Ethnic and sex bias in primary care screening tests for alcohol use disorders

BACKGROUND: The use of self-report screening tests for alcohol use disorders in the primary care setting has been advocated. OBJECTIVE: To test for ethnic and sex bias in three self-report screening tests for alcohol use disorders in a primary care population. DESIGN: Cross-sectional study with patients randomly selected from appointment lists. SETTING: University-based family practice clinic. PATIENTS: Probability sample of 1333 adult family practice patients stratified by sex and ethnicity. MEASUREMENTS: Patients completed 1) a diagnostic interview to determine the presence of a current alcohol use disorder and 2) three screening tests: the CAGE questionnaire, the Self-Administered Alcoholism Screening Test (SAAST), and the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: The areas under the receiver-operating characteristic (ROC) curves for the CAGE questionnaire and the SAAST ranged from 0.61 to 0.88 and were particularly poor for African-American men and Mexican-American women. For the AUDIT, the area under the ROC curves was greater than 0.90 for each patient subgroup. The sensitivity of the CAGE questionnaire and the SAAST at standard cut-points was lowest for Mexican-American women (0.21 and 0.13, respectively). Positive likelihood ratios for the AUDIT were similar to or higher than those for the other screening tests, whereas negative likelihood ratios were lowest for the AUDIT (<0.33), indicating the superiority of this test in ruling out a disorder. CONCLUSIONS: A marked inconsistency in the accuracy of common self-report screening tests for alcohol use disorders was found when these tests were used in a single clinical site with male and female family practice patients of different ethnic backgrounds. The AUDIT does not seem to be affected by ethnic and sex bias.     

Meningeal carcinomatosis in patient with esophagus adenocarcinoma

We assessed the practicality of using the Short Michigan Alcoholism Screening Test (SMAST) and the Alcohol Use Disorders Identification Test (AUDIT) in screening adolescents for alcoholism in a primary care setting. In addition, we sought to determine the prevalence of alcohol use among adolescents, 16-21 years of age, presenting to a private Family Medicine practice for medical care. A consecutive sample of 67 subjects presenting for medical care were asked to complete the SMAST and AUDIT questionnaires. Overall, 52 (78%) of the questionnaires were returned with complete data. Of the 52 patients, 25 (48%) admitted to drinking. Using a "positive" score on either the SMAST or AUDIT as a positive test for alcohol use yielded a sensitivity of 40% and a predictive value positive of 100%. Using a "negative" score on both the SMAST and AUDIT as a negative test for alcohol use yielded a specificity of 100% and a predictive value negative of 64%. Although alcohol use was relatively common considering the age group, using the SMAST and AUDIT to screen for alcoholism is labor intensive and is not practical in this situation. Because patients appeared to misinterpret some questions and were often accompanied to the office by their parents, their answers may not be valid. History of alcoholism taken upon typical office examination and relevant advice appears to be a better alternative to the use of questionnaires in determining the prevalence of alcohol use in this age group.     

Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test

OBJECTIVE: To compare self-administered versions of three questionnaires for detecting heavy and problem drinking: the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and an augmented version of the CAGE. DESIGN: Cross-sectional surveys. SETTING: Three Department of Veterans Affairs general medical clinics. PATIENTS: Random sample of consenting male outpatients who consumed at least 5 drinks over the past year ("drinkers"). Heavy drinkers were oversampled. MEASUREMENTS: An augmented version of the CAGE was included in a questionnaire mailed to all patients. The AUDIT was subsequently mailed to "drinkers." Comparison standards, based on the tri-level World Health Organization alcohol consumption interview and the Diagnostic Interview Schedule, included heavy drinking (> 14 drinks per week typically or > or = 5 drinks per day at least monthly) and active DSM-IIIR alcohol abuse or dependence (positive diagnosis and at least one alcohol-related symptom in the past year). Areas under receiver operating characteristic curves (AUROCs) were used to compare screening questionnaires. MAIN RESULTS: Of 393 eligible patients, 261 (66%) returned the AUDIT and completed interviews. For detection of active alcohol abuse or dependence, the CAGE augmented with three more questions (AUROC 0.871) performed better than either the CAGE alone or AUDIT (AUROCs 0.820 and 0.777, respectively). For identification of heavy-drinking patients, however, the AUDIT performed best (AUROC 0.870). To identify both heavy drinking and active alcohol abuse or dependence, the augmented CAGE and AUDIT both performed well, but the AUDIT was superior (AUROC 0.861). CONCLUSIONS: For identification of patients with heavy drinking or active alcohol abuse or dependence, the self-administered AUDIT was superior to the CAGE in this population.     

