University of Wales College of Medicine, Cardiff and
1 Middlesex University, London, UK
Received 8 May 2000; in revised form 5 June 2001; accepted 12 July 2001
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ABSTRACT |
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INTRODUCTION |
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Twenty-five years ago, the main focus of research workers and practitioners was severe alcohol dependence or alcoholism. It is only in recent years that there has been an attempt to broaden the base to include hazardous and harmful drinking as well as dependence (Institute of Medicine, 1990). This change is reflected in the screening instruments that were then developed, compared to those that have been developed more recently. The CAGE questionnaire (Mayfield et al., 1974
) includes items such as guilt related to heavy drinking and taking alcohol first thing in the morning. There is no attempt to assess risky levels of consumption. The AUDIT questionnaire, on the other hand, includes questions about the quantity and frequency of alcohol consumption. It assesses hazardous and harmful, as well as dependent, drinking (Babor et al., 1989
).
The AUDIT questionnaire is proving to be very useful in many community and hospital settings. It consists of just ten questions (see Appendix 1) and usually takes less than two minutes to complete. AUDIT was developed in a World Health Organization study and was validated across six countries. A solid body of evidence has demonstrated that sensitivity and specificity are high for criteria that define current hazardous use. Saunders et al. (1993) demonstrated that, for those diagnosed as having harmful or hazardous use, 92% had an AUDIT score of
8. For those with non-hazardous consumption 94% had a score of <8. Since its development, a number of independent studies have shown that the AUDIT questionnaire is a reliable and valid screening instrument (Barry and Fleming, 1993
; Isaacson et al., 1994
; Bohn et al., 1995
; Schmidt et al., 1995
; Allen et al., 1997
; Volk et al., 1997
; Bradley et al., 1998
). It should be emphasized that, unlike most other alcohol screening tests, the AUDIT questionnaire was specifically designed to identify current hazardous alcohol consumption (as well as, at higher scores, harmful or dependent use). Mackenzie et al. (1996) compared sensitivities of the AUDIT, CAGE and the Brief Michigan Alcoholism Screening Test (MAST). Sensitivities for the identification of weekly drinking over recommended limits were 93, 79 and 35% respectively. Daeppen et al. (2000) provided further evidence of high sensitivity and specificity against an interview diagnosis of alcohol dependence (91.7 and 90.2% respectively), though low sensitivity for their diagnosis of at-risk drinking based on consumption only. Similar results were obtained when the AUDIT items were incorporated into a General Health-Risk Screening Questionnaire. The AUDIT's testretest reliability over a 6-week interval was assessed in this study and was found to be 0.88.
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It could therefore be concluded that the AUDIT questionnaire is a very useful and robust screening test. Nevertheless, there is an urgent need for a far shorter questionnaire that screens for hazardous drinking as well as dependence. This need is particularly strong in Accident and Emergency (A&E) departments and other medical settings where time pressure is a major factor (Hodgson et al., 2000a,b
). Brief alcohol interventions as short as 5 min have been shown to be effective in reducing alcohol consumption within primary care settings (Wilk et al., 1997
; Poikolainen, 1999
). If alcohol misuse could be identified in <30 s then screening leading to a brief intervention is more likely to be a routine component of medical, mental health and social services.
Using the AUDIT questionnaire as the gold standard, the aim of the present study was to consider the possibility that just a few of the AUDIT items can substitute for the full questionnaire. The high internal consistency of the questionnaire suggests that this should be the case. (Indices of internal consistency, including Cronbach's alpha are generally >0.80.) More specifically, is it possible to use each item as a sequential filter? If one question accounts for a large percentage of the variance, could this one question quickly identify a large percentage of the population as either hazardous or non-hazardous drinkers?
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MATERIALS AND METHODS |
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Step 1.
AUDIT questionnaires were completed by 666 patients from two A&E departments in London, one inner city and the other suburban. The data were subjected to a principal components analysis, in order to identify the three highest loading items on the first component.
Step 2.
The aim was to identify one question that would serve as a first filter. This was achieved by asking whether any of the three highest loading questions could identify >50% of participants as either true positives or true negatives with few false positives or false negatives [positive meaning scoring 8 on the 10-item AUDIT, which will be termed hazardous' (although including some higher scorers who might have reached criteria for harmful or even dependent drinking)].
Step 3.
To develop a second filter, the other two highest loading questions were combined with each of the other seven AUDIT questions in order to identify the combination with the best sensitivity and specificity.
Step 4.
The data for both filters were combined, so that the sensitivity and specificity of the test as a whole could be calculated.
Step 5.
In order to ascertain whether this two-stage screening test would perform well in a range of settings, 100 AUDIT questionnaires were completed by an opportunistic sample of patients in each of the following National Health Service settings: a fracture clinic, a primary care health centre, an A&E department and a dental hospital, which follows up patients who have had maxillo-facial injuries.
Step 6.
The last step involved fine-tuning. Could any of the questions be slightly modified in order to improve sensitivity or specificity? Could the percentage of participants identified as positive or negative by the first screening item be increased? This was investigated in a further sample recruited from the waiting rooms of two A&E departments, at an inner city hospital and in a market town in South Wales.
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RESULTS |
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Step 3
Having classified 66% of patients as hazardous or non-hazardous drinkers using just Question 3, the next step was to explore how the other 34% can be sorted using Questions 5 plus 8 and possibly more. This involves calculating the sensitivity and specificity of each of the question combinations displayed in Table 3 when used to predict AUDIT positive and negative. Different cut-off scores were considered for each question combination and those cut-off scores that resulted in the best sensitivity and specificity are displayed in column 2 of Table 3
. It is clear from these results that, using questions 5, 8 and 10 on the second screen is the best combination.
