SELF-REPORTED ALCOHOL USE AMONG DUTCH EMERGENCY ROOM PATIENTS: VARIATIONS IN PREVALENCE RATES OWING TO METHODOLOGICAL DIFFERENCES

SALVATORE G. VITALE1,*, DIKE VAN DE MHEEN1, HENK F. L. GARRETSEN1,3 and ALBERT VAN DE WIEL2

1 Addiction Research Institute (IVO), Heemraadssingel 194, 3021 DM Rotterdam, The Netherlands, 2 Department of Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands and 3 Tilburg University, Faculty of Social and Behavioural Sciences, Tilburg, The Netherlands

* Author to whom correspondence should be addressed at: Tel.: +31 10 4253366; Fax: +31 10 2763988; E-mail: vitale{at}ivo.nl

(Received 23 March 2005; first review notified 13 May 2005; in revised form 28 June 2005; accepted 5 July 2005)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
Aims: This study compared different methods of assessing self-reported alcohol use among emergency room patients in order to explain the variations in reported prevalence rates. Methods: Alcohol use prior to patient's injury or illness was assessed in one hospital by a self-report questionnaire in three different ways: (i) administered by emergency room staff, (ii) administered by research staff, or (iii) sent to the patient's home by post. Results: Results show variations in self-reported alcohol use 6 h prior to the injury or illness ranging from 4.6 to 9.1%; these variations may be explained by sample selection bias and characteristics of the included study populations. When self-report is combined with staff judgement the corresponding prevalence rates are 6.8% for research staff and 16.2% for emergency room staff. This shows that the latter judge the patient's alcohol use more efficiently than the research staff. Using research staff 24 h a day resulted in almost no sample bias. Data collection via emergency room staff leads to the highest alcohol use prevalence rates and to the highest sample bias; this was influenced by the emergency room characteristics. A retrospective mail survey results in an older sample with age-related (lower) alcohol use and emergency room characteristics related to this age group. Conclusions: Future studies using patient self-report among emergency room samples should consider carefully the influence of sample selection bias. The combination of the research staff handing out the questionnaire and the emergency room staff giving their judgement on the patient's alcohol use seems to be a useful method.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
The relationship between alcohol use and injuries has been established in many studies, with most studies being conducted in emergency room settings. Estimated prevalence rates of emergency room patients, positive for alcohol, range from 9 to 24.4% (El-Guebaly et al., 1998Go). Alcohol use increases the risk of injury. Cherpitel (1993)Go reviewed these studies and reports that patients with injuries and positive for blood alcohol are more likely to be male, aged 25–45 years, and to visit the emergency room during the weekend evening or early morning hours. Prevalence rates vary from country to country and from place to place, partly owing to alcohol consumption patterns in a culture or in a region (Cherpitel, 1993Go, 1999Go; Cherpitel and Borges, 2002Go). Most of these studies have been conducted in the United States; data from European countries are scarce. Studies from individual countries (like the Netherlands) are needed to identify the global problems that result from alcohol use and misuse. In addition, they will provide information on prevalence rates of alcohol use among emergency room patients in various countries. Such data are crucial, because alcohol use is rising among certain groups in the general population. A recent Dutch study shows an increase of young people aged 12–17 years frequenting the emergency room as a result of alcohol intoxication (Wilsterman et al., 2004Go). More detailed studies and figures on alcohol use among emergency rooms in the Netherlands are very limited. The only available study reported that 8% of all victims of traffic accidents had consumed alcohol (Kingma and Klasen, 1994Go). Recent figures on problem drinking in the Netherlands show that 8% of the total population between 18 and 65 years has problems with alcohol (Verdurmen et al., 2003Go). This means that alcohol abuse is present among ~400 000 people and that ~350 000 people are addicted to alcohol in the Netherlands.

