University Greifswald, Medical Faculty, Institute of Epidemiology and Social Medicine, Walther-Rathenau-Str. 48, D-17487 Greifswald and
1 Medical University of Lübeck, Department of Psychiatry, Ratzeburger Allee 160, D-23538 Lübeck, Germany
Received 20 August 1998; in revised form 4 February 1999; accepted 22 March 1999
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ABSTRACT |
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INTRODUCTION |
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The present study has several purposes: (1) to ascertain the prevalence of alcohol dependence and abuse on grounds of screening measures in the two departments of one general hospital; (2) to determine if wards differ; (3) to find out whether intake months of the general hospital differ in prevalence of alcohol abuse or dependence; (4) to decide whether a screening mainly based on questionnaire is sufficient, or a two-step diagnostic procedure with a diagnostic interview in screening positive cases is necessary; (5) to question whether diagnostic information can be provided for cases in which alcohol abuse or dependence is only suspected.
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PATIENTS AND METHODS |
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Of the total eligible sample (n = 1736), 50.9% were in the medical, and 49.1% in the surgical departments; 43.4% were female. We excluded the intensive care ward, because most of its patients could not be interviewed. Of the total sample, 3.6% were too ill to participate, e.g. unable to speak, or deceased before being investigated, 7.0% refused the screening, 3.5% were foreigners unable to speak German sufficiently, 3.1% could not be investigated because of different reasons (highly infectious disease, patients in radiotherapy). Of the patients, 7.4% had been discharged before the diagnostic procedure could be finished. The final sample size was therefore 1309 in-patients. It included 41.9% females. In the medical department, the mean ± SD age was 48.6 ± 12.1; the mean age was lowest on the gastroenterology ward (M3) (43.4 ± 12.7). The medical wards differed significantly in age (analysis of variance, P < 0.000). In the surgical department the mean age was 41.5 ± 14.2); the mean age was lowest on the trauma wards (S3, S4) (39.0 ± 14.0 and 38.9 ± 14.4 respectively). These wards too differed significantly in age (analysis of variance, P < 0.000).
The sample patients gave informed consent to take part in a study with respect to alcohol and other health-related consumption behaviours. The diagnostic procedure included two steps: a screening and an ascertainment of a diagnosis. The screening comprised the CAGE (Ewing, 1984) as well as the MAST (Selzer, 1971
) instruments, proof of withdrawal on grounds of a corresponding medication, and chart review. In screening-negative cases, a further part of the first diagnostic step was to ascertain if any medication to treat withdrawal had been given. If this was not the case, then patient records were analysed with respect to the following criteria: withdrawal or other criteria of alcohol dependence, somatic disorders resulting from alcohol drinking, one or more raised laboratory measures on grounds of alcohol drinking (gamma-glutamyl transpeptidase, aspartate aminotransferase, alanine aminotransferase, mean corpuscular volume), self-reported high alcohol consumption (
40 g of pure alcohol/day in females,
60 g in males). These criteria were used for a diagnosis on suspicion. It seemed useful because diagnostic information based on self-report, such as CAGE and MAST, does not detect all alcohol-dependent or alcohol-abusing subjects in the general hospital due to denial of symptoms (Rumpf et al., 1997
). The laboratory parameters were included on the grounds of their diagnostic accuracy and as far as they were used in the diagnostic routine on the wards (Watson et al., 1986
). To take into consideration a diagnosis on suspicion was useful as diseases typically following from alcohol abuse (definitely alcohol-related diagnoses) were relatively rare among patients with a diagnosis on suspicion (21.2%) and relatively frequent among patients with alcohol dependence (68.5%), whereas diseases other than alcohol-related ones showed a higher rate among patients with a diagnosis on suspicion (32.7%), compared to those with an alcohol dependence (8.7%) (Gerke et al., 1997
).
