Alcohol-related problems in a general hospital and a general practice: screening and the preventive paradox

The incidence of alcohol-related problems and the risk of alcohol withdrawal in a general hospital population

A survey was carried out using the Canterbury Alcohol Screening Test (CAST) and clinical criteria for risk of alcohol withdrawal of 2000 randomly selected hospital in-patients in order to determine the prevalence of alcohol-related problems, the work-load for a specialist alcohol withdrawal service and the target group for early intervention. Patients at risk of alcohol withdrawal were followed prospectively.The major findings were: 14.3% of patients had a positive CAST and 8% were at risk of alcohol withdrawal; the prevalence of positive clinical criteria was greatest in men under the age of 30 years (OR 3.6) and very low (OR 0.34) in women over 60 years. In addition, patients who were too sick or refused to complete the questionnaire had high rates of being at risk for alcohol withdrawal. The prevalence of CAST positivity was greatest in men under the age of 40 years (OR 3.7) and lowest in women over 70 years (OR 0.2). It is concluded that 15-20% of in-patients have alcohol problems and 8% are at risk of withdrawal; questionnaires will produce underestimates of the order of 25%; and female in-patients over the age of 60 years are extremely unlikely to have problems with alcohol.

Prevalence and record of alcoholism among emergency department patients

OBJECTIVES

The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team.

METHODS

The study population consisted of all patients admitted to the emergency room at Hospital São Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test.

RESULTS

We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively.

CONCLUSION

Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

The frequency of smoking and problem drinking among general hospital inpatients in Brazil - using the AUDIT and Fagerström questionnaires

CONTEXT

Although the CAGE questionnaire is one of the most widely used alcohol screening instruments, it has been criticized for not identifying people who are drinking heavily or who have alcohol related problems but do not as yet show symptoms of alcohol dependence. The AUDIT (Alcohol Use Disorder Identification Test) questionnaire was developed by WHO as a screening instrument specifically designed to identify problem drinkers, as well as those who were already dependent on alcohol.

OBJECTIVE

The aim of this study was to use the AUDIT and Fagerström questionnaires in a general hospital inpatient population to measure the frequency of problem drinking and nicotine dependence, and to see if levels varied between medical speciality.

DESIGN

Retrospective cross-sectional study.

SETTING

Federally funded public teaching hospital.

SAMPLE

275 inpatients from both genders.

MAIN MEASUREMENTS

Socio-demographic data, AUDIT (Alcohol Use Disorders Identification Test) and Fagerström Test for Nicotine Dependence.

RESULTS

We interviewed 275 inpatients, 49% of whom were men and 51% women. Thirty-four patients were identified as "cases" by the Audit questionnaire; 22% of the male patients and 3% of the females. Just over 21% of inpatients were current smokers. The gastroenterology (26%) and general medicine (16%) inpatient units had the largest number of individual cases.

CONCLUSIONS

Only by knowing the prevalence of alcohol abuse/dependence and nicotine dependence in a general hospital can we evaluate the need for a specialized liaison service to identify and treat these patients.

Problem drinkers in acute care settings: validation of an assessment instrument

This article reports a validation study of a screening procedure for detecting those patients whose patterns of alcohol consumption places them at risk of developing alcohol-related health problems. The sample comprised 998 patients who were admitted to the wards of a general hospital for treatment of conditions which were not primarily alcohol-related. Twenty-six per cent of patients reported drinking more than published guidelines for low-risk drinking. The use of a diary was found to be a valid means of assessing patients' levels of alcohol consumption, and its reliability and validity was confirmed as a method of distinguishing potential problem drinkers from those whose level of alcohol consumption does not place them at risk. As such, the diary is recommended as an assessment tool which can readily be incorporated into standard assessment procedures.

Alcohol, casemix and hospitals: an opportunity?