Predictive capacity of the AUDIT questionnaire for alcohol-related harm

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed to screen for hazardous and harmful alcohol consumption. We examined its ability to predict alcohol-related illness and social problems, hospital admission and mortality over a 2-3-year period. At initial interview, 330 ambulatory care patients were assessed using a detailed interview including the AUDIT questions and laboratory tests. After 2-3 years, 250 (76%) subjects were reassessed and their experience of alcohol-related harm determined. Of those who scored eight or more on AUDIT at initial interview, 61% experienced alcohol-related social problems compared with 10% of those with lower scores (p < 0.0001); they also had a significantly greater experience of alcohol-related medical disorders and hospitalization. AUDIT score was a better predictor of social problems and of hypertension than laboratory markers. Its ability to predict other alcohol-related illnesses was similar to the laboratory tests. However, gamma glutamyltransferase was the only significant predictor of mortality. We conclude that AUDIT should prove a valuable tool in screening for hazardous and harmful alcohol consumption so that intervention can be provided to those at particular risk of adverse consequences.     

The Alcohol Use Disorders Identification Test (AUDIT) in a routine health examination of long-term unemployed

A representative sample of 310 long-term unemployed in Norway was followed for 2 years with clinical examinations and the AUDIT questionnaire. 30% of the men and 8% of the women scored over the cut-off point for an alcohol use disorder. This gives a probable prevalence of 16%. The test predicted return to employment in this sample. The AUDIT answers were also used as a basis for dividing into three groups: 'normal', 'hazardous' and 'harmful'. At 2 year follow-up, 27% had changed group, 32 respondents to the worse and 24 to the better. This 'unstable' group was characterized by weaker social network and more frequent drinking. The AUDIT was judged as a useful instrument both in a routine health examination and as an epidemiological tool.     

Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness.

State Psychiatric Hospital outpatients (93 men, 69 women) diagnosed with a serious persistent mental illness (SPMI) completed the Alcohol Use Disorders Identification Test (AUDIT) and Drug Abuse Screening Test (DAST-10) by interview as part of a general health/behavior screening instrument. Responses to the AUDIT and DAST-10 were compared with criteria of current diagnosis and occurrence of symptoms in the last year for both alcohol and drug use disorders, respectively. Results showed that for both diagnosis and symptoms, AUDIT cutpoints of 7 and 8 had good sensitivity and specificity, and DAST-10 cutpoint of 2 was identified for both criteria. These and other findings suggest that both instruments have promising clinical utility when used with individuals diagnosed with an SPMI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A critical evaluation of several alcohol screening instruments using the CIDI-SAM as a criterion measure

Four alcohol screening instruments (the AUDIT, CAGE, MAST, and Svanum's scale) were administered to a sample of 306 undergraduate students at a Midwestern university and were compared with regard to several test characteristics, using the alcohol section of the CIDI-SAM (DSM-IV version) as the criterion measure. The performance of these instruments was evaluated using two subsets of subjects: (1) students who currently met diagnostic criteria for alcohol dependence (n = 35); and (2) students who met diagnostic criteria for alcohol dependence in the past and/or at present (i.e., lifetime diagnosis; n = 50). The AUDIT performed significantly better than the other three instruments in identifying students who were currently alcohol dependent, providing a moderate degree of clinical utility with this group. The four instruments did not differ significantly in their ability to identify students with a lifetime diagnosis; each measure provided only a modest degree of clinical utility with this group.     

Analysis of cut points for screening instruments for alcohol problems in the emergency room

OBJECTIVE: The purpose of this study is to evaluate the performance of a number of alcohol screening instruments (CAGE, Brief MAST, AUDIT, TWEAK), in an emergency room population, against ICD-10 criteria for harmful drinking and for alcohol dependence from the CIDI, by gender, race and injury status. METHOD: A probability sample of patients were interviewed (N = 1,330) at the University of Mississippi Medical Center. Analyses were carried out on only current drinkers (n = 771; 58% of the sample). Instruments were compared on sensitivity, specificity and area under the curve using receiver operating characteristic (ROC) analysis to determine optimum cut points. RESULTS: Overall the TWEAK and AUDIT performed best (in relation to sensitivity and area under the ROC curve) at standard cut points (3 and 8, respectively) for both harmful drinking and alcohol dependence. These instruments did not perform equally well across all subgroups, however, particularly among women, and among whites where the CAGE, with a cut point of 1, outperformed both the TWEAK and AUDIT at standard cut points. The TWEAK at a cut point of 2 also did as well as the CAGE at a cut point of 1 among women. CONCLUSION: These data suggest that standard screening instruments do not perform equally well across ethnic and gender subgroups and that consideration of alternative cut points may be appropriate in some populations.     