The screening questionnaires were used after translation and back-translation with the help of an English native speaking co-worker. To make use of the CAGE as well as the MAST proved to be worthwhile, as only 57.0% of the screening questionnaire-positive cases could be detected by both of them. Most of the patients filled in the questionnaires by themselves. If this was not possible, for instance in persons illiterate or with disturbed reading capabilities, it was presented as an interview. This was the case in 35.6% of the screenings. A detailed analysis of the screening questionnaires is described elsewhere (Rumpf et al., 1997, 1998
).
In the second diagnostic step, in the case of a positive screening questionnaire (CAGE >1 or MAST >4) or if medication to treat withdrawal was prescribed, the diagnostic interview according to the Alcohol Section of the Schedules of Clinical Assessment in Neuropsychiatry (SCAN) (World Health Organization, 1992) was conducted by two trained psychologists and one physician experienced in psychiatry (Hapke et al., 1998
). The SCAN provided an ICD-10 as well as a DSM-III-R diagnosis of alcohol dependence or abuse. Systematic chart review led to additional cases of dependence or abuse when the patient records gave evidence of dependence or abuse according to ICD-10 or DSM-III-R. If this was not the case, criteria for a diagnosis on suspicion were checked on grounds of the case report file review: if two criteria were fulfilled, this diagnosis was given. The diagnostic procedure differentiates five alcohol-related diagnostic groups: (1) patients without evidence of alcohol abuse or dependence (no alcohol-related diagnosis); (2) a positive abuse but negative dependence diagnosis (abuse); (3) dependence diagnosis fulfilled (dependence); (4) a positive screening result, which, however, was not confirmed by a diagnosis of dependence or abuse (screening false positive), (5) patients exclusively with a diagnosis on suspicion (suspicion).
A total of 0.4% of the final sample could not be detected by the screening questionnaires, but by prescribed medication to treat withdrawal. All of them were confirmed as dependants. According to patient records, an additional 0.2% fulfilled the criteria for alcohol dependence and 1.3% for abuse. Of the sample, 2.0% showed a positive result in CAGE or MAST but could not be confirmed by SCAN. Of these 26 screening false-positive patients, three were positive by both CAGE and MAST, 14 by CAGE alone, and nine by MAST only. We did not conduct the SCAN systematically in screening negative cases, since, in another study, we showed that 1.0% of alcohol-dependent and 5.8% of alcohol-abusing patients according to a diagnosis on grounds of SCAN were not detected by screening questionnaires, including the CAGE (Rumpf et al., 1996).
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RESULTS |
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DISCUSSION |
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Second, there was substantial variation between intake months, from 11 to 29%, although the intake load was rather evenly distributed over the months. The data collection period included winter, spring, and summer on the medical, and summer, autumn and winter on the surgical ward. However, the variation by month did not confirm a pattern ac-cording to seasonal variation. Other reasons were considered and excluded, e.g. possible changes in hospital routine, holiday times, or weather periods. We cannot state that the variation is typical for a whole year. This would require data collection for a longer time period. Furthermore it is not feasible to relate monthly variations to drinking levels in the population. In Germany, no data about alcohol consumption in the population by month are available.
Third, a two-step diagnosis gives proof of valid diagnosis. Many studies are restricted to screening measures. According to our results this restriction leads to an overestimation of only 2%. On two of the eleven wards, there was no overestimation. This is a very small proportion which leads to the conclusion that pure prevalence estimates do not need a time-consuming measure in addition. For practical reasons, however, the diagnostic interview is important because it carries aspects of supporting motivation to change. Although we used all information available about alcohol-related problems, only a few cases screened as false negative could be proven otherwise by evidence of a prescribed medication to treat withdrawal or by chart review. As we showed in another study (Rumpf et al., 1996) there would be a gain of just 1% of detected alcoholics, if the diagnostic interview were to be conducted with all patients. This contributes to the assumption that those who deny alcohol problems in the screening questionnaire would do so too in an interview.
