Alcohol-related presentations to emergency departments on Crate Day in Waikato, New Zealand
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Alcohol causes a myriad of socio-economic and physical health issues in Aotearoa New Zealand including road traffic injuries, self-inflicted injuries, alcoholic liver cirrhosis, colorectal and breast cancer, alcohol use disorder, foetal alcohol spectrum disorder, depression, and domestic violence.[[1]] It has been estimated that 5.4% of deaths in New Zealanders are attributable to alcohol.[[2]]
There are large inequities in the distribution of alcohol-related harm between ethnicities such that the alcohol-related mortality rate for Māori is 2.5 times higher than non-Māori.[[1,2]] Males are also disproportionately affected, experiencing almost two times the rate of disability adjusted life years than females.[[2]] Furthermore, 15- to 29-year-old Māori males have the highest rate of years of life lost due to alcohol than any other population group.[[2]]
Alcohol-related health issues bear a significant economic burden, estimated to cost New Zealand $5.3 billion each year.[[3]] The pattern of drinking is an important consideration, with heavy episodic drinking (HED) being associated with greater harm.[[4]] In general, HED is defined as the consumption of 60g or more of pure alcohol on at least one single occasion at least once per month.[[1]] Hospital emergency departments (EDs) are significantly burdened by alcohol-related harm.[[5,6]] There is a high frequency of alcohol-related presentations (ARPs) during weekends, particularly late at night or in the early hours of the morning, and more commonly presenting with physical injuries, which can be severe and life threatening.[[5]] Alcohol is also reported to be the most common factor contributing to aggressive behaviour directed at ED staff by patients and visitors.[[7,8]] Intoxicated ED patients draw resources away from other patients.[[5,7]]
Crate Day is an unofficial observance held annually on the first Saturday of December, during which each participant attempts to consume one entire crate of beer.[[9]] A crate comprises of 12 large 745mL bottles of beer, containing 300g of pure alcohol.[[9,11]] This tradition was started by a radio station in 2009 who have continued to promote it alongside alcohol industry members.[[9,11–13]]
Crate Day is of public health concern because of the potential alcohol-related harm due to an increase in alcohol consumption, and in a high-risk manner that is likely to be distributed inequitably across society. In addition, it normalises HED, which could beget HED at other times of the year. Furthermore, Crate Day could cause indirect harm through consumption of scarce healthcare resource, and the associated opportunity cost of delaying other patients’ care.
Despite the potential harms of this event, there is a paucity of information about participation and consequences. Newspaper reports have raised concern about an increased burden on EDs from ARPs on Crate Day, one suggesting a doubling of alcohol-related injuries compared to an average December weekend.[[12,14,15]] Formal assessment of ARPs on Crate Day are required to inform alcohol promotion strategies, alcohol licensing decisions, local alcohol policies, and national legislation and policy to design a healthier alcohol environment. This knowledge could also inform ED workload planning to ensure safe staffing levels.
This study aims to describe the pattern of ED ARPs on Crate Day in the Waikato. Waikato District Health Board (WDHB) served a population of over 400,000, 25% of whom identify as Māori. Within WDHB, there is one urban hospital (Waikato Hospital) and four rural hospitals. To our knowledge, this is the first study examining the relationship between Crate Day and ARPs to New Zealand hospital EDs.
Method
This retrospective observational study used a descriptive analytical approach to examine ED attendance during the Crate Day weekends in 2019 and 2020 and adjacent weekends. Data were extracted from WDHB electronic records including data from all five WDHB hospitals. Alcohol related presentations were identified using a “alcohol involved” flag, a compulsory electronic field completed by staff for each patient which became a mandatory reporting requirement to the Ministry of Health in 2017.[[16]] There are four response types available for the alcohol involved field: “Yes”, where the patient was themselves intoxicated; “Secondary”, where the patient was not intoxicated, but their presentation was caused by another intoxicated individual; “No”, where the patient was not intoxicated; and “Unknown”, where the association with alcohol was not known or could not be determined.[[5,17]] Alcohol involvement is determined by healthcare staff based on clinical judgement and there is no formalised questioning or investigation. The vast majority of alcohol-related presentations identified with this flag are due to acute alcohol intoxication, such as trauma and toxicity, because the contribution of alcohol to those diagnoses can be clinically determined; unlike chronic harms e.g., breast cancer, where the relationship to alcohol is obscured (see Appendix 1). In this study ARPs refers to both primary and secondary cases.
Data from the Crate Day weekend (Crate Day and the day after) in 2019 and 2020 were pooled to form the Crate Day group. Weekends immediately before and after a Crate Day weekend for both 2019 and 2020 were pooled to form the reference group.
These weekends were selected to mitigate systematic bias secondary to seasonal variation in ARPs.[[5]] Reference weekends did not appear to be outliers on visual inspection of plots of ARPs vs time. Age-standardised rates (ASRs) per 100,000 person-weekends and age standardised relative rate (ASRR) with estimated 95% confidence intervals (CIs) were calculated. The 2018 Census population was used as the standard population for age-standardisation.[[18]] A subgroup analysis was performed for sex, ethnicity, socio-economic deprivation as measured by the New Zealand Deprivation Index 2013 (NZDep2013)[[19]] and hospital rurality.
Multiple ethnicities were managed using prioritised ethnicity.[[20]] Age-specific rates were calculated for the age groups 0–19, 20–34 and 35 years and over. Ideally, the lower age group would have been 0–17 years because the legal alcohol purchasing age in New Zealand is 18 years; however, population data were restricted to five-year bands. The grouping used (0–19 years) minimises the mixing of legal and non-legal alcohol purchasers as compared to the next best grouping (0–14 years). Statistical testing was performed using Chi squared tests. Population estimates were taken from a demographic model developed by WDHB derived from Waikato Integrated Scenario Explorer model.[[21]] Data analysis was performed on Qlik Sense software,[[22]] Microsoft Excel and the online statistical calculator available at www.socscistatistics.com. Analysis for the study was done as part of a routine public health audit; therefore, ethics approval was deemed unnecessary.
Results
During the pooled 2019 and 2020 Crate Day period, there were 1,533 presentations to WDHB EDs, 100 (6.5%) of which were ARP and 277 (18.7%) where the alcohol involvement was unknown. Seventy-two percent (72/100) of ARPs were male and 36.0% (36/100) were of Māori ethnicity. In comparison, during the reference period, there were 2,969 presentation, 136 (4.6%) of which were alcohol related and 457 (15.4%) of unknown alcohol involvement. Of the ARPs, 64.7% (88/136) were male and 36.1% (48/133) were of Māori ethnicity. There were no statistically significant differences in sex, ethnicity, hospital or deprivation between Crate Day period and reference period (see Table 1). A majority (72.0%) of ARPs occurred between 5pm and 3am during the Crate Day period.