Oral and dental health in alcohol misusing patients

Dental and oral health and their relationship to nutritional status among a group of alcohol misusers (n = 107) from south London is reported. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was validated as an accurate and reliable screening questionnaire for use in alcohol misuse detection by a dentist. Half of the study population consumed >200 units of alcohol/week, and 80% were heavy smokers. A high incidence of tooth wear and trauma to the dentition was recorded. Eight subjects had oral mucosal lesions, including two previously treated carcinomas. The dental health in alcoholics overall was not compromised, but nutritional impairment (body mass index and reduced midarm muscle circumference) was associated with periodontal lesions. Oral mucosal health of alcoholics is of concern, particularly in heavy smokers. The interrelationships between dental-oral health and alcohol-tobacco usage have implications for preventative counseling in this patient group.     

Substance abuse and the emergency room: programmatic implications

A literature review (1984 to 1995) was conducted to identify cost effective policy implications regarding substance use in the emergency room (ER) and trauma unit. Prevalence rates, ranging from 9% to 47%, vary according to where, when and who is tested. Other drugs, most commonly marijuana, benzodiazepines and cocaine, follow a similar pattern to alcohol. The optimal method of measuring substance use depends on the goal of the assessment and a combination of clinical, self-report and biochemical markers is recommended. Simple screening questions such as the TWEAK or AUDIT should be routinely used with all attendants and further assessment provided only when high risk factors have been identified. These include: males, younger patients, metropolitan centres, after midnight and on weekends, injury from violence, accidents including MVAs, high acuity and psychiatric morbidity. Further, this screening should be complimented by an intervention, referral and treatment resource for those in need.     

Comparison of screening instruments for alcohol problems between black and white emergency room patients from two regions of the country

A number of brief screening instruments to identify alcohol dependence exist, but the validity of these instruments across ethnic groups or regions of the country is not well established. The sensitivity and specificity of a number of standard screening instruments (CAGE, brief MAST, AUDIT, TWEAK, and RAPS), as well as other measures (History of Trauma Scale, breathalyzer reading, self-reported drinking before the event, and consuming five or more drinks at a sitting at least monthly) are compared against ICD-10 and DSM-IV criteria for alcohol dependence between probability samples of Black and White emergency room patients in Santa Clara County, CA (n = 716) and in Jackson, MS (n = 1330). Variability in the sensitivity of screening instruments among current drinkers was found to be greater between samples for both Blacks and Whites, than for Blacks compared with Whites within the same sample. The AUDIT, TWEAK, and RAPS seemed to perform well by gender and injury status for both Blacks and Whites in the two samples, and no significant differences were found in the performance of these instruments across sample sites. To evaluate the influence of regional differences in alcohol dependence on differences found in the performance of screening instruments, using logistic regression with the simultaneous entry of demographic variables (age, gender, ethnicity, injury status, and site) and drinking variables (breathalyzer reading, self-reported drinking before the event, and drinking five or more drinks at a sitting at least monthly) to predict alcohol dependence in a merged sample of these patients (Jackson vs. Santa Clara) site was not found to be significant. Data suggest that, whereas region of the country may not be important in predicting alcohol dependence in emergency room populations, regional differences in the performance of screening instruments for alcohol dependence may exist, even when ethnicity is taken into account. Given distinct regional differences in drinking patterns and problems in the U.S., further research on commonly used screening instruments is needed to determine those screeners most efficient for identifying problem drinking.     

Screening trauma patients for alcoholism according to NIAAA guidelines with alcohol use disorders identification test questions

Drinking pattern criteria (drinking frequency and number of drinks per occasion) issued by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA) to screen primary practice patients for alcohol problems were evaluated in 1216 injured patients treated in a regional trauma center. Vehicular crash victims predominated (50.2%, of whom 64.5% were drivers), followed by victims of violence (31.2%) and nonviolent-injury victims (18.5%). Alcohol Use Disorders Identification Test (AUDIT) questions #1 (drinking frequency) and #2 (drinks/day) were used to assess the patients for current alcohol dependence (CAD). AUDIT responses roughly approximating NIAAA guidelines (high threshold: drinks > or = 4 times/week, > or = 5 drinks/day) and those indicating less drinking (low threshold: drinks > or = 2-3 times/ week, > or = 3 drinks/day) were chosen. Comparisons were made relative to sensitivity and specificity of responses in detecting CAD. When low threshold responses were used for either question, sensitivity to detect CAD increased overall (#1 from 0.53 to 0.80, #2 from 0.62 to 0.88) as well as among the subgroups of patients, whereas specificity remained high or at acceptable levels overall (#1 from 0.95 to 0.82, #2 from 0.92 to 0.71) and among the subgroups of patients. Study findings suggest that, among injured drivers and other groups of trauma center patients, lesser amounts of drinking should be used as screening criteria for CAD than are used for the general population.     

