Improving the Safety of Treatment for Hospitalized Patients with Alcohol Withdrawal Syndrome

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PROJECT SUMMARY/ABSTRACT BACKGROUND. The goal of this proposal is to improve outcomes for hospitalized patients with Alcohol Withdrawal Syndrome (AWS). AWS is common in hospitals and can be fatal without appropriate management; however, treatments for AWS also have dangerous side effects. Suboptimal treatment (persistent agitation or oversedation) leads to adverse events (e.g., use of physical restraints or mechanical ventilation), which are potentially avoidable but have never been studied. Moreover, the two types of medications used as first-line therapy for inpatient AWS—benzodiazepines and phenobarbital—have never been rigorously compared in hospitalized patients. Both treatments are recommended by guidelines at the discretion of clinicians, yet their comparative safety remains unknown. CANDIDATE. Dr. Tessa Steel is a critical care physician who co-led a national panel of experts to develop a comprehensive research agenda for improving the care of severe AWS. The proposed K23 builds on this foundation and her prior studies, showing wide variation in current treatments for inpatient AWS. RESEARCH. First, Dr. Steel will investigate how and why inpatient physicians choose to treat inpatient AWS with benzodiazepines versus phenobarbital, using interviews and an implementation science framework for understanding provider behavior. Second, she will evaluate the risk of adverse events (e.g., use of physical restraints) associated with benzodiazepines versus phenobarbital in diverse groups of hospitalized patients, using real-world data from electronic health records (EHRs). These studies will inform her third aim—to design and pilot a pragmatic randomized trial, embedded in hospital care, comparing benzodiazepines to phenobarbital for hospitalized patients with AWS. The pilot will serve as groundwork for a definitive multi-center randomized trial (Dr. Steel’s planned R01) to determine the safest first-line therapy for inpatient AWS. CAREER DEVELOPMENT. Dr. Steel’s goal is to be an innovative clinical researcher who improves outcomes for hospitalized patients with alcohol use disorder. To launch her career as an independent physician scientist, the proposed K23 award provides essential training in (1) qualitative research methods, (2) advanced analytic strategies for using EHR data, and (3) the design and conduct of embedded pragmatic clinical trials. Dr. Steel will conduct her research at the University of Washington (UW) under the primary mentorship of Dr. Katharine Bradley, who is an expert in mixed methods research using EHR data, including pragmatic trials. She will be co-mentored by Dr. Nicholas Johnson, providing expertise related to clinical trials conducted in hospital settings and Dr. Kevin Hallgren, a methodologic expert on the use of EHR data for clinical AUD research. PUBLIC HEALTH IMPACT. The proposed career development award will support an early-career investigator conducting research to improve management of AWS for the ~2 million patients hospitalized with this problem per year in the United States.