The estimated crude incidence rate was 12.6 per 100,000 person-weekends (95% CI: 9.13 to 16.13) during the Crate Day period and 8.6 per 100,000 person weekends (95% CI: 5.70 to 11.47) during the reference period (see Appendix 2). This equates to a crude relative rate of 1.5 (95% CI: 0.97 to 2.32). The ASR was 12.8 per 100,000 person-weekends (95% CI: 4.31 to 21.36) during the Crate Day period and 8.7 per 100,000 person-weekends (95% CI: 1.69 to 15.61) during the reference period, a relative rate of 1.5 (95% CI: 0.96 to 2.26) (see Table 2).
The ASR (per 100,000 person-weekends) of ARPs was 16.9 for Māori during the Crate Day period compared to 12.5 during the reference period, a relative rate of 1.4 (95% CI: 0.66 to 2.78). The ASRs were 10.2 and 6.6 respectively for non-Māori, a relative rate of 1.6 (95% CI: 0.89 to 2.68). Age-standardised ARP rates increase as socio-economic deprivation increases for both Crate Day period and reference period; however, the ASR was 1.5 times higher in areas of high (NZDep 8–10) and medium (NZDep 4–7) deprivation during the Crate Day period compared to the reference period. Estimated 95% CIs for the relative rates cross 1, suggesting differences are not statistically significant. The relative rate in low deprivation (NZDep 1–3) areas was 1.0. Following age standardisation, males were 1.7 (95% CI: 0.98 to 2.82) times more likely to present to EDs for alcohol related issues during the Crate Day period than reference period. Those of Māori ethnicity were 1.4 (95% CI: 0.66 to 2.78) times more likely, and non-Māori were 1.6 (95% CI: 0.89 to 2.68) times more likely, to present to ED for an alcohol related issue during the Crate Day period compared to reference period.
View Tables 1–3 and Figure 1.
Rates of ARPs also differed by age (see Figure 1). The rates of ARPs were approximately twice as high for those aged 20–24 years and 25–34 years during the Crate Day period.
There was a statistically significant association between ARPs and Crate Day with a relative rate of 2.00 (95% CI: 1.11 to 3.59), but not in other age groups (see Table 3).
Discussion
New Zealand has a liberal alcohol consumption culture, where drinking is deeply ingrained in social norms and binge drinking is commonplace, especially amongst youths.[[23,24]] It is no surprise that alcohol-related harm places a significant burden on New Zealand EDs.[[25]] The purpose of this study is to identify and quantify any burden that Crate Day may place on EDs in Waikato, New Zealand and in doing so identify populations most at risk. To our knowledge, this is the first study to examine the effect of Crate Day on alcohol related presentations to New Zealand hospital EDs. The study shows that alcohol played a role in 6.5% of presentations, equating to 100 patients, on Crate Day weekends across 2019 and 2020, which was greater than the proportion of ARPs on reference weekends (136/2969; 4.6%).
Analysis of ARPs by ethnicity showed that Māori have higher rates of ARP to ED than non-Māori at baseline. This result is consistent with findings from Svensen et al., who found that Māori were over represented in ARPs to Auckland City Hospital ED.[[5]] The higher rate of ARPs on Crate Day are similar between Māori and non Māori on crude analysis (Appendix 2), and slightly lower (though not statistically significant) after age standardisation, with an estimated ASRR of 1.4 and 1.6 respectively. This raises the possibility that the social practice of Crate Day may be more integrated into non-Māori, mainly New Zealand European, culture. However, on a population scale Māori may be more vulnerable to the harms associated with Crate Day due, in part, to their younger age structure.
The age group analysis of the study shows a significantly higher ASR for those aged 20–34 years on Crate Day weekends with an ASRR of 2.00. Though causality between Crate Day and ARPs cannot be established from this study, this finding is consistent with the hypothesis that young adults are more likely to drink to excess on Crate Day than other age groups. This vulnerability is not surprising given that young adults are known to have a higher risk of ARPs at baseline.[[5,26,27]] An alternative explanation of this association could be that healthcare staff are more likely to categorise presentations as alcohol related on Crate Day due to their knowledge of the event. This measurement bias would result in an artificial large effect size, especially in young adults who may be perceived as more likely to participate in Crate Day.
This study shows that males accounted for two thirds of ARPs on any weekend (either Crate Day or reference) and were approximately twice as likely to present during the Crate Day period compared to the reference period. This is in line with the study by Sevensen et al.,[[5]] which found that 65% of ARPs were male. By studying 1,000 ARPs to New South Wales EDs in Australia, Whitlam et al.[[28]] also showed that two thirds of ARPs were male. In our analysis, we were unable to detect a statistically significant change in the gender composition of ARPs.
Analysis by deprivation areas enables socioeconomic trends to be explored. Our results are consistent with Sevensen et al.,[[5]] Collins,[[29]] and Katikireddi et al.,[[30]] who found that a higher proportion of ARPs were from people who live in high socio-economic deprivation areas. The present results also suggest a possible interaction between socio-economic status and Crate Day such that people of medium and high deprivation are at an increased risk of requiring ED care on Crate Day, an effect not observed in areas of low deprivation. Based on the power analysis calculation performed by Cohen (1992, p.158),[[31]] the sample size required to attain a statistical power of 80% (at 5% significance level), for comparing the two samples using Chi-squared test, for a small size relationship (“small effect”), is 785 observations in each group. Though the aforementioned findings are not statistically significant, in what is an underpowered analysis, these findings are consistent with a general trend of higher vulnerability to stressors[[32]] seen in people of low socio-economic status. The corollary is that people of medium high deprivation have the most to gain from public health intervention. Given the predictable geographic distribution of deprivation, some interventions, such as lowering the density of alcohol outlet stores, which are known to be more concentrated in high-deprivation areas,[[39]] and limiting alcohol promotion can be easily targeted in these areas. If true, this finding would have implication on equity between ethnicities because Māori are over-represented in areas of high deprivation; therefore, may be vulnerable to the harmful effects of alcohol promoting activities.
This study supports the existing literature by confirming that high proportion of ARPs during the reference period occurred late at night.[[5,26,33,34]] Moreover, it shows that ARPs were more frequent from 5pm to 3am during the Crate Day period, compared to the reference period. By reviewing 12 months of ARP data to the Auckland City Hospital ED, Sevensen et al. found that ARPs were more frequent at night, during the weekends, public holidays and during summer.[[5]]
Quantification of the burden and characteristics of ARPs associated with Crate Day can help inform ED planning. For example, this information could help determine the number of additional doctors, nurses and security staff required on Crate Day to maintain normal service. This information can also inform alcohol promotion strategies, licencing decisions and local alcohol policy development. For example, if there is evidence of alcohol related harm in the form of a rise in ARPs on Crate Day, a local alcohol policy might implement narrower opening hours in the first weekend of December.