Prevalence of psychoactive substance use among psychiatric in-patients in Harare, Zimbabwe

OBJECTIVE: To determine the prevalence of psychoactive substance use among psychiatric in-patients in Harare. DESIGN: A cross sectional study that was conducted in 1994. SETTING: Harare Central Hospital Psychiatric Unit. SUBJECTS: A total of 194 consecutively admitted patients to Harare Central Hospital Psychiatric Unit, aged from 16 to 55 years with a mean (SD) age of 33.5 (11.4) years. MAIN OUTCOME MEASURES: The psychiatric diagnoses were made according to the ICD10 diagnostic criteria, while the substance abuse was evaluated by the modified WHO AUDIT core questionnaire, which was translated into the Shona language. RESULTS: The point prevalence rate of psychoactive substance abuse among the psychiatric in-patients were alcohol 28.4% (95% CI = 22.1, 34.7), tobacco 27.6% (95% CI = 18.7, 36.5) and cannabis 14.3% (95% CI = 7.4, 21.2). CONCLUSION: The data have provided scientific evidence on the moderate prevalence and pattern of substance abuse among psychiatric patients in Zimbabwe.     

Incidence of alcohol abuse among patients with emergency admissions to a psychiatric department. Evaluation based on clinical and biochemical markers

Alcoholism and drug abuse were investigated in psychiatric patients, who were acutely admitted to a general psychiatric ward at Silkeborg Hospital in Denmark during a six month period. Several standardized diagnostic systems and assessment instruments were applied: ICD-8 and DSM-III diagnoses and the WHO Alcohol Use Disorder Identification Test (AUDIT) and Short Michigan Alcoholism Screening Test (SMAST). Furthermore, several biochemical markers were studied, including carbohydrate-deficient-transferrin (CDT), gamma-glutamyltransferase (GGT), and S-ethanol. Finally, thin layer chromatography of the urine was used to detect drugs abuse. A diagnosis of Alcoholism (code 303) was obtained in 39% of the included patients, while 13% were considered drug abusers (main and subsidiary diagnosis). These findings are in accordance with several previously published Danish studies and illustrate that alcohol abuse is a common diagnosis among acutely admitted patients to a psychiatric department situated outside the metropolitan areas in Denmark. When comparing alcohol abuse as assessed by clinical information and by biochemical markers, only CDT and GGT gave estimates similar to clinical evaluations. CDT was positive in 41% of the patients. Taking ICD-8 diagnoses of alcoholism as "golden standards" the sensitivity and specificity of the marker was 0.67 and 0.74, respectively. Although this is not as high as previously found values, these figures suggest CDT to be a useful biological marker in the delineation of alcohol related problems in psychiatric patients.     

An empirical investigation of the factor structure of the AUDIT.

This study investigated the Alcohol Use Disorders Identification Test's (AUDIT) factor structure and psychometric properties. The factor structure was derived from a sample of 7,035 men and women primary care patients. A principal components analysis identified 2 factors in the AUDIT data and was supported in a confirmatory factor analysis (CFA). The 2 factors were Dependence/Consequences and Alcohol Consumption. The CFA also provided support for a 3-factor model whose factors (Alcohol Consumption, Alcohol Dependence, and Related Consequences) matched those proposed by the AUDIT'S developers. Psychometric indexes were determined by use of the baseline and 12-month follow-up data of 301 men and women who entered a clinical trial. The results showed that the 2 factors had good reliability. Validity tests supported the interpretation of what the 2 factors measure, its implications for relationships to other variables, and the comparability of the 2- and 3-factor models. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Availability of the Alcohol Use Disorders Identification Test (AUDIT) for a complete health examination in Japan