The number of patients in hospitals who experience alcohol-related problems is high, and the provision of intervention for these patients is a significant public health measure. The current move towards casemix funding of acute hospital services provides an opportunity for the development of such programmes. Modifications to the Diagnosis Related Groups categorization of alcohol-related problems that would allow for appropriate funding are discussed.

Identification of at-risk drinkers in an orthopaedic inpatient population

The prevalence of hazardous drinking of alcohol in orthopaedic inpatients and its impact on patient management was determined. A prospective survey was performed on acute and arranged admissions in the orthopaedic wards at St Vincent's Hospital, Melbourne, over a 3 month period. At-risk drinking was measured by the AUDIT questionnaire, a score of eight or more suggesting hazardous drinking and a score of 20 or more suggesting dependence. A separate questionnaire recorded relevant details of the admission, complications during hospital stay, degree of difficulty nursing the patient and any past history of alcohol problems. Thirty-four (36%) of 94 patients were drinking at hazardous levels. Of these, 62% gave no prior history of problems with alcohol. Thirty-four per cent of 53 acute admissions and 39% of 41 arranged admissions were harmful drinkers suggesting that trauma may not be the only contribution to problem drinking in the orthopaedic setting. Hazardous drinking occurred in both male and female groups aged less than 55 years and in males greater than 55 years. Hazardous drinking was associated with more inpatient complications (chi 2 = 6.6, d.f. = 1, P = 0.01) and greater nursing difficulty (chi 2 = 5.5, d.f. = 1, P = 0.02). A third of the patients in the orthopaedic wards drink alcohol at hazardous levels, whether they are acute or arranged admissions. Hazardous drinking is associated with more complications and greater difficulty in nursing patients.

Predictive validity of the Readiness to Change Questionnaire

Following the development of the Readiness to Change Questionnaire described by Rollnick et al., this article reports on the predictive validity of the questionnaire among a sample of 174 male excessive drinkers identified by screening on wards of general hospitals. Relationships between patients' "stage of change" derived from questionnaires administered prior to discharge from hospital and changes in drinking behaviour at 8 weeks and 6 months follow-up are analysed. Allocated stage of change provided statistically significant relationships with drinking outcome. Multiple regression analysis showed that stage of change remained a significant predictor of changes in alcohol consumption when other possible predictors were taken into account. Two methods for allocating stage of change on the basis of questionnaire responses for use in different circumstances, a "quick" and a "refined" method, are described.

Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II

The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.

Alcoolismo e problemas relacionados: dificuldades na implementação de estudos de prevalência

No artigo, são apresentadas algumas dificuldades metodológicas no estudo da prevalência do alcoolismo e dos problemas relacionados com o consumo abusivo de bebidas alcoólicas. Abordam-se questões como a definição de alcoolista e os obstáculos para a sua identificação através de instrumentos utilizados em estudos populacionais. Discutem-se ainda as vantagens e desvantagens dos diferentes deliamentos de pesquisa para estimar a prevalência do alcoolismo e dos problemas associados ao álcool.

Screening elderly veterans for alcoholism

OBJECTIVE

To determine the sensitivity and specificity of an alcoholism screening test not previously tested in the elderly.

DESIGN

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

SETTING

Veterans Administration (VA) outpatient facility.

PATIENTS/PARTICIPANTS

Men greater than or equal to 70 years old seeking care in a newly established VA outpatient facility were invited to participate in a health assessment program. Of 109 participants who enrolled, 96 completed both interviews.

INTERVENTIONS

The screening test was administered by an internist as part of a medical history. The Michigan Alcoholism Screening Test (MAST), used as the "gold standard," was administered by a trained interviewer as part of a longer structured interview.

MEASUREMENTS AND MAIN RESULTS

The screening test had a sensitivity of 0.52 and a specificity of 0.76 in this sample.

CONCLUSIONS

The sensitivity and specificity of the screening test were lower in this sample in comparison with previously reported results in a younger population. Differences in the test performance may be related to differences in attitudes and drinking behaviors of elderly veterans when compared with those of younger men and women.