Studies outside the emergency room focusing on alcohol use and injuries are conducted by surveys among the general population (Cherpitel, 1999Go) or within specific groups, especially among people involved in car or motor accidents (Del Rio et al., 2002Go; Weber et al., 2002Go; Kurzthaler et al., 2003Go). Results from a household survey among the general population show that alcohol consumption was predictive for emergency treatment, and that heavier drinking was associated with treatment for an injury and lighter drinking with treatment for an illness (Cherpitel, 1999Go). However, because household surveys make it difficult to assess a causal relationship between alcohol use and the injury, the emergency room is the most obvious place to study a possible causality. Such emergency room studies mostly employ patient self-reported alcohol use, blood alcohol concentrations, or breathalysers. Another, less frequently employed, measure of assessing alcohol use by patients is to use clinical or staff assessment/recognition. Self-report and tested blood alcohol concentration both have advantages and disadvantages, and it remains debatable whether to use self-reported drinking or to test for blood alcohol concentration (Treno et al., 1998Go). No single instrument or method stands out as the ‘gold standard’; a combination of clinical, self-report and biochemical markers is considered optimal, but will vary according to the purpose of the measurement (El-Guebaly et al., 1998Go).

Numerous studies have compared self-reported alcohol use with blood alcohol concentration measures. In contrast, studies comparing differences in self-reported alcohol use among emergency room samples are scarce. Therefore, this study focuses on this topic in order to identify factors that influence found prevalence rates of self-reported alcohol use among emergency room patients. The two main issues explored in this study are factors related to differences resulting from study procedure and resulting from sample selection bias. Several studies conclude that self-report is sufficiently valid to measure alcohol use prior to the injury event (Cherpitel, 1993Go; Treno et al., 1998Go). Although self-report of alcohol consumption shows adequate reliability and validity, social context factors, respondent characteristics, and task attributes can influence response validity (Del Roca and Darkes, 2003Go). In addition to differences resulting from alcohol measures and cultural drinking patterns, sample selection bias in the emergency room should not be underestimated and can lead to difficulties in that the emergency room sample cannot truly represent the general population of injured (Treno et al., 1998Go).

In this study, the aspects of sample selection bias and study procedure related to alcohol prevalence rates are examined more closely by studying different methods of self-report in an emergency room population of one hospital. The aim is to compare three different methods of data collection using patient self-report among an emergency room population in order to identify variations in study results. The main questions to be addressed are

  1. Do different self-report methods result in different alcohol prevalence rates?
  2. Are the differences in prevalence rates the result of sample selection bias?
  3. Are there other explanations for these differences in alcohol prevalence rates?
In addition, the potential value of staff information on the patient's alcohol use was explored. In order to answer these questions, results concerning response rates, sample selection bias, characteristics of the research population, and alcohol prevalence rates are reported.


    METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
Procedure and sample
This study was conducted at the Meander Medical Center in Amersfoort (~130 000 inhabitants); the emergency room of this hospital has ~35 000 patients per year. The medical review board of the Meander Medical Center approved the study protocol. All patients presenting at the emergency room in three different time periods between July 2003 and May 2004 were included in this study. Because alcohol use among youngsters in the Netherlands has increased (Monshouwer et al., 2004Go) and more alcohol intoxicated patients aged 12–17 years attend emergency rooms in the Netherlands (Wilsterman et al., 2004Go), the minimum age for inclusion in this study was 12 years. Patients treated in the emergency room for injuries or illness were included; excluded were those attending for a control visit and those without sufficient command of the Dutch language. Instruction on the study procedures was given to the emergency room and research staff by the main researcher. Three different methods of data collection were consecutively administered using an identical questionnaire.

Method 1 (M1)
In the first method emergency room personnel (nurses and administrative personnel) were responsible for data collection (M1). The period of data collection was from July 2003 to January 2004. In this method, patients were approached in two ways: (i) Patients with minor injuries/illness meeting the inclusion criteria were handed a questionnaire by the administrative staff shortly after entering the emergency room; the questionnaire was then completed in the waiting room. (ii) Patients with more serious/severe injuries/illness were approached in the treatment room by the nurses before or shortly after the treatment; the patients then filled in the questionnaire.

Method 2 (M2)
The second method consisted of research staff handing out the questionnaire (M2). This method was used for 2 weeks in May 2004. Patients with minor injuries/illness were invited to participate by the research staff while waiting for treatment (i.e. shortly after entering the emergency room). Patients with more severe injuries/illness were approached after their consultation with the emergency room personnel, by the research staff before or shortly after treatment; the patient then filled in the questionnaire.

Method 3 (M3)
The third method collected data retrospectively via a postal questionnaire (M3). All patients aged 12 years and older visiting the emergency room in April 2004 were approached. At the end of the emergency room visit, each eligible patient was given a letter to take home with information about the study and the questionnaire. After this (~7–10 days after the visit) all patients received a mailed questionnaire at home, accompanied by a second letter with information about the study.