This study has several limitations; notably, it is significantly underpowered to detect changes in the rate of ARPs for the population, let alone for the subgroups. As a result, the chance of a type two (false negative) result is high. This should be taken into consideration while interpreting these results and the lack of statistical significance should not be taken as the absence of difference. Furthermore, the small number of weekends included in the analysis leave the analysis vulnerable to bias from major public events such as international sporting events which may increase the rate of ARPs.[[35]] There were no public holidays during the observed weekends; however, there were two international cricket test matches played in Waikato, one on a Crate Day weekend and another on a reference weekend. There was also an international rugby match, and two Waikato horse-racing events on reference weekends, which would be likely to, if anything, reduce the magnitude of association between Crate Day and ARPs. Additionally, the COVID-19 pandemic might have an impact on alcohol consumption; however, the effect of the pandemic on Crate Day behaviours are unknown.[[36]] Notably, there were no lockdowns during the observed period and Waikato Region was on alert level one during the 2020 Crate Day and reference periods. Another limitation is high number of unknown presentations, which introduces risk of selection bias and limits the sample size, thus reducing statistical power. A fourth limitation is a lack of definition of what qualifies as alcohol related or not. Judgement is up to the treating clinicians, which is likely to cause a reporting bias. Due to limitations in data availability, this study used NZDep2013 as the socio-economic status dataset. This is not the most recent available; therefore, the deprivation level attributed to a patient may not reflect their actual status. Furthermore, area-level deprivation may misclassify individuals when the geographic distribution of socio-economic status fails to align with NZDep2013 boundaries. Another limitation is that ethnicity data was obtained from the WDHB patient management database, which is known to have poor concordance with census data, and to undercount Māori.[[37]] This misclassification bias adds uncertainty to estimates by ethnicity and likely results in underestimates of Māori incidence rate. These data exclusively pertain to Crate Day in the WDHB region, which may limit generalisability of the findings to wider Aotearoa New Zealand and to other organised binge drinking activities.
The present study highlights the burden of alcohol consumption and binge drinking on Eds. There is significant need for public health interventions aimed to reduce alcohol-related harm presenting to Eds and generally. Such interventions would need to target deep structural issues, such as the inequitable distribution of resources, as well as ingrained cultural norms. Possible interventions include tightening restrictions on advertising and promotion, alcohol regulations, and changing the drinking context using community-based solutions.[[5,38]]
Crate Day appears to have originated from a radio broadcast in 2009. There have been several Crate Day promotion campaigns since, despite the Sale and Supply of Alcohol Act 2012.[[12,14]] Given the influence of broadcast media and advertising, and the potential harms of alcohol promotion, as is the case with Crate Day, further restriction of alcohol promotion in New Zealand would be justified. Furthermore, broadcast media should appreciate their significant and lasting social impact and ensure internal policy and culture results in content that discourages harmful alcohol use.
The findings of the present study provide the evidence for continued efforts to develop effective national policy that addresses alcohol promotion and drinking culture in an effort to minimise alcohol harm. In addition, the information can support ED workload planning across the five hospitals in Waikato and provides evidence that may inform alcohol health promotion, licensing and policy decisions.
View Appendices.
Summary
Abstract
Aim
To describe the effect of Crate Day on alcohol-related presentations (ARPs) to Waikato District Health Board (WDHB) emergency departments (EDs).
Method
This retrospective observational study used a descriptive analytical approach to examine alcohol-related ED attendance. Age standardised ED ARP rates and relative rates (RR) were calculated for the weekends on which Crate Day falls (pooled 2019 and 2020) with respect to reference weekends. A sub-group analysis was performed for various age, ethnicity, gender and socio-economic factors.
Results
The age-standardised RR of ARPs for Crate Day weekends relative to the reference weekends was 1.5 (95% confidence interval (CI): 0.96–2.26). The rate of ARPs of 20- to 34-year-olds was significantly higher during Crate Day weekends with a RR of 2.00 (95% CI: 1.11–3.59). There was a disproportionate non-significant increase in ED ARPs in males, those who are living in areas of high deprivation, and people of non-Māori ethnicity on Crate Day weekends compared to reference weekends. Alcohol-related presentations were more frequent (72%) between 5pm and 3am on Crate Day weekends.
Conclusion
The findings from this study suggest an association between ARPs and Crate Day, which varies between demographic groups. Further research is required to determine if this is a reproducible and national finding. Crate Day is a potential target for public health intervention and policy change aimed at reducing alcohol-related harms.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Alcohol-related presentations to emergency departments on Crate Day in Waikato, New Zealand
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Alcohol causes a myriad of socio-economic and physical health issues in Aotearoa New Zealand including road traffic injuries, self-inflicted injuries, alcoholic liver cirrhosis, colorectal and breast cancer, alcohol use disorder, foetal alcohol spectrum disorder, depression, and domestic violence.[[1]] It has been estimated that 5.4% of deaths in New Zealanders are attributable to alcohol.[[2]]
There are large inequities in the distribution of alcohol-related harm between ethnicities such that the alcohol-related mortality rate for Māori is 2.5 times higher than non-Māori.[[1,2]] Males are also disproportionately affected, experiencing almost two times the rate of disability adjusted life years than females.[[2]] Furthermore, 15- to 29-year-old Māori males have the highest rate of years of life lost due to alcohol than any other population group.[[2]]
Alcohol-related health issues bear a significant economic burden, estimated to cost New Zealand $5.3 billion each year.[[3]] The pattern of drinking is an important consideration, with heavy episodic drinking (HED) being associated with greater harm.[[4]] In general, HED is defined as the consumption of 60g or more of pure alcohol on at least one single occasion at least once per month.[[1]] Hospital emergency departments (EDs) are significantly burdened by alcohol-related harm.[[5,6]] There is a high frequency of alcohol-related presentations (ARPs) during weekends, particularly late at night or in the early hours of the morning, and more commonly presenting with physical injuries, which can be severe and life threatening.[[5]] Alcohol is also reported to be the most common factor contributing to aggressive behaviour directed at ED staff by patients and visitors.[[7,8]] Intoxicated ED patients draw resources away from other patients.[[5,7]]
Crate Day is an unofficial observance held annually on the first Saturday of December, during which each participant attempts to consume one entire crate of beer.[[9]] A crate comprises of 12 large 745mL bottles of beer, containing 300g of pure alcohol.[[9,11]] This tradition was started by a radio station in 2009 who have continued to promote it alongside alcohol industry members.[[9,11–13]]
Crate Day is of public health concern because of the potential alcohol-related harm due to an increase in alcohol consumption, and in a high-risk manner that is likely to be distributed inequitably across society. In addition, it normalises HED, which could beget HED at other times of the year. Furthermore, Crate Day could cause indirect harm through consumption of scarce healthcare resource, and the associated opportunity cost of delaying other patients’ care.
