Annual Rescreening for Alcohol Misuse: Diminishing Returns for Some Patient Subgroups.

*Health Services Research & Development (HSR&D) Northwest Center of Excellence †Department of Health Services, University of Washington ‡Group Health Research Institute §Department of Biostatistics, University of Washington ∥Center of Excellence in Substance Abuse Treatment and Education (CESATE) Departments of ¶Psychiatry and Behavioral Sciences #Medicine, University of Washington, Seattle, WA.
Medical care (Impact Factor: 3.23). 08/2013; 51(10). DOI: 10.1097/MLR.0b013e3182a3e549
Source: PubMed


Routine alcohol screening is widely recommended, and Medicare now reimburses for annual alcohol screening. Although up to 18% of patients will screen positive for alcohol misuse, the value of annual rescreening for patients who repeatedly screen negative is unknown.
To evaluate the probability of converting to a positive alcohol screen at annual rescreening among VA outpatients who previously screened negative 2-4 times.
Retrospective cohort study.
A total of 179,035 VA outpatients (10,588 women) who previously screened negative on 2 and up to 4 consecutive annual alcohol screens and were rescreened the next year.
AUDIT-C alcohol screening scores (range, 0-12) were obtained from electronic medical record data. The probability of converting to a positive screen (scores: men ≥4; women, ≥3) at rescreening after 2-4 prior negative screens was evaluated overall and across subgroups based on age, sex, and prior negative screen scores (scores: men, 0-3; women, 0-2).
The overall probability of converting to a positive subsequent screen decreased modestly from 3.5% to 1.9% as the number of prior consecutive negative screens increased from 2 to 4, yet varied widely across subgroups based on age, sex, and prior negative screen scores (0.6%-38.7%).
The likelihood of converting to a positive screen at annual rescreening is strongly influenced by age, sex, and scaled screening scores on prior negative alcohol screens. Algorithms for the frequency of repeat alcohol screening for patients who repeatedly screen negative should be based on these factors. These results may have implications for other routine behavioral health screenings.

1 Follower
5 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: AimsThe U.S. Veterans Health Administration (VA) used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.DesignObservational, retrospective cohort study using secondary clinical and administrative data.Setting30 VA facilities.ParticipantsOutpatients who screened positive for unhealthy alcohol use (AUDIT-C ≥ 5) in the 6 months after the brief intervention performance measure (n=22,214) and had follow-up screening 9-15 months later (n=6,210; 28%).MeasurementsMultilevel logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥ 2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).FindingsAmong 6,210 patients with follow-up alcohol screening, 1,751 (28%) had brief intervention and 2,922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health, and more severe unhealthy alcohol use than those without (p-values <0.05). Adjusted prevalences of resolution were 47% (95% Confidence Interval (CI) 42% - 52%) and 48% (95% CI 42% - 54%) for patients with and without documented brief intervention, respectively (p=0.50).Conclusions During early implementation of brief intervention in the U.S. Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.
    Addiction 04/2014; 109(9). DOI:10.1111/add.12600 · 4.74 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Routine screening for unhealthy alcohol use is widely recommended in primary care settings. However, the validity of repeat screening among patients who have previously screened negative remains unknown. This study aims to evaluate the performance of a clinical alcohol screen compared to a confidential comparison alcohol screen among patients with previous negative alcohol screens. Methods: This study included four nested samples of Veteran Health Administration (VA) outpatients with at least one (N=18,493) and up to four (N=714) prior negative annual clinical AUDIT-C screens who completed the AUDIT-C the following year, both in a VA clinic (clinical screen) and on a confidential mailed survey (comparison screen). AUDIT-C screens were categorized as either negative (0-3 points men; 0-2 women) or positive (≥4 men; ≥3 women). For each sample, the performance of the clinical screen was compared to the comparison screen, the reference measure for unhealthy alcohol use. Results: The sensitivity of clinical screens decreased as the number of prior negative screens in a sample increased (40.0-17.4%) for patients with 1-4 negative screens. The positive predictive value also decreased as the number of prior negative screens in a sample increased (67.7-33.3%) while specificity was consistently high for all samples (≥97.8%). Conclusions: Repeat clinical alcohol screens became progressively less sensitive for identifying unhealthy alcohol use among patients who repeatedly screened negative over several years. Alternative approaches for assessing unhealthy alcohol use may be needed for these patients.
    Drug and Alcohol Dependence 06/2014; 142. DOI:10.1016/j.drugalcdep.2014.06.017 · 3.42 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Alcohol is a hepatotoxin that is commonly consumed worldwide and is associated with a spectrum of liver injury including simple steatosis or fatty liver, alcoholic hepatitis, fibrosis, and cirrhosis. Alcoholic liver disease (ALD) is a general term used to refer to this spectrum of alcohol-related liver injuries. Excessive or harmful alcohol use is ranked as one of the top five risk factors for death and disability globally and results in 2.5 million deaths and 69.4 million annual disability adjusted life years. All patients who present with clinical features of hepatitis or chronic liver disease or who have elevated serum elevated transaminase levels should be screened for an alcohol use disorder. The diagnosis of ALD can generally be made based on history, clinical and laboratory findings. However, the diagnosis of ALD can be clinically challenging as there is no single diagnostic test that confirms the diagnosis and patients may not be forthcoming about their degree of alcohol consumption. In addition, clinical findings may be absent or minimal in early ALD characterized by hepatic steatosis. Typical laboratory findings in ALD include transaminase levels with aspartate aminotransferase greater than alanine aminotransferase as well as increased mean corpuscular volume, gamma-glutamyltranspeptidase, and IgA to IgG ratio. In unclear cases, the diagnosis can be supported by imaging and liver biopsy. The histological features of ALD can ultimately define the diagnosis according to the typical presence and distribution of hepatic steatosis, inflammation, and Mallory-Denk bodies. Because of the potential reversible nature of ALD with sobriety, regular screening of the general population and early diagnosis are essential.
    World Journal of Gastroenterology 09/2014; 20(33):11684-11699. DOI:10.3748/wjg.v20.i33.11684 · 2.37 Impact Factor