Understanding the alcohol harm paradox: an analysis of sex- and condition-specific hospital admissions by socioeconomic group for alcohol-associated conditions in England.
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BACKGROUND AND AIMS: In many countries conflicting gradients in alcohol consumption and alcohol-associated mortality have been observed. To understand this 'alcohol harm paradox' we analysed the socioeconomic gradient in alcohol-associated hospital admissions to test whether it was greater in conditions which were : (1) chronic (associated with long-term drinking) and partially alcohol-attributable, (2) chronic and wholly alcohol-attributable, (3) acute (associated with intoxication) and partially alcohol-attributable, (4) acute and wholly-alcohol attributable. Our aim was to clarify how (1) drinking patterns (e.g. intoxication linked to acute admissions or dependence linked to chronic conditions) and (2) non-alcohol causes (e.g. smoking and poor diet which are risks for partially alcohol-attributable conditions) contribute to the paradox. DESIGN: Regression analysis testing the modifying effects of condition-group (1-4 above) and sex on the relationship between areas-based deprivation and admissions. SETTING: England, April 2010-March 2013 PARTICIPANTS: 9.2 million English hospital admissions where a primary or secondary cause was one of 36 alcohol-associated conditions MEASUREMENTS: Admissions by condition and deciles of Index of Multiple Deprivation (IMD). Socioeconomic gradient measured as the relative index of inequality (RII, the slope of a linear regression of IMD on admissions adjusted for overall admission rate). Conditions were categorised by ICD-10 code. FINDINGS: A socioeconomic gradient in hospitalisations was seen for all conditions except partially attributable chronic conditions. The gradient was significantly steeper for conditions which were wholly attributable to alcohol and for acute conditions than for conditions partially alcohol-attributable and for chronic conditions. Gradients were steeper for men than for women in cases of wholly alcohol attributable conditions. CONCLUSIONS: There is a socioeconomic gradient in English hospital admissions for most alcohol-associated conditions. The greatest inequalities are in conditions associated with alcohol dependence, such as liver disease and mental and behavioural conditions, and in acute conditions, like alcohol poisoning and assault. Socioeconomic differences in harmful drinking patterns (dependence and intoxication) may contribute to the 'alcohol harm paradox'.
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