Despite the potential harms of this event, there is a paucity of information about participation and consequences. Newspaper reports have raised concern about an increased burden on EDs from ARPs on Crate Day, one suggesting a doubling of alcohol-related injuries compared to an average December weekend.[[12,14,15]] Formal assessment of ARPs on Crate Day are required to inform alcohol promotion strategies, alcohol licensing decisions, local alcohol policies, and national legislation and policy to design a healthier alcohol environment. This knowledge could also inform ED workload planning to ensure safe staffing levels.
This study aims to describe the pattern of ED ARPs on Crate Day in the Waikato. Waikato District Health Board (WDHB) served a population of over 400,000, 25% of whom identify as Māori. Within WDHB, there is one urban hospital (Waikato Hospital) and four rural hospitals. To our knowledge, this is the first study examining the relationship between Crate Day and ARPs to New Zealand hospital EDs.
Method
This retrospective observational study used a descriptive analytical approach to examine ED attendance during the Crate Day weekends in 2019 and 2020 and adjacent weekends. Data were extracted from WDHB electronic records including data from all five WDHB hospitals. Alcohol related presentations were identified using a “alcohol involved” flag, a compulsory electronic field completed by staff for each patient which became a mandatory reporting requirement to the Ministry of Health in 2017.[[16]] There are four response types available for the alcohol involved field: “Yes”, where the patient was themselves intoxicated; “Secondary”, where the patient was not intoxicated, but their presentation was caused by another intoxicated individual; “No”, where the patient was not intoxicated; and “Unknown”, where the association with alcohol was not known or could not be determined.[[5,17]] Alcohol involvement is determined by healthcare staff based on clinical judgement and there is no formalised questioning or investigation. The vast majority of alcohol-related presentations identified with this flag are due to acute alcohol intoxication, such as trauma and toxicity, because the contribution of alcohol to those diagnoses can be clinically determined; unlike chronic harms e.g., breast cancer, where the relationship to alcohol is obscured (see Appendix 1). In this study ARPs refers to both primary and secondary cases.
Data from the Crate Day weekend (Crate Day and the day after) in 2019 and 2020 were pooled to form the Crate Day group. Weekends immediately before and after a Crate Day weekend for both 2019 and 2020 were pooled to form the reference group.
These weekends were selected to mitigate systematic bias secondary to seasonal variation in ARPs.[[5]] Reference weekends did not appear to be outliers on visual inspection of plots of ARPs vs time. Age-standardised rates (ASRs) per 100,000 person-weekends and age standardised relative rate (ASRR) with estimated 95% confidence intervals (CIs) were calculated. The 2018 Census population was used as the standard population for age-standardisation.[[18]] A subgroup analysis was performed for sex, ethnicity, socio-economic deprivation as measured by the New Zealand Deprivation Index 2013 (NZDep2013)[[19]] and hospital rurality.
Multiple ethnicities were managed using prioritised ethnicity.[[20]] Age-specific rates were calculated for the age groups 0–19, 20–34 and 35 years and over. Ideally, the lower age group would have been 0–17 years because the legal alcohol purchasing age in New Zealand is 18 years; however, population data were restricted to five-year bands. The grouping used (0–19 years) minimises the mixing of legal and non-legal alcohol purchasers as compared to the next best grouping (0–14 years). Statistical testing was performed using Chi squared tests. Population estimates were taken from a demographic model developed by WDHB derived from Waikato Integrated Scenario Explorer model.[[21]] Data analysis was performed on Qlik Sense software,[[22]] Microsoft Excel and the online statistical calculator available at www.socscistatistics.com. Analysis for the study was done as part of a routine public health audit; therefore, ethics approval was deemed unnecessary.
Results
During the pooled 2019 and 2020 Crate Day period, there were 1,533 presentations to WDHB EDs, 100 (6.5%) of which were ARP and 277 (18.7%) where the alcohol involvement was unknown. Seventy-two percent (72/100) of ARPs were male and 36.0% (36/100) were of Māori ethnicity. In comparison, during the reference period, there were 2,969 presentation, 136 (4.6%) of which were alcohol related and 457 (15.4%) of unknown alcohol involvement. Of the ARPs, 64.7% (88/136) were male and 36.1% (48/133) were of Māori ethnicity. There were no statistically significant differences in sex, ethnicity, hospital or deprivation between Crate Day period and reference period (see Table 1). A majority (72.0%) of ARPs occurred between 5pm and 3am during the Crate Day period.
The estimated crude incidence rate was 12.6 per 100,000 person-weekends (95% CI: 9.13 to 16.13) during the Crate Day period and 8.6 per 100,000 person weekends (95% CI: 5.70 to 11.47) during the reference period (see Appendix 2). This equates to a crude relative rate of 1.5 (95% CI: 0.97 to 2.32). The ASR was 12.8 per 100,000 person-weekends (95% CI: 4.31 to 21.36) during the Crate Day period and 8.7 per 100,000 person-weekends (95% CI: 1.69 to 15.61) during the reference period, a relative rate of 1.5 (95% CI: 0.96 to 2.26) (see Table 2).
The ASR (per 100,000 person-weekends) of ARPs was 16.9 for Māori during the Crate Day period compared to 12.5 during the reference period, a relative rate of 1.4 (95% CI: 0.66 to 2.78). The ASRs were 10.2 and 6.6 respectively for non-Māori, a relative rate of 1.6 (95% CI: 0.89 to 2.68). Age-standardised ARP rates increase as socio-economic deprivation increases for both Crate Day period and reference period; however, the ASR was 1.5 times higher in areas of high (NZDep 8–10) and medium (NZDep 4–7) deprivation during the Crate Day period compared to the reference period. Estimated 95% CIs for the relative rates cross 1, suggesting differences are not statistically significant. The relative rate in low deprivation (NZDep 1–3) areas was 1.0. Following age standardisation, males were 1.7 (95% CI: 0.98 to 2.82) times more likely to present to EDs for alcohol related issues during the Crate Day period than reference period. Those of Māori ethnicity were 1.4 (95% CI: 0.66 to 2.78) times more likely, and non-Māori were 1.6 (95% CI: 0.89 to 2.68) times more likely, to present to ED for an alcohol related issue during the Crate Day period compared to reference period.
View Tables 1–3 and Figure 1.
Rates of ARPs also differed by age (see Figure 1). The rates of ARPs were approximately twice as high for those aged 20–24 years and 25–34 years during the Crate Day period.
There was a statistically significant association between ARPs and Crate Day with a relative rate of 2.00 (95% CI: 1.11 to 3.59), but not in other age groups (see Table 3).
