Department of Family and Community Medicine, University of Missouri-Columbia, Columbia, MO 65212, USA
* Author to whom correspondence should be addressed at: Daniel C. Vinson, Department of Family and Community Medicine, University of Missouri-Columbia, MO 65212, USA. Tel.: +1 573 882 3184; Fax: +1 573 884 5734; E-mail: VinsonD{at}health.missouri.edu
(Received 3 November 2004; first review notified 16 December 2004; in revised form 8 March 2005; accepted 9 March 2005; Advance Access publication 29 March 2005)
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ABSTRACT |
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INTRODUCTION |
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Up to one-fourth of patients in primary care settings may be hazardous or harmful drinkers (Whitlock et al., 2004). Using brief interventional measures, primary care clinicians can help 40% of the harmful drinkers (compared with 20% in control groups) to reduce their drinking to safe levels (Wallace et al., 1988
; Fleming et al., 1997
), with documented improvements in health outcomes in one study shown even 4 years later (Fleming et al., 2002
). Hazardous and harmful drinkers, however, often go undetected (Spandorfer et al., 1999
; Vinson et al., 2000
; McGlynn et al., 2003
; Rush et al., 2003
). Screening is therefore necessary to identify the individuals who would benefit from intervention (U.S. Preventive Services Task Force, 2004
).
Several studies have examined the sensitivity and specificity of various screening instruments (Fiellin et al., 2000). The 4-item cutting down, annoyance by criticism, guilty feeling and eye-openers (CAGE) and the 10-item alcohol use disorders identification test (AUDIT) are widely recommended. With the CAGE, the area under a receiver operating characteristic (ROC) curve is lower in outpatient settings (0.600.71) than among hospitalized patients (0.87) (Aertgeerts et al., 2004
). In another study, when the CAGE was augmented to include quantityfrequency (QF) questions, the area under the ROC curve increased from 0.73 to 0.78 (Bradley et al., 2001
). In identifying hazardous drinking or current alcohol abuse or dependence, the AUDIT outperformed both the CAGE and the augmented CAGE (areas under the ROC curves of 0.86, 0.72 and 0.77, respectively) (Bradley et al., 1998
).
The first three AUDIT items, called AUDIT-C, ask about the usual frequency of drinking, typical quantity and frequency of heavy drinking. It performed as well as the full AUDIT in detecting heavy drinking, with an area under the ROC curve of 0.89 vs 0.88, but had a somewhat lower area under the ROC curve for detecting active alcohol abuse and dependence alone (0.79) than the full AUDIT (0.81) (Bush et al., 1998). These findings have been confirmed in several European studies. In Germany, the AUDIT-C had an area under the ROC curve of 0.88 in detecting hazardous or harmful drinking (Rumpf et al., 2002
); in Belgium, the areas under the ROC curves were 0.83 for men and 0.82 for women in detecting hazardous or harmful drinking; and in Spain, the areas under the ROC curves were 0.91 for men and 0.96 for women in detecting physician-diagnosed hazardous drinking (Gual et al., 2002
).
Although it was asked in the research interviews in the context of the full AUDIT, the third AUDIT question by itself, How often do you have 6 or more drinks on one occasion, has also been examined as a single screening question. It had an area under the ROC curve of 0.83 in detecting current alcohol use disorder or hazardous drinking in men (Bush et al., 1998) and 0.76 in women (Bradley et al., 2003
). With a modified version of the question (4 or more drinks), the area under the ROC curve in women increased to 0.86 (Bradley et al., 2003
).
Using the same dataset examined here, we previously reported (Williams and Vinson, 2001) a study of a single alcohol screening question (SASQ), When was the last time you had more than X drinks in 1 day, with X = 4 for women and 5 for men (one standard drink in the US contains 14 g ethanol). Based on previous work (Taj et al., 1998
), the threshold numbers were set one drink higher than usually recommended (National Institute on Alcohol Abuse and Alcoholism, 2003
) to balance sensitivity and specificity. Open-ended answers were coded as never, >12 months ago, 312 months ago, and within the last 3 months, with the last category considered a positive screen. Both sensitivity and specificity were 0.86 in identifying the past-month hazardous drinking, current alcohol use disorders, or both. The area under the ROC curve was 0.90 (Williams and Vinson, 2001
).
Questions about quantity or frequency of drinking may have reasonable sensitivity and specificity, but not all studies have supported their use. In their systematic review, Fiellin et al. (2000) concluded that the CAGE and AUDIT consistently performed better than other methods, including QF questions. Using data from a population-based US study, Dawson concluded that single- or dual-item indicators of alcohol consumption have limited value as screeners of alcohol dependence (Dawson, 1994
).
Finding time to screen for alcohol problems in a busy primary care clinic is challenging, and only a third of primary care doctors regularly screen patients for alcohol problems (The National Center on Addiction and Substance Abuse at Columbia University, 2000; Aertgeerts et al., 2001
). When doctors do screen patients, they generally use QF questions, not the CAGE or the AUDIT (Spandorfer et al., 1999
). We therefore decided to examine more closely the utility of two standard QF questions in detecting hazardous or harmful drinking, comparing them with the SASQ.
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SUBJECTS AND METHODS |
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Cases were matched with two separate groups of control participants by age group, sex and rural versus urban. Inclusion criteria were the same as for cases. One group of controls was patients presenting to the same emergency departments for care of a medical illness; 88% of those approached participated. The second group was recruited by random-digit dialing using the telephone exchanges of Boone County and contiguous counties, with a response rate of 47%.