Measures
Data were collected using a combination of self-report and emergency room data. In the first two studies (M1 and M2), emergency room and research personnel were able to score reasons for non-response (physical status and/or mental status, refusal, without sufficient command of the Dutch language) and give their judgement on the patient's alcohol consumption at the time of the emergency room visit. This was done for patients not able to fill in the questionnaire owing to their medical condition.

All three methods used an identical questionnaire which addressed the following topics: reason for the emergency room visit (traffic accident, accident, injury/illness, aggression/violence, suicide attempt, or self-mutilation), location of accident or illness (home, other people's home, public place, catering establishment, work, school, or street), demographic data (cultural background, work, and living situation), alcohol use, location of alcohol consumption, licit drug use, illicit drug use, and location of illicit drug use. Alcohol use, 24 and 6 h prior to the visit was asked, as was general alcohol consumption pattern (number of drinking days in the weekend and during the week, average number of consumptions on a drinking day in the weekend and during the week). Based on alcohol consumption the patient was classified as abstainer, moderate drinker, occasional excessive drinker, and frequent excessive drinker (Table 1). This classification has been used by Lahaut et al. (2002)Go, based on the classification of Garretsen (1983)Go. This classification was used among emergency room patients because data on the relationship between injuries and occasional/frequent excessive drinking are valuable from a prevention point of view, i.e. to identify which alcohol consumers are at risk for injuries.


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Table 1. Classification of alcohol consumption used in the present study

 
Data on all patients visiting the emergency room in the study period were abstracted from the hospital patient database. Information consisted of demographic (gender and age) and emergency room data (date and time of emergency room visit, type of referral to the emergency room, and type of injury/illness). Data from the patient questionnaire and emergency room data were combined using a unique patient number. This resulted in two groups of patients: patients included in the present study with information available from the questionnaire, and patients excluded from the study because they did not fill in the questionnaire. Demographic and emergency room data were available for these two groups of patients.

Statistical analysis
The response and non-response populations for each method were compared regarding demographics, emergency room characteristics and alcohol use, using bivariate cross-tabulation. Chi-square tests were conducted to determine whether included and excluded patients per method differed significantly. The categories of the various variables were tested separately. A Bonferroni correction was used to decrease the possibility of false positives. Only mean age was compared using a t-test. The different response populations in the three methods were compared using bivariate cross-tabulation. Chi-square tests were conducted to determine whether included patients in the three methods differed significantly. All results were regarded significant at P < 0.05, except for those variables with more than two categories, where the Bonferroni correction was applied in which case results were significant at P < 0.05/n (=number of variable categories).


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
Response and non-response rates
Table 2 gives data on response and non-response in the three study methods. A distinction can be made between ‘Patient plus Staff report’ (i.e. questionnaire filled in by the patient and information on the patient given by emergency room staff or research staff) and ‘Patient only report’ (i.e. patient completed questionnaire). Data collection through emergency room personnel (M1) leads to the lowest ‘Patient plus Staff report’ (14.6%) and ‘Patient only report’ (12.6%) response. Data through research staff responsible for the administration of the patient questionnaire (M2) result in the highest ‘Patient plus Staff report’ response (74.3%), but the ‘Patient only report’ response (40.0%) is equal to the ‘Patient only report’ response (40%) of the mail survey (M3). It should be noted that the non-response was not always attributable to the patient, especially when emergency room staff was responsible for the questionnaire; e.g. during urgent medical situations the questionnaire had a low priority and as a result was not always handed out by the staff.


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Table 2. Response and non-response rates in the three study methods

 
Alcohol use
Table 3 gives alcohol use prevalence rates 24 and 6 h (self-report, and judgement of emergency room and research staff) prior to the event leading to the emergency room visit and alcohol consumption. It can be seen that the prevalence of alcohol use 24 h prior to the event is lowest for M3 (17.9%) and highest for M2 (34.2%). Differences were found between M1 and M3 (28.8% vs 17.9%) and between M2 and M3 (34.2% vs 17.9%). No significant differences in alcohol use 24 h prior to the injury were found between M1 and M2.