Discussion
New Zealand has a liberal alcohol consumption culture, where drinking is deeply ingrained in social norms and binge drinking is commonplace, especially amongst youths.[[23,24]] It is no surprise that alcohol-related harm places a significant burden on New Zealand EDs.[[25]] The purpose of this study is to identify and quantify any burden that Crate Day may place on EDs in Waikato, New Zealand and in doing so identify populations most at risk. To our knowledge, this is the first study to examine the effect of Crate Day on alcohol related presentations to New Zealand hospital EDs. The study shows that alcohol played a role in 6.5% of presentations, equating to 100 patients, on Crate Day weekends across 2019 and 2020, which was greater than the proportion of ARPs on reference weekends (136/2969; 4.6%).
Analysis of ARPs by ethnicity showed that Māori have higher rates of ARP to ED than non-Māori at baseline. This result is consistent with findings from Svensen et al., who found that Māori were over represented in ARPs to Auckland City Hospital ED.[[5]] The higher rate of ARPs on Crate Day are similar between Māori and non Māori on crude analysis (Appendix 2), and slightly lower (though not statistically significant) after age standardisation, with an estimated ASRR of 1.4 and 1.6 respectively. This raises the possibility that the social practice of Crate Day may be more integrated into non-Māori, mainly New Zealand European, culture. However, on a population scale Māori may be more vulnerable to the harms associated with Crate Day due, in part, to their younger age structure.
The age group analysis of the study shows a significantly higher ASR for those aged 20–34 years on Crate Day weekends with an ASRR of 2.00. Though causality between Crate Day and ARPs cannot be established from this study, this finding is consistent with the hypothesis that young adults are more likely to drink to excess on Crate Day than other age groups. This vulnerability is not surprising given that young adults are known to have a higher risk of ARPs at baseline.[[5,26,27]] An alternative explanation of this association could be that healthcare staff are more likely to categorise presentations as alcohol related on Crate Day due to their knowledge of the event. This measurement bias would result in an artificial large effect size, especially in young adults who may be perceived as more likely to participate in Crate Day.
This study shows that males accounted for two thirds of ARPs on any weekend (either Crate Day or reference) and were approximately twice as likely to present during the Crate Day period compared to the reference period. This is in line with the study by Sevensen et al.,[[5]] which found that 65% of ARPs were male. By studying 1,000 ARPs to New South Wales EDs in Australia, Whitlam et al.[[28]] also showed that two thirds of ARPs were male. In our analysis, we were unable to detect a statistically significant change in the gender composition of ARPs.
Analysis by deprivation areas enables socioeconomic trends to be explored. Our results are consistent with Sevensen et al.,[[5]] Collins,[[29]] and Katikireddi et al.,[[30]] who found that a higher proportion of ARPs were from people who live in high socio-economic deprivation areas. The present results also suggest a possible interaction between socio-economic status and Crate Day such that people of medium and high deprivation are at an increased risk of requiring ED care on Crate Day, an effect not observed in areas of low deprivation. Based on the power analysis calculation performed by Cohen (1992, p.158),[[31]] the sample size required to attain a statistical power of 80% (at 5% significance level), for comparing the two samples using Chi-squared test, for a small size relationship (“small effect”), is 785 observations in each group. Though the aforementioned findings are not statistically significant, in what is an underpowered analysis, these findings are consistent with a general trend of higher vulnerability to stressors[[32]] seen in people of low socio-economic status. The corollary is that people of medium high deprivation have the most to gain from public health intervention. Given the predictable geographic distribution of deprivation, some interventions, such as lowering the density of alcohol outlet stores, which are known to be more concentrated in high-deprivation areas,[[39]] and limiting alcohol promotion can be easily targeted in these areas. If true, this finding would have implication on equity between ethnicities because Māori are over-represented in areas of high deprivation; therefore, may be vulnerable to the harmful effects of alcohol promoting activities.
This study supports the existing literature by confirming that high proportion of ARPs during the reference period occurred late at night.[[5,26,33,34]] Moreover, it shows that ARPs were more frequent from 5pm to 3am during the Crate Day period, compared to the reference period. By reviewing 12 months of ARP data to the Auckland City Hospital ED, Sevensen et al. found that ARPs were more frequent at night, during the weekends, public holidays and during summer.[[5]]
Quantification of the burden and characteristics of ARPs associated with Crate Day can help inform ED planning. For example, this information could help determine the number of additional doctors, nurses and security staff required on Crate Day to maintain normal service. This information can also inform alcohol promotion strategies, licencing decisions and local alcohol policy development. For example, if there is evidence of alcohol related harm in the form of a rise in ARPs on Crate Day, a local alcohol policy might implement narrower opening hours in the first weekend of December.
This study has several limitations; notably, it is significantly underpowered to detect changes in the rate of ARPs for the population, let alone for the subgroups. As a result, the chance of a type two (false negative) result is high. This should be taken into consideration while interpreting these results and the lack of statistical significance should not be taken as the absence of difference. Furthermore, the small number of weekends included in the analysis leave the analysis vulnerable to bias from major public events such as international sporting events which may increase the rate of ARPs.[[35]] There were no public holidays during the observed weekends; however, there were two international cricket test matches played in Waikato, one on a Crate Day weekend and another on a reference weekend. There was also an international rugby match, and two Waikato horse-racing events on reference weekends, which would be likely to, if anything, reduce the magnitude of association between Crate Day and ARPs. Additionally, the COVID-19 pandemic might have an impact on alcohol consumption; however, the effect of the pandemic on Crate Day behaviours are unknown.[[36]] Notably, there were no lockdowns during the observed period and Waikato Region was on alert level one during the 2020 Crate Day and reference periods. Another limitation is high number of unknown presentations, which introduces risk of selection bias and limits the sample size, thus reducing statistical power. A fourth limitation is a lack of definition of what qualifies as alcohol related or not. Judgement is up to the treating clinicians, which is likely to cause a reporting bias. Due to limitations in data availability, this study used NZDep2013 as the socio-economic status dataset. This is not the most recent available; therefore, the deprivation level attributed to a patient may not reflect their actual status. Furthermore, area-level deprivation may misclassify individuals when the geographic distribution of socio-economic status fails to align with NZDep2013 boundaries. Another limitation is that ethnicity data was obtained from the WDHB patient management database, which is known to have poor concordance with census data, and to undercount Māori.[[37]] This misclassification bias adds uncertainty to estimates by ethnicity and likely results in underestimates of Māori incidence rate. These data exclusively pertain to Crate Day in the WDHB region, which may limit generalisability of the findings to wider Aotearoa New Zealand and to other organised binge drinking activities.