Instruments
The first question of the structured interview asked about tobacco use in all the three groups of participants. The second Question was the SASQ, quoted above. The subsequent questions about alcohol were a timeline follow-back interview, a retrospective calendar-based review of day-by-day consumption (Sobell and Sobell, 1992). We reviewed the past 28 days for injured cases and telephone controls and the past 8 days for the medical controls (keeping their interview shorter to avoid missing cases).
Following the timeline, the interviewer asked questions from the structured diagnostic interview schedule (DIS) (Robins et al., 1996). The first DIS question was, In the last year, have you had 6 or more drinks? Participants who twice denied drinking
6 drinks in the entire previous year were not asked the remaining DIS questions. The next DIS question addressed the frequency of drinking, with answers on a 5-point ordinal scale from less than once a month to almost every day. The third DIS question asked the average number of drinks per occasion, with the answer recorded as the number given by the respondent. Using these questions, we created a QF measure by multiplying the usual frequency of drinking times average quantity. We also examined the utility of the single question about average quantity.
We identified current (past 12 months) alcohol abuse and dependence using the criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), based on answers from the DIS. Hazardous drinking was defined as drinking >4 drinks in 1 day or >14 drinks in 1 week for men, >3 drinks in 1 day or 7 drinks in 1 week for women (National Institute on Alcohol Abuse and Alcoholism, 2003
).
Statistical analysis
We used Stata (Stata Corporation, 2003) to estimate the area under the ROC curve (Jaeschke et al., 1994
) with 95% confidence intervals (CIs), directly comparing the ability to identify hazardous drinking and/or alcohol use disorders of three screening approaches: the single alcohol screening question, the QF product calculated from the DIS questions and the question about average quantity alone. Analyses took into account the correlations caused by applying the three screening approaches to the same respondents.
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RESULTS |
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The numbers of participants from ethnic groups other than African-American and Caucasian were too small to allow meaningful comparisons. Combining all three samples and comparing African-Americans (n = 330) and Caucasians (n = 3262), the areas under the ROC curves were almost identical for the QF product (0.84 and 0.85, respectively) and for the quantity question (0.80 and 0.81, respectively), but different for the SASQ: 0.74 (95% CI 0.690.79) among African-Americans and 0.81 (0.80 to 0.83) among Caucasians.
Using all three samples combined, Table 3 shows the sensitivity and specificity of each screening test at selected threshold values for the SASQ, the QF product and the quantity question.
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DISCUSSION |
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Our previous study found that the SASQ performed well in identifying persons with either hazardous drinking or a current alcohol use disorder, with an area under the ROC curve of 0.90 (95% CI 0.880.91) (Williams and Vinson, 2001). The analyses reported then assumed that cases who did not answer the DIS questions (because they twice denied drinking
6 drinks in the entire previous 12 months) did not have an alcohol use disorder. The value for the area under the ROC curve presented here is lower because non-drinkers were excluded from the analyses.
Using QF questions in screening for alcohol problems in clinical settings is feasible, though not straightforward. First, when using the quantity question alone, one must use a threshold of 3 drinks/occasion to have a sensitivity of 77%. At a threshold of
4, sensitivity is substantially lower (Table 3). Second, the frequency question used an ordinal scale, and remembering that scale would make screening with the QF product harder. Third, some QF results can be produced in different ways and thus indicate different patterns of drinking. For example, a QF score of 6 could be derived from 6 drinks less than once a month, 3 drinks 13 days a month, or 2 drinks once or twice a week. This ambiguity may dissuade clinicians from using it.
Other screening tests also use questions about quantity, frequency or maximal quantity. The 10-item AUDIT (Saunders et al., 1993) starts with three questions about frequency, typical quantity and frequency of drinking
6 drinks on one occasion. Used as a separate scale, these three questions also have good psychometric properties in both men (Bush et al., 1998
) and women (Bradley et al., 2003
). The fast alcohol screening test (Hodgson et al., 2002
) starts with the third AUDIT question. That question alone was able to correctly classify about half of the patients as hazardous or non-hazardous drinkers in their study (Hodgson et al., 2002
). The Paddington alcohol test (Patton et al., 2004
) asks patients who acknowledge any drinking, what is the most you will drink in any one day?, then asks about the frequency of heavy drinking. Using the AUDIT as the criterion standard, it had a sensitivity of 97% and specificity of 88% (Patton et al., 2004
).
Limitations
We studied the utility of these three screening approaches in identifying current alcohol use disorders or recent hazardous drinking. All three would be less effective in identifying patients with a past alcohol use disorder who are not currently drinking hazardous amounts.
The structure of the interview may have influenced the results. The detailed review of recent consumption came immediately before the questions about average quantity and usual frequency. That may have enabled respondents to recall their drinking more accurately when asked the QF questions than when asked the SASQ, which was asked at the beginning of the interview. However, the results were similar for the medical controls, who had an 8-day timeline, and the cases and telephone controls who had a 28-day timeline, suggesting that the differences seen here were not owing solely to the effect of doing a timeline right before the QF questions. Alternatively, an 8-day timeline may be sufficient to enhance the utility of subsequently asked QF questions.
The amount of data used in applying the criterion standard to identify hazardous drinkers was limited and varied by group. This may have led to true-positive screening results among individuals whose hazardous drinking was not confirmed because the timeline covered only the last 28 days or, even more a problem, 8 days.
Of the individuals who answered both the SASQ and QF questions, 9.2% were African-American, which is similar to the 8.5% African-American population in central Missouri, but lower than the 12.3% US average. Future research could develop and validate other rapid screening approaches based on quantity and/or frequency that have greater utility among ethnicities other than Caucasians.
The non-participation rate varied among the three samples. The effects of non-response bias are uncertain, particularly among the telephone controls, but the similarity of the findings across all three groups suggest that the non-response did not bias the results substantially.
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CONCLUSIONS |
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ACKNOWLEDGEMENTS |
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