Fourth, there was a substantial rate of patients with a diagnosis on suspicion, which was of only moderate validity, but of high practical relevance. The diagnosis on suspicion could not be checked with respect to validity. Patients with suspected dependence or abuse might preferably be cases for early intervention. There were considerable differences in the rate of a diagnosis on suspicion. On the gastroenterological ward, there was an overall high rate of patients with an alcohol-related diagnosis, whereas on one of the traumatological wards the high rate of patients with a diagnosis on suspicion suggests denial by young patients in the questionnaires. The latter point receives support from the low mean age of the trauma patients. On the whole, however, age differences did not explain variations in prevalence rates between wards. With respect to false positives on screening, no specific subgroups, e.g. subjects with previous but not recent heavy drinking episodes, could be identified.
We conclude that data should be collected on all wards of a hospital and a time span including different intake months over at least one year, with a two-step diagnostic procedure. Further studies should concentrate on the development of criteria for a diagnosis on suspicion. Practical diagnostic and intervention routine measures should follow from the present confirmation that all wards in a general hospital have a considerable case-load of alcohol-dependent patients.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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Dongier, M., Hill, J. M., Kealey, S. A. and Joseph, L. (1994) Screening for alcoholism in general hospitals. Canadian Journal of Psychiatry 39, 1220.[ISI][Medline]
Ewing, J. A. (1984) Detecting alcoholism. The CAGE questionnaire. Journal of the American Medical Association 252, 19051907.[Abstract]
Gerke, P., Hapke, U., Rumpf, H.-J. and John, U. (1997) Alcohol-related diseases in general hospital patients. Alcohol and Alcoholism 32, 179184.[Abstract]
Hapke, U., Rumpf, H.-J. and John, U. (1998) Differences between hospital patients with alcohol problems referred for counselling by physicians' routine clinical practice versus screening questionnaires. Addiction 39, 17771786.
Lloyd, G., Chick, J. and Crombie, E. (1982) Screening for problem drinkers among medical inpatients. Drug and Alcohol Dependence 10, 355359.[ISI][Medline]
McIntosh, I. D. (1982) Alcohol-related disabilities in general hospital patients: A critical assessment of the evidence. International Journal of the Addictions 17, 609639.[ISI][Medline]
Moore, A. D., Bone, L. R., Geller, G., Mamon, J. A., Stokes, E. J. and Levine, D. M. (1989) Prevalence, detection, and treatment of alcoholism in hospitalized patients. Journal of the American Medical Association 261, 403407.[Abstract]
Rambaldi, A., Gluud, C., Belli, A., Nielsen, S., Storgaard, H. and Moesgaard, F. (1995) Prevalence of alcohol problems among adult somatic inpatients in Naples. Alcohol and Alcoholism 30, 441448.[Abstract]
Rumpf, H.-J., Hapke, U. and John, U. (1996) Empirical evidence of methodological standards in estimating the prevalence of alcohol dependence or abuse in the general hospital. Paper presented at the 10th International Conference on Alcohol, Liverpool, April 1417.
Rumpf, H.-J., Hapke, U., Hill, A. and John, U. (1997) Development of a screening questionnaire for the general hospital and general practices. Alcoholism: Clinical and Experimental Research 21, 894898.[ISI][Medline]
Rumpf, H.-J., Hapke, U., Erfurth, A. and John, U. (1998) Screening questionnaires in the detection of hazardous alcohol consumption in the general hospitaldirect or disguised assessment. Journal of Studies on Alcohol 59, 698703.[ISI][Medline]
Selzer, M. L. (1971) The Michigan Alcoholism Screening Test: the quest for a new diagnostic instrument. American Journal of Psychiatry 127, 16531658.[ISI][Medline]
Seppä, K. and Mäkelä, R. (1993) Heavy drinking in hospital patients. Addiction 88, 13771382.[ISI][Medline]
Statistisches Bundesamt (1994) Statistisches Jahrbuch. Metzler-Poeschel, Wiesbaden.
Watson, R. R., Mohs, M. E., Eskelson, C., Sampliner, R. E. and Hartmann, B. (1986) Identification of alcohol abuse and alcoholism with biological parameters. Alcoholism: Clinical and Experimental Research 10, 364385.[ISI][Medline]
World Health Organization (1992) Schedules for Clinical Assessment in Neuropsychiatry. World Health Organization, Division on Mental Health, Geneva.