The present study highlights the burden of alcohol consumption and binge drinking on Eds. There is significant need for public health interventions aimed to reduce alcohol-related harm presenting to Eds and generally. Such interventions would need to target deep structural issues, such as the inequitable distribution of resources, as well as ingrained cultural norms. Possible interventions include tightening restrictions on advertising and promotion, alcohol regulations, and changing the drinking context using community-based solutions.[[5,38]]
Crate Day appears to have originated from a radio broadcast in 2009. There have been several Crate Day promotion campaigns since, despite the Sale and Supply of Alcohol Act 2012.[[12,14]] Given the influence of broadcast media and advertising, and the potential harms of alcohol promotion, as is the case with Crate Day, further restriction of alcohol promotion in New Zealand would be justified. Furthermore, broadcast media should appreciate their significant and lasting social impact and ensure internal policy and culture results in content that discourages harmful alcohol use.
The findings of the present study provide the evidence for continued efforts to develop effective national policy that addresses alcohol promotion and drinking culture in an effort to minimise alcohol harm. In addition, the information can support ED workload planning across the five hospitals in Waikato and provides evidence that may inform alcohol health promotion, licensing and policy decisions.
View Appendices.
Summary
Abstract
Aim
To describe the effect of Crate Day on alcohol-related presentations (ARPs) to Waikato District Health Board (WDHB) emergency departments (EDs).
Method
This retrospective observational study used a descriptive analytical approach to examine alcohol-related ED attendance. Age standardised ED ARP rates and relative rates (RR) were calculated for the weekends on which Crate Day falls (pooled 2019 and 2020) with respect to reference weekends. A sub-group analysis was performed for various age, ethnicity, gender and socio-economic factors.
Results
The age-standardised RR of ARPs for Crate Day weekends relative to the reference weekends was 1.5 (95% confidence interval (CI): 0.96–2.26). The rate of ARPs of 20- to 34-year-olds was significantly higher during Crate Day weekends with a RR of 2.00 (95% CI: 1.11–3.59). There was a disproportionate non-significant increase in ED ARPs in males, those who are living in areas of high deprivation, and people of non-Māori ethnicity on Crate Day weekends compared to reference weekends. Alcohol-related presentations were more frequent (72%) between 5pm and 3am on Crate Day weekends.
Conclusion
The findings from this study suggest an association between ARPs and Crate Day, which varies between demographic groups. Further research is required to determine if this is a reproducible and national finding. Crate Day is a potential target for public health intervention and policy change aimed at reducing alcohol-related harms.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Alcohol-related presentations to emergency departments on Crate Day in Waikato, New Zealand
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Alcohol causes a myriad of socio-economic and physical health issues in Aotearoa New Zealand including road traffic injuries, self-inflicted injuries, alcoholic liver cirrhosis, colorectal and breast cancer, alcohol use disorder, foetal alcohol spectrum disorder, depression, and domestic violence.[[1]] It has been estimated that 5.4% of deaths in New Zealanders are attributable to alcohol.[[2]]
There are large inequities in the distribution of alcohol-related harm between ethnicities such that the alcohol-related mortality rate for Māori is 2.5 times higher than non-Māori.[[1,2]] Males are also disproportionately affected, experiencing almost two times the rate of disability adjusted life years than females.[[2]] Furthermore, 15- to 29-year-old Māori males have the highest rate of years of life lost due to alcohol than any other population group.[[2]]
Alcohol-related health issues bear a significant economic burden, estimated to cost New Zealand $5.3 billion each year.[[3]] The pattern of drinking is an important consideration, with heavy episodic drinking (HED) being associated with greater harm.[[4]] In general, HED is defined as the consumption of 60g or more of pure alcohol on at least one single occasion at least once per month.[[1]] Hospital emergency departments (EDs) are significantly burdened by alcohol-related harm.[[5,6]] There is a high frequency of alcohol-related presentations (ARPs) during weekends, particularly late at night or in the early hours of the morning, and more commonly presenting with physical injuries, which can be severe and life threatening.[[5]] Alcohol is also reported to be the most common factor contributing to aggressive behaviour directed at ED staff by patients and visitors.[[7,8]] Intoxicated ED patients draw resources away from other patients.[[5,7]]
Crate Day is an unofficial observance held annually on the first Saturday of December, during which each participant attempts to consume one entire crate of beer.[[9]] A crate comprises of 12 large 745mL bottles of beer, containing 300g of pure alcohol.[[9,11]] This tradition was started by a radio station in 2009 who have continued to promote it alongside alcohol industry members.[[9,11–13]]
Crate Day is of public health concern because of the potential alcohol-related harm due to an increase in alcohol consumption, and in a high-risk manner that is likely to be distributed inequitably across society. In addition, it normalises HED, which could beget HED at other times of the year. Furthermore, Crate Day could cause indirect harm through consumption of scarce healthcare resource, and the associated opportunity cost of delaying other patients’ care.
Despite the potential harms of this event, there is a paucity of information about participation and consequences. Newspaper reports have raised concern about an increased burden on EDs from ARPs on Crate Day, one suggesting a doubling of alcohol-related injuries compared to an average December weekend.[[12,14,15]] Formal assessment of ARPs on Crate Day are required to inform alcohol promotion strategies, alcohol licensing decisions, local alcohol policies, and national legislation and policy to design a healthier alcohol environment. This knowledge could also inform ED workload planning to ensure safe staffing levels.
This study aims to describe the pattern of ED ARPs on Crate Day in the Waikato. Waikato District Health Board (WDHB) served a population of over 400,000, 25% of whom identify as Māori. Within WDHB, there is one urban hospital (Waikato Hospital) and four rural hospitals. To our knowledge, this is the first study examining the relationship between Crate Day and ARPs to New Zealand hospital EDs.
Method
This retrospective observational study used a descriptive analytical approach to examine ED attendance during the Crate Day weekends in 2019 and 2020 and adjacent weekends. Data were extracted from WDHB electronic records including data from all five WDHB hospitals. Alcohol related presentations were identified using a “alcohol involved” flag, a compulsory electronic field completed by staff for each patient which became a mandatory reporting requirement to the Ministry of Health in 2017.[[16]] There are four response types available for the alcohol involved field: “Yes”, where the patient was themselves intoxicated; “Secondary”, where the patient was not intoxicated, but their presentation was caused by another intoxicated individual; “No”, where the patient was not intoxicated; and “Unknown”, where the association with alcohol was not known or could not be determined.[[5,17]] Alcohol involvement is determined by healthcare staff based on clinical judgement and there is no formalised questioning or investigation. The vast majority of alcohol-related presentations identified with this flag are due to acute alcohol intoxication, such as trauma and toxicity, because the contribution of alcohol to those diagnoses can be clinically determined; unlike chronic harms e.g., breast cancer, where the relationship to alcohol is obscured (see Appendix 1). In this study ARPs refers to both primary and secondary cases.
Data from the Crate Day weekend (Crate Day and the day after) in 2019 and 2020 were pooled to form the Crate Day group. Weekends immediately before and after a Crate Day weekend for both 2019 and 2020 were pooled to form the reference group.
