1 Senior House Officer, Musgrove Park Academy, Taunton and Somerset Hospital, Musgrove Park, Taunton, Somerset, TA1 5DA, UK and 2 Consultant Gastroenterologist, Department of Gastroenterology, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, UK
* Author to whom correspondence should be addressed at: Musgrove Park Academy, Taunton and Somerset Hospital, Musgrove Park, Taunton, Somerset, TA1 5DA, UK; E-mail: dolman{at}doctors.org.uk
(Received 17 March 2005; first review notified 6 May 2005; in final revised form 14 June 2005; accepted 14 June 2005)
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ABSTRACT |
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INTRODUCTION |
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Over the past 30 years, a number of questionnaires have been developed to identify alcohol use disorders. The CAGE and Michigan Alcoholism Screening Test (MAST) questionnaires identify alcohol-dependent patients, with low sensitivity for those without alcohol dependence (Saunders and Kershaw, 1980). The WHO collaborative project sought to develop a questionnaire to screen for harmful drinking: the alcohol use disorders identification test (AUDIT) (Saunders et al., 1993
). A 10-item questionnaire covering alcohol consumption, drinking behaviour, and alcohol-related problems, it detects these end-points with high sensitivity and specificitya score of 8 or more identifies individuals with an alcohol use disorder. Higher cut-off scores of 13, 16, and 20 or more have been suggested to improve discrimination for the severity of alcohol use disorders and in identifying alcohol-dependent patients at risk of withdrawal (Conigrave et al., 1995
; Babor et al., 2001
). However, these are yet to be established.
Hospital admission provides an excellent opportunity to screen large numbers for alcohol use disorders. There is ongoing debate as to the effectiveness of brief intervention in primary care, with very few secondary care studies conducted (Beich et al., 2003). The value of questionnaires in the identification of excess alcohol consumption in hospital settings has been previously demonstrated (Canning et al., 1999
; Hodgson et al., 2002
). Many patients slip through the treatment net of alcohol management when they are admitted to hospital, often due to the clinician's oversight (DiPaula et al., 1998
). What objective screening test could be used on all patients to overcome this problem? This paper considers the diagnostic ability of the AUDIT questionnaire to accurately predict which patients will go on to develop a clinically meaningful alcohol withdrawal syndrome, when used in combination with traditional laboratory markers.
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PATIENTS AND METHODS |
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Venous blood samples were taken on the day of admission. MCV was measured on a Sysmex SE-9500, using a reference range 80100 fl. The parameters GGT, ALT and AST were measured on a Beckman Synchron LX-20, using a reference range suggested by the manufacturer (764 U/l, 535 IU/l, and 535 IU/l, respectively).
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RESULTS |
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DISCUSSION |
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Use of the AUDIT questionnaire has the advantage of avoiding much of the disagreement in the literature surrounding the terminology and the definition of alcohol problems (Wetterling et al., 1998). An AUDIT positive score alerts the clinician to the possibility of alcohol misuse. Higher cut-off scores of 13 or more and 23 or more have been suggested as better predictors of alcohol-related social problems, liver disease, or gastrointestinal bleeding, with high specificity at the expense of sensitivity (Conigrave et al., 1995
). We found no such fall in sensitivity using a cut-off value of 13 or more.
It is not established what AUDIT score can best predict the severity of the alcohol use disorder or the presence of dependence with physiological manifestations as defined in ICD-10 (World Health Organization, 1992). However, Reoux et al. (2002)
tested the use of AUDIT alone as a predictor of an alcohol withdrawal syndrome in 118 alcohol-dependent patients, using CIWA-Ar to indicate a withdrawal syndrome. In their study, a cut off of 12 or more increased specificity at the cost of sensitivity. They conclude that AUDIT should be explored alone and in combination with other parameters to improve screening for clinically meaningful AWS in other settings. This is what we have sought to do.
A further limitation of the AUDIT questionnaire in the acute medical setting is the demand on clinical staff in terms of the time required to calculate the AUDIT score and complete serial CIWA-Ar questionnaires. Of the 98 patients identified by the AUDIT cut-off 8 or more, only 17 manifested symptoms of clinical withdrawal, that is, nursing staff had to complete CIWA-Ar forms for 81 patients who did not require treatment for alcohol withdrawal. Shorter, alternative questionnaires have already been outlined. An abbreviated form of the AUDIT exists: the three question AUDIT-C. This uses the first three questions of the longer AUDIT, appearing to be effective at screening for heavy drinking and/or active alcohol abuse or dependence (Bush et al., 1998). Another way to reduce the clinical demand would be to use subsections of the AUDIT, such as the dependence questions or single questions.
The local laboratory employed a relatively high upper limit value of GGT compared with the values for ALT and AST. Previous studies (Steffensen et al., 1997; Lee et al., 2001
) show that non-drinkers with healthy livers typically have similar levels of all three enzymes. In our study GGT provided the highest PPV, which may be influenced by this relatively high upper limit value.
The usefulness of questionnaires versus blood tests in identifying alcohol misuse has been much debated (Lock et al., 1999), with a focus on the ability of the screening test, whether biological or questionnaire, to identify either alcohol misuse or dependency (Wetterling and Kanitz, 1996
). One such study, conducted on behalf of the WHO, concluded that a combination of CDT, GGT and AST provided better detection of high-risk than of intermediate consumption (Conigrave et al., 2002
). The use of the panel of four traditional biological markers with selected AUDIT cut-off scores enhanced the positive predictive value of the AUDIT questionnaire in this study population. This panel of 4 biological markers were chosen as they are widely available and would be applicable to the majority of patients admitted on acute medical admissions. If, given an initial AUDIT score 8 or more, a serial CIWA-Ar questionnaire were only completed if two or more out of the panel of 4 biological markers were abnormal, due to the increased PPV of this combined result, workload for clinical staff might be considerably reduced whilst maintaining a high sensitivity and specificity for detecting patients likely to experience withdrawal. This model using a combination of the AUDIT questionnaire and panel of 4 biological markers requires further validation in the clinical setting.
AUDIT has been demonstrated to be effective at identifying alcohol use disorders including dependency as well as episodic and short duration drinking patterns (Saunders et al., 1993). It is possible that blood tests are raised when there is prolonged, heavy alcohol use or in the presence of co-morbidity leading to hospital admission, giving rise to an increased risk of alcohol withdrawal syndrome. This may help to explain why our results indicate that a combination of both questionnaire and biological tests increase the ability to detect and potentially prevent alcohol withdrawal.
In conclusion, the AUDIT questionnaire can be used in the acute medical setting to detect alcohol use disorders, offering opportunities for intervention in the hope of preventing alcohol withdrawal, and minimizing long-term risk. Combining routinely available biological markers with an AUDIT questionnaire enhances screening for alcohol use disorders and those patients at risk of alcohol withdrawal symptoms. Further investigation of such a combined screening tool is warranted to explore its potential in reducing the workload passed on to the clinical staff implementing the screening process.
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ACKNOWLEDGEMENTS |
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