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Table 3. Alcohol use prevalence rates reported by the patients in the three study methods

 
Self-reported alcohol use 6 h prior to the event, leading to the emergency room visit is lowest for M1 (4.6%) and M3 (4.8%) compared with M2 (9.1%). The self-reported alcohol use 6 h prior to the event for M2 differs compared with both M1 (P = 0.000) and M3 (P = 0.004). Self-reported alcohol use and the judgement of emergency room and research personnel combined, results in different prevalence rates of alcohol use 6 h prior to the event, being 16.2% based on the judgement of emergency room staff and 6.8% based on the judgement of research staff. Emergency room staff judged 84.4% (n = 250) of the 278 patients who were not able to fill in the questionnaire, as being alcohol positive. Research staff only judged 4% (n = 15) of the 375 patients not able to fill in the questionnaire, as being alcohol positive. With respect to alcohol consumption, M3 resulted in significantly higher proportions of abstainers (37.8%) and significantly lower proportions of occasional excessive drinkers (2.6%) compared with both M1 and M2. The highest proportions of occasional excessive drinkers and frequent excessive drinkers are reported in M1 and M2. No significant differences in alcohol consumption were found between M1 and M2.

Sample selection bias
Table 4 presents the characteristics of the included and excluded patients according to the three study methods. Patients included in the study population of M1 differed significantly from those excluded with respect to gender, mean age, age category, time of emergency room visit, and referral to emergency room. In M2 the included patients differed significantly from the excluded patients only with respect to the part of the week. Significant differences were found between included and excluded patients in M3 with respect to gender sex, mean age, age category, and referral to the emergency room.


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Table 4. Characteristics of the patients included and excluded in the three study methods

 
In addition to the comparison between included and excluded patients per method the included populations were compared with respect to each method (data not shown), which showed that the included emergency room populations differed significantly on the following variables: gender (more males in M1 compared with M2 and M3), mean age (M1 younger compared with M2 and M3), age category (more patients aged 61 years and older in M3 compared with M1 and M2, and in M1 more patients aged 18–35 years compared with M2 and M3), time of the emergency room visit (more patients between 8:00–16:00 h in M1 compared with M2 and M3), and referral to emergency room (less by ambulance in M1 compared with M2 and M3). M2 and M3 showed the least differences with respect to included patients; both methods differed only with respect to gender (M2 more males compared with M1), age category (M2 more aged 18–35 years and less aged 61 years and older compared to M3) and referral to the emergency room (less own initiative in M3).

To summarize the results, M1 resulted in a study sample (those included) that has relatively more males, is younger, less patients arriving between 0:00–8:00 h and less patients frequenting the emergency room by ambulance compared with the excluded population in this method. In M2 the included patient sample only resulted in relatively more patients frequenting the emergency room during weekends compared with those patients excluded. M3 results in an older sample with more females and more referrals by ambulance, but with no variation in the part of the week and time of emergency room visit compared with the excluded population. The three methods compared showed that least differences occurred concerning included population between M2 and M3.

Sample characteristics
Table 5 presents the characteristics of the study samples in the three methods. M2 included significantly less patients with a Dutch cultural background than M1 and M3. Concerning living situation no differences were found between the three methods concerning patients who live alone and those who live with others. The occupational status and reason for emergency room visit did not differ between M1 and M2, with the exception of M2 including more students compared with M1. M3 included more patients who were retired compared with M1 and M2. Also, more patients in M3 seek emergency treatment as a result of an illness compared with M1 and M2. Among injured patients, less injuries were caused by accidents in M3 compared with M1 and M2.


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Table 5. Characteristics of response patients per method

 

    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
This is the first study to compare three different types of self-report methods (emergency room personnel, research staff, and a mail survey) of alcohol use among emergency room populations. We will first describe the conclusions with respect to the study questions, then discuss the study limitations and recommendations for further research.