These weekends were selected to mitigate systematic bias secondary to seasonal variation in ARPs.[[5]] Reference weekends did not appear to be outliers on visual inspection of plots of ARPs vs time. Age-standardised rates (ASRs) per 100,000 person-weekends and age standardised relative rate (ASRR) with estimated 95% confidence intervals (CIs) were calculated. The 2018 Census population was used as the standard population for age-standardisation.[[18]] A subgroup analysis was performed for sex, ethnicity, socio-economic deprivation as measured by the New Zealand Deprivation Index 2013 (NZDep2013)[[19]] and hospital rurality.
Multiple ethnicities were managed using prioritised ethnicity.[[20]] Age-specific rates were calculated for the age groups 0–19, 20–34 and 35 years and over. Ideally, the lower age group would have been 0–17 years because the legal alcohol purchasing age in New Zealand is 18 years; however, population data were restricted to five-year bands. The grouping used (0–19 years) minimises the mixing of legal and non-legal alcohol purchasers as compared to the next best grouping (0–14 years). Statistical testing was performed using Chi squared tests. Population estimates were taken from a demographic model developed by WDHB derived from Waikato Integrated Scenario Explorer model.[[21]] Data analysis was performed on Qlik Sense software,[[22]] Microsoft Excel and the online statistical calculator available at www.socscistatistics.com. Analysis for the study was done as part of a routine public health audit; therefore, ethics approval was deemed unnecessary.
Results
During the pooled 2019 and 2020 Crate Day period, there were 1,533 presentations to WDHB EDs, 100 (6.5%) of which were ARP and 277 (18.7%) where the alcohol involvement was unknown. Seventy-two percent (72/100) of ARPs were male and 36.0% (36/100) were of Māori ethnicity. In comparison, during the reference period, there were 2,969 presentation, 136 (4.6%) of which were alcohol related and 457 (15.4%) of unknown alcohol involvement. Of the ARPs, 64.7% (88/136) were male and 36.1% (48/133) were of Māori ethnicity. There were no statistically significant differences in sex, ethnicity, hospital or deprivation between Crate Day period and reference period (see Table 1). A majority (72.0%) of ARPs occurred between 5pm and 3am during the Crate Day period.
The estimated crude incidence rate was 12.6 per 100,000 person-weekends (95% CI: 9.13 to 16.13) during the Crate Day period and 8.6 per 100,000 person weekends (95% CI: 5.70 to 11.47) during the reference period (see Appendix 2). This equates to a crude relative rate of 1.5 (95% CI: 0.97 to 2.32). The ASR was 12.8 per 100,000 person-weekends (95% CI: 4.31 to 21.36) during the Crate Day period and 8.7 per 100,000 person-weekends (95% CI: 1.69 to 15.61) during the reference period, a relative rate of 1.5 (95% CI: 0.96 to 2.26) (see Table 2).
The ASR (per 100,000 person-weekends) of ARPs was 16.9 for Māori during the Crate Day period compared to 12.5 during the reference period, a relative rate of 1.4 (95% CI: 0.66 to 2.78). The ASRs were 10.2 and 6.6 respectively for non-Māori, a relative rate of 1.6 (95% CI: 0.89 to 2.68). Age-standardised ARP rates increase as socio-economic deprivation increases for both Crate Day period and reference period; however, the ASR was 1.5 times higher in areas of high (NZDep 8–10) and medium (NZDep 4–7) deprivation during the Crate Day period compared to the reference period. Estimated 95% CIs for the relative rates cross 1, suggesting differences are not statistically significant. The relative rate in low deprivation (NZDep 1–3) areas was 1.0. Following age standardisation, males were 1.7 (95% CI: 0.98 to 2.82) times more likely to present to EDs for alcohol related issues during the Crate Day period than reference period. Those of Māori ethnicity were 1.4 (95% CI: 0.66 to 2.78) times more likely, and non-Māori were 1.6 (95% CI: 0.89 to 2.68) times more likely, to present to ED for an alcohol related issue during the Crate Day period compared to reference period.
View Tables 1–3 and Figure 1.
Rates of ARPs also differed by age (see Figure 1). The rates of ARPs were approximately twice as high for those aged 20–24 years and 25–34 years during the Crate Day period.
There was a statistically significant association between ARPs and Crate Day with a relative rate of 2.00 (95% CI: 1.11 to 3.59), but not in other age groups (see Table 3).
Discussion
New Zealand has a liberal alcohol consumption culture, where drinking is deeply ingrained in social norms and binge drinking is commonplace, especially amongst youths.[[23,24]] It is no surprise that alcohol-related harm places a significant burden on New Zealand EDs.[[25]] The purpose of this study is to identify and quantify any burden that Crate Day may place on EDs in Waikato, New Zealand and in doing so identify populations most at risk. To our knowledge, this is the first study to examine the effect of Crate Day on alcohol related presentations to New Zealand hospital EDs. The study shows that alcohol played a role in 6.5% of presentations, equating to 100 patients, on Crate Day weekends across 2019 and 2020, which was greater than the proportion of ARPs on reference weekends (136/2969; 4.6%).
Analysis of ARPs by ethnicity showed that Māori have higher rates of ARP to ED than non-Māori at baseline. This result is consistent with findings from Svensen et al., who found that Māori were over represented in ARPs to Auckland City Hospital ED.[[5]] The higher rate of ARPs on Crate Day are similar between Māori and non Māori on crude analysis (Appendix 2), and slightly lower (though not statistically significant) after age standardisation, with an estimated ASRR of 1.4 and 1.6 respectively. This raises the possibility that the social practice of Crate Day may be more integrated into non-Māori, mainly New Zealand European, culture. However, on a population scale Māori may be more vulnerable to the harms associated with Crate Day due, in part, to their younger age structure.
The age group analysis of the study shows a significantly higher ASR for those aged 20–34 years on Crate Day weekends with an ASRR of 2.00. Though causality between Crate Day and ARPs cannot be established from this study, this finding is consistent with the hypothesis that young adults are more likely to drink to excess on Crate Day than other age groups. This vulnerability is not surprising given that young adults are known to have a higher risk of ARPs at baseline.[[5,26,27]] An alternative explanation of this association could be that healthcare staff are more likely to categorise presentations as alcohol related on Crate Day due to their knowledge of the event. This measurement bias would result in an artificial large effect size, especially in young adults who may be perceived as more likely to participate in Crate Day.
This study shows that males accounted for two thirds of ARPs on any weekend (either Crate Day or reference) and were approximately twice as likely to present during the Crate Day period compared to the reference period. This is in line with the study by Sevensen et al.,[[5]] which found that 65% of ARPs were male. By studying 1,000 ARPs to New South Wales EDs in Australia, Whitlam et al.[[28]] also showed that two thirds of ARPs were male. In our analysis, we were unable to detect a statistically significant change in the gender composition of ARPs.
