BACKGROUND: Mortality from alcohol-related liver disease (ARLD) in England rose after the COVID-19 pandemic. Existing reports lack data on prior healthcare use, which is key to understanding care pathways before death. This study examined long-term trends in ARLD mortality before, during and after the pandemic and assessed changes in relation to prior inpatient care.

METHODS: In this population-based observational study using English national mortality records linked to NHS hospital data, all ARLD deaths in adults aged 25-84 were analysed from January 2004 to December 2024. Monthly mortality trends were examined by age, sex, deprivation, region and prior inpatient care. Interrupted time series estimated changes in mortality after the pandemic onset.

RESULTS: Over the study period, 97 058 ARLD deaths occurred, with about one-third out-of-hospital. Following the pandemic, ARLD mortality increased by 27.7% (95% CI 23.3% to 32.3%), representing 5571 excess deaths between March 2020 and December 2024. The step-increase was greater for out-of-hospital deaths (34.9%, 95% CI 28.4% to 41.7%) than for in-hospital deaths (22.9%, 95% CI 18.2% to 27.8%), and the increase in out-of-hospital deaths was driven by deaths in people who had no recent discharge in the previous year (75.7%, 95% CI 61.7% to 90.9%).

CONCLUSIONS: The increase in deaths from ARLD has been driven by a disproportionate increase in those without recent inpatient care. Efforts to understand ARLD mortality should increasingly be focused on the out-of-hospital setting.