Do different self-report methods result in different alcohol prevalence rates?
Alcohol prevalence rates vary between the different self-report methods. Despite these differences, some similarities between the methods are also seen. Alcohol use 6 h prior to the emergency room visit was reported by ~5% of the patients in both M1 and M3. Prevalence of self-reported alcohol use in M2 was 9.1%. When additionally using emergency room and research staff judgements on the patient's alcohol use, prevalence rates are 16.2% (M1) and 6.8% (M2), respectively. Despite the lower proportion of self-reported alcohol use 6 h prior to the visit in M1 compared with M2, results show that emergency room staff identifies relatively more patients under the influence of alcohol compared with the research staff, eventually leading to higher prevalence rates. This is probably attributable to the selection bias resulting from this method. Using emergency room staff leads to a small sample; however, staff seem to have selected a biased sample with a relatively large proportion of alcohol positive patients. This is illustrated by the large differences in alcohol judgement between emergency room staff and research staff. In the present study, using only patient self-report would have resulted in an underestimation of alcohol prevalence. The mail survey leads to almost the same proportion of self-reported alcohol use (4.8%) as M1 and approximately half the proportion of self-reported alcohol use 6 h prior to the visit compared with M2. However, with M3 no judgement of the patient's alcohol use by emergency room or research staff is possible. The only other Dutch emergency room study on self-reported alcohol use combined with emergency room staff recognition of alcohol use among victims of traffic accidents reported a prevalence rate of 8% (Kingma and Klasen, 1994Go). In our study self-reported alcohol use combined with staff recognition of alcohol use was almost twice as high (16.2%). This can be explained by the fact that our study also included all emergency room patients and not only victims of traffic accidents. Emergency room staff was able to identify significantly more patients who were positive for alcohol at the time of the emergency room visit compared with research staff. Alcohol consumption rates show no differences between M1 and M2, but the retrospective study reported a higher proportion of abstainers and less frequent excessive drinkers. In our study another explanation for the lower alcohol consumption rates in M3 are the characteristics of the sample population selected in M3, which included relatively old people.

Are the differences in prevalence rates the result of sample selection bias?
Two of the three methods resulted in sample selection bias on various demographic and emergency room characteristics. Only M2 (with research staff available 24 h) resulted in almost no sample selection bias. Comparing sample selection biases, the methods using emergency room staff (M1) and research staff (M2) show more similarities on demographic variables regarding the included emergency room population compared with the retrospective method (M3), with M1 and M2 including relatively more males and more patients aged 18–60 years. Emergency room staff seem to include more alcohol ‘suspect’ patients: males and patients aged 18–35 years identified by previous studies (Cherpitel, 1993Go).

Data collection through emergency room staff (M1) also differed with respect to patients included in the study population compared with the other two methods (M2 and M3): with respect to emergency room variables, more patients visited the emergency room between 8:00–16:00 h and less patients arrived at the emergency room by ambulance. The first result can be explained by the fact that during the day more emergency room staff are present. For the second finding the explanation lies in the fact that these are more seriously injured patients, who need direct treatment for injury or illness. Therefore, there is less time (or it is not possible) to approach these patients to participate in the study, because they are less eligible to be interviewed, as also pointed out by Treno et al. (1998)Go.

Are there other explanations for these differences in alcohol prevalence rates?
In addition to sample selection bias, differences in alcohol prevalence rates can be explained by characteristics of the included population. In contrast to the two research methods using emergency room staff and research staff, use of a retrospective mail survey among an emergency room population seems to select a different emergency room population, including significantly more older people with an age-related referral pattern (more ambulance and GP). Consequently, the M3 sample population includes more patients who are retired and who visit the emergency room owing to an illness compared with the other two methods. Previous research among the general Dutch population via postal questionnaires show that the response among elderly individuals is higher (Van de Mheen, 1998Go). It can be assumed that older people and people with an illness are less likely to drink (excessive amounts of) alcohol.


    STUDY LIMITATIONS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
This study has some limitations. The lower response rates in this study compared with other emergency room studies are probably because this study also included seriously injured patients, whereas other emergency room studies usually do not include this group of patients. Some studies specifically focus on seriously injured patients, but use blood alcohol concentrations to determine alcohol use. A second limitation of this study is the difference in study period between the three methods. To make a more accurate comparison, the study periods should have been identical. Particularly in the collection of data through emergency room staff, the total period of data collection may have influenced the response rate; a shorter study period would have augmented the response rate. Another possible limitation is the exclusion of patients who were unable to speak the Dutch language. Previous emergency room studies have shown that cultural differences are present with respect to alcohol consumption (Cherpitel and Borges, 2002Go). Although the exclusion of non-Dutch speaking patients in our study may have influenced prevalence rates, since <2% of the patients were unable to fill in the questionnaire this seems unlikely.

Recommendations for further research
Directions for further research on self-report of alcohol use among emergency room populations are the following. Research should focus on the possibility to combine different methods in order to limit sample selection bias; for example, data collection through emergency room staff for specific groups of patients (e.g. seriously injured) combined with research staff for other groups (e.g. milder injured patients).