Analysis by deprivation areas enables socioeconomic trends to be explored. Our results are consistent with Sevensen et al.,[[5]] Collins,[[29]] and Katikireddi et al.,[[30]] who found that a higher proportion of ARPs were from people who live in high socio-economic deprivation areas. The present results also suggest a possible interaction between socio-economic status and Crate Day such that people of medium and high deprivation are at an increased risk of requiring ED care on Crate Day, an effect not observed in areas of low deprivation. Based on the power analysis calculation performed by Cohen (1992, p.158),[[31]] the sample size required to attain a statistical power of 80% (at 5% significance level), for comparing the two samples using Chi-squared test, for a small size relationship (“small effect”), is 785 observations in each group. Though the aforementioned findings are not statistically significant, in what is an underpowered analysis, these findings are consistent with a general trend of higher vulnerability to stressors[[32]] seen in people of low socio-economic status. The corollary is that people of medium high deprivation have the most to gain from public health intervention. Given the predictable geographic distribution of deprivation, some interventions, such as lowering the density of alcohol outlet stores, which are known to be more concentrated in high-deprivation areas,[[39]] and limiting alcohol promotion can be easily targeted in these areas. If true, this finding would have implication on equity between ethnicities because Māori are over-represented in areas of high deprivation; therefore, may be vulnerable to the harmful effects of alcohol promoting activities.
This study supports the existing literature by confirming that high proportion of ARPs during the reference period occurred late at night.[[5,26,33,34]] Moreover, it shows that ARPs were more frequent from 5pm to 3am during the Crate Day period, compared to the reference period. By reviewing 12 months of ARP data to the Auckland City Hospital ED, Sevensen et al. found that ARPs were more frequent at night, during the weekends, public holidays and during summer.[[5]]
Quantification of the burden and characteristics of ARPs associated with Crate Day can help inform ED planning. For example, this information could help determine the number of additional doctors, nurses and security staff required on Crate Day to maintain normal service. This information can also inform alcohol promotion strategies, licencing decisions and local alcohol policy development. For example, if there is evidence of alcohol related harm in the form of a rise in ARPs on Crate Day, a local alcohol policy might implement narrower opening hours in the first weekend of December.
This study has several limitations; notably, it is significantly underpowered to detect changes in the rate of ARPs for the population, let alone for the subgroups. As a result, the chance of a type two (false negative) result is high. This should be taken into consideration while interpreting these results and the lack of statistical significance should not be taken as the absence of difference. Furthermore, the small number of weekends included in the analysis leave the analysis vulnerable to bias from major public events such as international sporting events which may increase the rate of ARPs.[[35]] There were no public holidays during the observed weekends; however, there were two international cricket test matches played in Waikato, one on a Crate Day weekend and another on a reference weekend. There was also an international rugby match, and two Waikato horse-racing events on reference weekends, which would be likely to, if anything, reduce the magnitude of association between Crate Day and ARPs. Additionally, the COVID-19 pandemic might have an impact on alcohol consumption; however, the effect of the pandemic on Crate Day behaviours are unknown.[[36]] Notably, there were no lockdowns during the observed period and Waikato Region was on alert level one during the 2020 Crate Day and reference periods. Another limitation is high number of unknown presentations, which introduces risk of selection bias and limits the sample size, thus reducing statistical power. A fourth limitation is a lack of definition of what qualifies as alcohol related or not. Judgement is up to the treating clinicians, which is likely to cause a reporting bias. Due to limitations in data availability, this study used NZDep2013 as the socio-economic status dataset. This is not the most recent available; therefore, the deprivation level attributed to a patient may not reflect their actual status. Furthermore, area-level deprivation may misclassify individuals when the geographic distribution of socio-economic status fails to align with NZDep2013 boundaries. Another limitation is that ethnicity data was obtained from the WDHB patient management database, which is known to have poor concordance with census data, and to undercount Māori.[[37]] This misclassification bias adds uncertainty to estimates by ethnicity and likely results in underestimates of Māori incidence rate. These data exclusively pertain to Crate Day in the WDHB region, which may limit generalisability of the findings to wider Aotearoa New Zealand and to other organised binge drinking activities.
The present study highlights the burden of alcohol consumption and binge drinking on Eds. There is significant need for public health interventions aimed to reduce alcohol-related harm presenting to Eds and generally. Such interventions would need to target deep structural issues, such as the inequitable distribution of resources, as well as ingrained cultural norms. Possible interventions include tightening restrictions on advertising and promotion, alcohol regulations, and changing the drinking context using community-based solutions.[[5,38]]
Crate Day appears to have originated from a radio broadcast in 2009. There have been several Crate Day promotion campaigns since, despite the Sale and Supply of Alcohol Act 2012.[[12,14]] Given the influence of broadcast media and advertising, and the potential harms of alcohol promotion, as is the case with Crate Day, further restriction of alcohol promotion in New Zealand would be justified. Furthermore, broadcast media should appreciate their significant and lasting social impact and ensure internal policy and culture results in content that discourages harmful alcohol use.
The findings of the present study provide the evidence for continued efforts to develop effective national policy that addresses alcohol promotion and drinking culture in an effort to minimise alcohol harm. In addition, the information can support ED workload planning across the five hospitals in Waikato and provides evidence that may inform alcohol health promotion, licensing and policy decisions.
View Appendices.
Summary
Abstract
Aim
To describe the effect of Crate Day on alcohol-related presentations (ARPs) to Waikato District Health Board (WDHB) emergency departments (EDs).
Method
This retrospective observational study used a descriptive analytical approach to examine alcohol-related ED attendance. Age standardised ED ARP rates and relative rates (RR) were calculated for the weekends on which Crate Day falls (pooled 2019 and 2020) with respect to reference weekends. A sub-group analysis was performed for various age, ethnicity, gender and socio-economic factors.
Results
The age-standardised RR of ARPs for Crate Day weekends relative to the reference weekends was 1.5 (95% confidence interval (CI): 0.96–2.26). The rate of ARPs of 20- to 34-year-olds was significantly higher during Crate Day weekends with a RR of 2.00 (95% CI: 1.11–3.59). There was a disproportionate non-significant increase in ED ARPs in males, those who are living in areas of high deprivation, and people of non-Māori ethnicity on Crate Day weekends compared to reference weekends. Alcohol-related presentations were more frequent (72%) between 5pm and 3am on Crate Day weekends.
Conclusion
The findings from this study suggest an association between ARPs and Crate Day, which varies between demographic groups. Further research is required to determine if this is a reproducible and national finding. Crate Day is a potential target for public health intervention and policy change aimed at reducing alcohol-related harms.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Alcohol-related presentations to emergency departments on Crate Day in Waikato, New Zealand
Crate Day is of public health concern because of the potential alcohol-related harm due to an increase in alcohol consumption, and in a high-risk manner that is likely to be distributed inequitably across society.
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