Screening for alcoholism

Item bias in the CAGE screening test for alcohol use disorders

OBJECTIVE

To explore potential item bias in the CAGE questions (mnemonic for cut-down, annoyed, guilty, and eye-opener) when used to screen for alcohol use disorders in primary care patients.

DESIGN AND SETTING

Cross-sectional study, conducted in a university-based, family practice clinic, with the presence of an alcohol use disorder determined by structured diagnostic interview using the Alcohol Use Disorder and Associated Disabilities Interview Schedule.

PATIENTS

A probability sample of 1,333 adult primary care patients, with oversampling of female and minority (African-American and Mexican-American) patients.

MAIN RESULTS

Unadjusted analyses showed marked differences in the sensitivity and specificity of each CAGE question against a lifetime alcohol use disorder, across patient subgroups. Women, Mexican-American patients, and patients with annual incomes above $40,000 were consistently less likely to endorse each CAGE question "yes," after adjusting for the presence of an alcohol use disorder and pattern of alcohol consumption. In results from logistic regression analyses predicting an alcohol use disorder, cut-down was the only question retained in models for each of the subgroups. The guilty question did not contribute to the prediction of an alcohol use disorder; annoyed and eye-opener were inconsistent predictors.

CONCLUSIONS

Despite its many advantages, the CAGE questionnaire is an inconsistent indicator of alcohol use disorders when used with male and female primary care patients of varying racial and ethnic backgrounds. Gender and cultural differences in the consequences of drinking and perceptions of problem alcohol use may explain these effects. These biases suggest the CAGE is a poor "rule-out" screening test. Brief and unbiased screens for alcohol use disorders in primary care patients are needed.

The feasibility of a new intake routine to assess substance use disorders by means of a structured interview

A structured interview, ADDIS (Alkohol Drog Diagnos InStrument), designed to assess substance use disorders, was included as a part of the intake protocol in a department of orthopedics at a general hospital. To evaluate both the effectiveness and feasibility of the new procedure, the attitudes of 29 staff members were sampled during follow-up interviews. In addition, a questionnaire was sent to 254 patients to examine their opinions about the interview. The staff made a global evaluation of the new routine on a 10-point scale, ranging from completely negative (1) to completely positive (10). The mean rating was 8.2 (range 5-10). The evaluations made by the staff members in the interviews were very positive. Of the 254 patients, 177 (70%) returned the questionnaire. More than 90% of the patients appreciated being asked about their use of analgesics and sedatives, and 77% felt it was positive to be asked about their alcohol use. The result of the patient questionnaire supports the feasibility of the routine, suggesting that a structured interview can be included in the intake protocol in order to improve the assessment of substance use disorders.

Physician detection of drinking problems in patients attending a general medicine practice

OBJECTIVE

To assess the patient and physician characteristics that influence physicians' detection of problem drinking in their medical patients.

SETTING

The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents.

DESIGN

Cross-sectional study of a randomly chosen subsample of consecutive patients.

MEASUREMENT

Univariate and multivariate analysis with calculated adjusted odds ratios of factors associated with physician detection of drinking problems. A problem was diagnosed according to the patient's results on the alcohol module of the Diagnostic Interview Schedule (DIS).

RESULTS

Physicians detected 22% of 189 presumably inactive problems and 49% of 92 current problems, i.e., those that have occurred within the preceding year. Multivariate correlates of detection of active problems included male patient gender, presence of gastrointestinal complications of excessive drinking, number of concurrent medical disorders, and previous medical record reference to alcohol (p less than 0.05). Physician gender and year of training were not associated with detection.

CONCLUSION

Our physicians appear to rely on specific patient characteristics as well as the patient's medical record to detect drinking problems in their ambulatory patients. Their reliance upon these factors may hinder their detection of drinking problems in women patients and less seriously impaired individuals.

The effect of patient gender on the prevalence and recognition of alcoholism on a general medicine inpatient service

OBJECTIVES

1) to determine the rate of alcoholism among general internal medicine inpatients, 2) to assess the recognition and referral rates of these patients by their physicians, 3) to determine the effect of patient gender on physician recognition of alcoholism, and 4) to compare the observed alcoholism rates with rates reported in frequently cited studies, controlling for gender distribution.

DESIGN

Cross-sectional study, face-to-face interviews.

SETTING

A large, county-owned metropolitan teaching hospital.

PATIENTS/PARTICIPANTS

Adult patients admitted to an inpatient general medical firm. From among 95 consecutive admissions, 78 patients (81%) entered the study.

INTERVENTION

The Michigan Alcoholism Screening Test (MAST) was administered to all study subjects. Chart reviews provided evidence of physician recognition and referral of patients with alcoholism. The observed rate of alcoholism was compared with rates reported in frequently cited studies after stratifying by type of service sampled and alcoholism assessment method used. Rates were then standardized for gender using the direct method.

MEASUREMENTS AND MAIN RESULTS

Twenty-two patients (28%) were found to be alcoholic by MAST criteria (scores of 5 or higher). Scores in the range indicative of alcoholism were observed more frequently among the 36 men than among the 42 women (p = 0.002) and varied by age group. Only the interaction between gender and age group was significant (p = 0.023). Sixteen of the 22 patients (73%) with alcoholism by MAST criteria were identified as alcoholic by physician evaluation. Physicians were significantly more likely to identify as alcoholic those patients with MAST scores higher than 29 and tended to more readily identify men who had alcoholism than women. Among physician-identified patients, only about one in five was referred for rehabilitation. The standardized alcoholism rate found (291/1,000) ranked about halfway between the highest and the lowest standardized rates from nine other studies of medicine inpatient services (465/1,000 and 112/1,000).

CONCLUSIONS

Patient gender affected the prevalence of alcoholism and influenced its recognition by physicians. Alcoholism by MAST criteria was found in one in eight female and nearly one in two male inpatients. Physician recognition was higher for men and for more severely affected patients. An understanding of gender effects is essential to the appropriate interpretation of the results of screening tests for alcoholism and to understanding differences in reported crude rates of alcoholism among studies. Supplementing clinical impressions with the routine use of standardized methods for detecting alcoholism is recommended.