OBJECTIVE: The Alcohol Use Disorders Identification Test (AUDIT) is an instrument designed to identify hazardous drinkers, harmful drinkers and alchoholics. It was translated into Japanese using the WHOQOL method. The concurrent validity and reliability of the Japanese version of AUDIT were evaluated in a complete health examination. The instrument was also compared with the CAGE questionnaire. METHOD: The subjects were 93 applicants attending for health checks in a human dry dock. They completed self-report questionnaires containing the Core AUDIT and CAGE. and underwent a semi-structured interview conducted by a professional physician. RESULT: From the semi-structured interview, it was determined that 23 of the subjects were problem drinkers and 10 were alcoholics. Analyses indicated that the Core AUDIT was sufficiently sensitive and specific for discriminating problem drinkers and alcoholics. Core AUDIT was also superior to CAGE for discriminating problem drinkers from non-problem drinkers, as well as identifying alcoholics. CONCLUSION: The data suggest that the Japanese version of AUDIT is useful for early detection of hazardous or harmful drinkers.     

Brief screening for psychological and substance abuse disorders in veterans with long-term spinal cord injury.

Objective: To determine rates of positive screens for psychological and substance use disorders in persons with long-term spinal cord injury (SCI). Study Design: A naturalistic cohort design wherein consecutive admissions during an 8-month period completed the screening battery. Setting: Veterans Affairs SCI Center. Participants: One hundred fifteen men, 2 women, mean age 57.4 years, injured an average of 20 years, readmitted for various reasons. Main Outcome Measures: The Alcohol Use Disorders Identification Test (AUDIT) and screening items for depression and anxiety disorders. Results: Rates of positive screens ranged from 6.2% for alcohol problems to over 40% for anxiety disorders. Positive screens for depression and anxiety correlated positively with the number of recent hospital admissions. Conclusions: Systematic brief screening for psychological and substance abuse disorders in this population revealed rates of positive screens at least equal to those in other medical patient populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intervention in alcohol use disorder in a general practice

AIM: To report the outcome of intervention in 70 patients with alcohol use disorder in a general practice. METHOD: Of the 84 patients age 18-69 years identified clinically or by a screening programme with alcohol use disorder, 70 who were available for at least 2 year follow up after diagnosis were included in the study group. The clinical notes of these patients were reviewed to determine evidence of sustained achievement of abstinence or controlled drinking and factors contributing to successful change in alcohol use. RESULTS: Sustained abstinence or controlled drinking was verified for 31 patients (44%) with a further 26 patients (37%) reporting reduction in alcohol use without evidence of sustained improvement. The mean interval from diagnosis to sustained improvement was 4 years. Only five patients accepted referral to specialist alcohol units. Successful change in the 31 patients achieving their drinking goal was directly related to intervention at the surgery for 9 patients. CONCLUSION: A motivational approach with focus on the patient's perception of the issues proved relatively successful in this practice. A prolonged period of change was required to achieve drinking goals. Other factors contributing to improvement are discussed.     

Differences in detection of alcohol use in a prenatal population (on a Northern Plains Indian Reservation) using various methods of ascertainment

Although Fetal Alcohol Syndrome (FAS) rates have been reported to be higher in American Indian populations, no screening tool has been validated for alcohol use in American Indian women. The objectives of this study were to compare the detection of prenatal alcohol use by a self-administered questionnaire to detection by clinical interview; and to ascertain whether the screening tool would increase detection of pregnant women who are abusing alcohol. The hospital records of the women were reviewed for any history of alcohol-related illnesses or injuries to compare with results obtained from the questionnaire. Seventy women attending their first prenatal clinic visit on a reservation were screened for alcohol use. There was a wide range in detection of prenatal alcohol use (20%-71% of the sample detected) depending on the method used. There was a large variation in sensitivities (7%-93%) of the individual questions in identifying patients detected as "high risk" by the clinicians. The T-ACE screening questions significantly increased detection of alcohol use compared to detection by the clinicians (p = 0.04 Fisher's exact test). Due to the large variation between different methods of detection, it is recommended that screening tools that increase detection of alcohol use should be combined with methods of higher specificity such as using questions about quantity and frequency of alcohol intake, medical chart review and clinical interview. We also found that various interpretations of the screening questions by the patients highlighted the need to tailor the wording of individual questions to the particular patient population.     

Information on results of pilot project studies of the Slovak Ministry of Health. Audit of diagnostic and therapeutic approaches in patients with acute coronary syndromes

The basic analysis of the Pilot study fully confirms the possibilities of the realization of the project AUDIT ... in the planned form, the necessity to realize this project regarding the discovery of several negative facts in the management of patients with AMI, which can affect infavourable the course of the disease in patients with AMI and their prognosis or unjustifiably increase the economic impact. The most severe of them are investigated in this information and we present them in subsequent order of individual phases of the management of patients afflicted by AMI.