In this study, the most influential factor in the variation in alcohol prevalence rates is sample selection bias as a result of the chosen research method; i.e. a retrospective mail survey among emergency room patients leads to a relatively older sample with more abstainers and therefore, lower alcohol consumption 6 h prior to the emergency room visit. Using the judgement of research staff, and especially using emergency room staff, results in higher alcohol prevalence rates compared with a retrospective mail survey, or to relying only on patient self-report. As a result of this, variations in alcohol prevalence rates among emergency room studies between and within countries not only result from consumption patterns in a culture or region, but can also be influenced by sample selection. Therefore, unless sample selection bias is controlled, comparing results between studies and countries should be done carefully. The identification of patients positive for alcohol is done more efficiently by emergency room staff, but results in a biased sample; including more alcohol ‘suspect’ patients. In contrast, the method using research staff is less biased, but it is the most expensive method of data collection in this study. Future emergency room studies on patient's self-reported alcohol use should take into account that the selected method can influence the alcohol prevalence rates. Therefore, future studies should confirm if a combination of research staff handing out the questionnaire and emergency room staff judging patient's alcohol use results in the lowest sample bias and more accurate alcohol prevalence rates.


    ACKNOWLEDGEMENTS
 
This study was funded by the Dutch Ministry of Health, Welfare and Sport.


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 STUDY LIMITATIONS
 REFERENCES
 
Cherpitel, C. J. (1993) Alcohol and injuries: a review of international emergency room studies. Addiction 88, 923–937.[ISI][Medline]

Cherpitel, C. J. (1999) Drinking patterns and problems, drug use and health services utilization: a comparison of two regions in the US general population. Drug Alcohol and Dependence 53, 231–237.[CrossRef]

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Del Rio, M. C., Gomez, J., Sacho, M. et al. (2002) Alcohol, illicit drugs and medicinal drugs in fatally injured drivers in Spain between 1991 and 2000. Forensic Science International 127, 63–70.[CrossRef][ISI][Medline]

Del Roca, F. K. and Darkes, J. (2003) The validity of self-reports of alcohol consumption: state of the science and challenges for research. Addiction 98 (Suppl 2), 1–12.[CrossRef]

El-Guebaly, N., Armstrong, S. J. and Hodgins, D. C. (1998) Substance abuse and the emergency room: programmatic implications. Journal of Addictive Diseases 17, 21–40.[ISI][Medline]

Garretsen, H. F. L. (1983) Probleemdrinken: prevalentiebepaling, beinvloedende factoren en preventiemogelijkheden., Dissertatie, Swets & Zeitlinger B.V., Lisse.

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Kurzthaler, I., Wambacher, M., Golser, K. et al. (2003) Alcohol and/or benzodiazepine use in inured road users. Human Psychopharmacology 18, 361–367.[CrossRef][ISI][Medline]

Lahaut, V. M., Jansen, H.A., van de Mheen, D. et al. (2002) Non-response bias in a sample survey on alcohol consumption. Alcohol and Alcoholism 37, 256–260.[Abstract/Free Full Text]

Monshouwer, K., Dorsselaer van, S., Gorter, A. et al. (2004). Jeugd en riskant gedrag. Kerngegevens uit het Peilstationonderzoek 2003. Utrecht: Trimbos-instituut [In Dutch].

Treno, A. J., Gruenewald, P. J. and Johnson, F. W. (1998) Sample selection bias in the emergency room: an examination of the role of alcohol in injury. Addiction 91, 113–129.

Van de Mheen, D. (1998) Inequalities in health, to be continued? A life-course perspective on socio-demographic inequalities in health. Dissertation, Erasmus University Rotterdam.

Verdurmen, J., Monshouwer, K., Van Dorsselaer, S. (2003). Bovenmatig drinken in Nederland: uitkomsten van de ‘Netherlands mental health survey and incidence study’ [NEMESIS]. Utrecht: Trimbos-instituut [In Dutch].

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Wilsterman, M. E. F., Dors, N., Sprij, A. J. et al. (2004). Clinical characteristics and management of adolescents admitted to the emergency ward for alcohol intoxication in the region of The Hague during the period 1999–2001. Nederlands Tijdschrift voor Geneeskunde 148, 1496–1500 [In Dutch].[Medline]





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