1 Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland, 2 Department of Psychiatry, Tampere University Hospital and 3 Medical School, University of Tampere, Finland
* Author to whom correspondence should be addressed at: National Public Health Institute, PO Box 33, FIN-00251 Helsinki, Finland. Tel: +358 9 4744 8139; Fax: +358 9 4744 8133; E-mail: mauri.aalto{at}ktl.fi
(First received 19 March 2005; first review notified 2 June 2005; accepted in final revised form 1 September 2005)
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ABSTRACT |
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INTRODUCTION |
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The Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993) has been recommended as a first-line method to screen patients' alcohol abuse, because of its good sensitivity and specificity (Aertgeerts et al., 2001
). Reinert and Allen (2002)
found that its median sensitivity was 86% and its median specificity was 89%, in different studies. However, its length for busy practice has been considered as a possible problem (Roche and Freeman, 2004
; Seppä et al., 2004
).
Both CDT and AUDIT were introduced over a decade ago (Stibler, 1991; Saunders et al., 1993
). During the same period promotion to increase the awareness of alcohol issues, especially brief intervention, has been active in primary health care stressing the importance of using several tools in detection (Kääriäinen et al., 2001
; Aalto et al., 2003b
). However, there is little knowledge of how these methods are adapted by physicians and how often they are used in relation to brief intervention in primary health care. The purpose of the present study was to investigate these issues among all and some subgroups of primary care physicians in Finland.
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SUBJECTS AND METHODS |
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Questionnaire
A self-administered questionnaire was designed for this study. There were several structured questions related to demographics and professional background, including gender, age, and having a specialist licence (no licence, licence in general practice, or licence in occupational health care). Structured questions about the frequency with which the physicians used CDT, any laboratory marker (MCV, GGT, ASAT, ALAT, or CDT), and AUDIT were included. The use of the conventional markers (MCV, GGT, ASAT, ALAT) was calculated based on these questions. There were three options in each of these questions: (i) regular use, (ii) occasional use, and (iii) no use. Likewise the physicians were asked to report their activity in using brief intervention. If the alternative of no use was reported, physicians were further asked to report whether or not they were familiar with that particular method.
The questionnaire was accompanied by a prepaid envelope and a short covering letter stating that the purpose of the survey was to collect information for the implementation of brief alcohol intervention and that the anonymity of the respondents was guaranteed. Anonymity was assured by the fact that only the envelopes, not the questionnaires, had the identification codes needed for the next mailing wave, and the returned envelopes were opened and separated from the questionnaires by a person who did not have access to opening the codes.
A response rate of 65.7% (2099/3193) was achieved in three mailing waves. The mean age of the respondents (SD) was 42.5 (8.7) years. Table 1 shows the respondents' other characteristics and that they were similar to all primary care physicians.
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RESULTS |
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Regular or occasional use of brief intervention was associated with more frequent use of all the detection methods studied, even if those not doing brief intervention at all used laboratory markers and the AUDIT questionnaire quite often (95.6 and 44.0%, respectively) (Fig. 2). Those who did brief intervention regularly used AUDIT regularly 4.2 times more commonly than those with no brief intervention activity at all (Fig. 2c). Instead, use of the detection methods did not differ between those reporting regular and those reporting occasional brief intervention activity (Fig. 2).
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DISCUSSION |
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Almost all the respondents in our study used some laboratory marker to detect alcohol abuse. This was expected, because in Finland MCV and transaminases are available to all primary care physicians and they are familiar with their use for other purposes. In spite of the recommendation to use CDT as a first-line biological marker of alcohol abuse (Schwan et al., 2004), its use was not so frequent. The most probable reason for this is that it is not as well known as the conventional markers. Less frequent use of CDT can also be partly explained by the fact that the only indication for its use is alcohol abuse, in contrast to conventional alcohol markers. This means that physicians may find it difficult to justify using CDT.
Almost 70% of the physicians used AUDIT, which contrary to some results (Roche and Freeman, 2004; Seppä et al., 2004
) indicates that most of the primary care physicians consider AUDIT useful as a part of routine practice. Another explanation is that physicians in Finland are forced to use AUDIT occasionally in the case of physicians' examinations in relation to driving licence applications. The use of AUDIT was more common than of CDT. Differences in the costs of these methods may partly explain this finding. Another probable reason is that the validity of CDT is still questionable (Koch et al., 2004
) and AUDIT has been recommended as a first-line method to screen for alcohol abuse (Aertgeerts et al., 2001
).
It is natural that the use of brief alcohol intervention was associated with the higher likelihood that physicians use different methods to detect alcohol abuse. It also seems that physicians do not choose between CDT and AUDIT, but the use of one of these methods increases the likelihood that the physician also uses the other method. The data also indicate that some factors in relation to physicians influence activity in using detection methods. These included gender, age and, specialist licence.
It should be admitted that physicians usually overestimate practice behaviour. A 10% audit of physicians records (charts) would have been a way of estimating the extent of possible over-reporting, but due to the anonymous nature of the questionnaire this was not possible.
A careful clinical interview is the method of choice to detect alcohol abuse. A limitation of this study is that we have no information on this and thus cannot compare it with the use of AUDIT and laboratory markers. It is possible, even if unlikely, that those who do not use AUDIT or even laboratory markers utilize a thorough clinical interview instead.
Another possible limitation of the present study is that the data was based on the physicians' self-reports. Such an approach may have produced an overestimate of the use of different methods. A guarantee assuring anonymity was included in the covering letter accompanying the questionnaire in order to address this concern.
In spite these limitations it can be concluded that, considering the ambivalences that there have been in relation to alcohol issues in health care, the use of CDT and AUDIT are already reasonably frequent. This may indicate that tools to facilitate the work may also help in adapting new activities. However, the results also point out that the use of CDT and AUDIT should still be promoted.
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ACKNOWLEDGEMENTS |
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REFERENCES |
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