS. (Patients with alcoholic liver disease are also regular health service users before the disease develops.)
We also found that the rate of readmission for these patients has been increasing over the past 20 years. This makes the recent rise in incidence of chronic ALD in Scotland particularly concerning. And it’s not just the ALD figures that are concerning when it comes to alcohol-related diseases – the latest national figures show that death rates from liver cancer have increased by 52% in the last ten years. It is all a reminder of the seriousness of Scotland’s problem.
In short, preventative strategies need to be a focus for further research. For example, the Scottish government is rolling out what are known as alcohol brief interventions, which involve the person keeping an alcohol diary then being offered support and advice. (While the evidence is generally supportive for this approach, it should be said there are a lot of unanswered questions surrounding their effectiveness). Other possibilities are abstinence and lifestyle motivation programmes, educational programmes in schools over dangers of alcohol, social support and nutritional support and drug treatments combined with different kinds of support.
And given the high cost of hospital care, it is highly likely that minimum unit pricing of alcohol will be cost-effective as well. We welcome the recent ruling by the Scottish courts to reject a challenge by Scotland’s drinks industry which claimed minimum unit pricing was in breach of European law.
Although not perfect, it has made a difference in the likes of Canada and will directly target the cheap alcohol that is consumed by most dependent drinkers. This should tackle the problem among the poorest drinkers, which is an added attraction.