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Step 6
One of the strengths of the FAST questionnaire is that one question successfully identifies hazardous and non-hazardous use for >50% of most samples. Although the question How often do you have six or more drinks on one occasion was a good first filter there were some doubts about face validity. Shepherd et al. (1990) found that a cut-off of 8 units of alcohol on one occasion differentiated male A&E patients with an alcohol-related injury, from a friend or relative who accompanied them to the trauma clinic. The next step was, therefore, to consider using How often do you have eight or more drinks on one occasion? as the first filter for men. It is universally recognized that women face hazardous consequences at lower levels of consumption than men, and so the six drinks' question could be retained for them. The next step therefore compared the eight drinks' version of the FAST with the six drinks' version. This was accomplished by administering the AUDIT with the new eight drinks' question inserted either before or after Question 3. Attendees at two A&E departments were recruited, 58% male, and 69% aged >25 years.
Only seven out of 48 women had positive AUDIT scores, so calculating a sensitivity index for women would be inappropriate. Combining sensitivity and specificity data to obtain an accuracy index provided a more reliable measure for this relatively small sample. Accuracy is defined as true positives plus true negatives as a percentage of the total. For men, both the eight drinks' and six drinks' versions of FAST produced an accuracy index of 93%. For women, both versions resulted in an accuracy of 95%. So the accuracy of the test provided no grounds for deciding between them.
Although there were very few differences between the two versions of FAST, there were, in fact, good reasons for keeping six drinks for women and eight drinks for men. For women, the correlations between the AUDIT score and scores for the two versions of the test strongly favoured the six drinks' version (Spearman rho = 0.745 for the six drinks' version and 0.587 for the eight drinks' version). The main advantage of the eight drinks' version was the use of this question as a first filter for men. In this particular sample, the six drinks' question alone identified 56% of the men as hazardous or non-hazardous drinkers, whereas the eight drinks' question identified 63%. Since the aim of this investigation was to develop a quick alcohol-screening test, the ability to screen out over 60% of a male sample with just one question is a major benefit. The six drinks' filter identified 58% of women so that, for men and women combined, the first FAST question identified 61% as hazardous or non-hazardous drinkers, with an accuracy of 95%.
Finally a minor modification was made to the question: Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? In the AUDIT, this particular question is not confined to the previous year and can therefore result in false positives if the concern occurred a few years earlier.
The question and the responses were therefore altered to focus upon the last year. In the above sample, this made no difference to any of the conclusions, since only six participants noted that concern had been expressed but not in the last year. All six remained in the same categories (hazardous versus non-hazardous) if their response was altered to never.
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DISCUSSION |
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Scoring method 1.
Questions 2, 3 and 4. FAST negative if responses to Questions 2 and 3 are Never and Question 4 is No; FAST positive for any other response, i.e. any hint of a problem.
Scoring method 2.
Each question is scored 0 to 4 and a FAST positive if the total score for all four questions is 3.
The authors' preference is for scoring method 2, since this results in slightly fewer positives. In our experience, the AUDIT tends to be biased towards producing false positives, rather than false negatives. Not only does this quick test perform well against the AUDIT, but it also has good face validity. The main focus is upon the frequency of risky levels of alcohol consumption. This first question accurately identifies >50% of respondents as either hazardous drinkers (i.e. those who respond weekly or daily or almost daily) or non-hazardous drinkers (i.e. those who respond never). Those who respond with monthly or less than monthly to this question are then asked three questions related to dependence and harm. If there is a hint of dependence or harm, they are then assigned to the hazardous or harmful drinking group. One reason why this questionnaire is so quick to administer (mean time 12 s: Hodgson et al., 2000b) is that most respondents only have to answer one question.
The FAST has proved to be useful in busy medical settings, but there are a number of further questions that need to be addressed. First, to what extent is the accuracy of the FAST influenced by ethnicity, and age? Cherpitel and Clark (1995) noted that no one screening instrument is consistent across all ethnic groups. Second, the FAST was tested against the AUDIT, which is itself a screening instrument. How would the FAST perform when compared with a longer diagnostic instrument such as the Composite International Diagnostic Interview (Robins et al., 1989). Third, the FAST, like the AUDIT, is designed to identify hazardous drinking, as well as alcohol-related harm and dependence. For health promotion or brief intervention projects, this will be ideal. Further research could explore the possibility of different cut-off scores for different projects. For example, screening for an intensive treatment service would require a higher level of hazardous drinking. It should be emphasized, however, that a screening test is not a diagnostic instrument. Screening will usually be followed by a further more detailed assessment.
There are now several very brief alcohol screening instruments in existence. One of them is a shortened version of the AUDIT proposed by Piccinelli et al. (1997). They recommend using five items, only two of which are included in the FAST. The short AUDIT and the FAST are strongly correlated (0.92 in our A&E data), but the main strength of the FAST is the use of one item as a first filter. The range of instruments includes the CAGE (Mayfield et al., 1974), the TWEAK (Russell et al., 1994
), the brief MAST (Pokorny et al., 1972
), the RAPS (Cherpitel, 2000
), the five-shot test (Seppa et al., 1998
), the short AUDIT (Piccinelli et al., 1997
) and the PAT (Smith et al., 1996
), not to mention the FAST and the AUDIT. Soderstrom et al. (1998) use the first two AUDIT questions to assess quantity and frequency of alcohol consumption, and the TICS (Brown et al., 1997
) attempts to assess both alcohol and drug misuse. Further work is now needed to explore which of these is the most useful and cost-effective instrument for which client groups and for what purpose.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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