Screening for problem drinking: Impact on physician behavior and patient drinking habits

Section of General Internal Medicine, VA Pittsburgh Health Care System, Center for Research on Healthcare, University of Pittsburgh, PA 15240, USA.
Journal of General Internal Medicine (Impact Factor: 3.45). 05/1998; 13(4):251-6. DOI: 10.1046/j.1525-1497.1998.00075.x
Source: PubMed


To assess the effect of a screen for problem drinking on medical residents and their patients.
Descriptive cohort study.
Veterans Affairs Medical Clinic.
Patients were screened 2 weeks before a scheduled visit (n = 714). Physicians were informed if their patients scored positive.
Physician discussion of alcohol use was documented through patient interview and chart review. Self-reported alcohol consumption was recorded. Of 236 current drinkers, 28% were positive for problem drinking by the Alcohol Use Disorders Identification Test (AUDIT). Of 58 positive patients contacted at 1 month, 78% recalled a discussion about alcohol use, 58% were advised to decrease drinking, and 9% were referred for treatment. In 57 positive patient charts, alcohol use was noted in 33 (58%), and a recommendation in 14 (25%). Newly identified patients had fewer notations than patients with prior alcohol problems. Overall, 6-month alcohol consumption decreased in both AUDIT-positive and AUDIT-negative patients. The proportion of positive patients who consumed more than 16 drinks per week (problem drinking) decreased from 58% to 49%. Problem drinking at 6 months was independent of physician discussion or chart notation.
Resident physicians discussed alcohol use in a majority of patients who screened positive for alcohol problems but less often offered specific advice or treatment. Furthermore, residents were less likely to note concerns about alcohol use in charts of patients newly identified. Finally, a screen for alcohol abuse may influence patient consumption.

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Available from: Joseph Conigliaro, Sep 11, 2014
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    • "Sensitivity, specificity, and positive and negative predictive values [21] of each score on the AUDIT-C and AUDIT-3 were calculated, relative to cutoff scores on the 10-item AUDIT, as follows: at-risk drinkers (score ≥ 8); high-risk drinkers (score ≥ 13); and likely dependent drinkers (score ≥ 20) [5,8,11]. For this study, sensitivity is the proportion of respondents identified as problem drinkers on the 10-item AUDIT who are also identified as problem drinkers on AUDIT-C and/or AUDIT-3. "
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    ABSTRACT: Background The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item alcohol screener that has been recommended for use in Aboriginal primary health care settings. The time it takes respondents to complete AUDIT, however, has proven to be a barrier to its routine delivery. Two shorter versions, AUDIT-C and AUDIT-3, have been used as screening instruments in primary health care. This paper aims to identify the AUDIT-C and AUDIT-3 cutoff scores that most closely identify individuals classified as being at-risk drinkers, high-risk drinkers, or likely alcohol dependent by the 10-item AUDIT. Methods Two cross-sectional surveys were conducted from June 2009 to May 2010 and from July 2010 to June 2011. Aboriginal Australian participants (N = 156) were recruited through an Aboriginal Community Controlled Health Service, and a community-based drug and alcohol treatment agency in rural New South Wales (NSW), and through community-based Aboriginal groups in Sydney NSW. Sensitivity, specificity, and positive and negative predictive values of each score on the AUDIT-C and AUDIT-3 were calculated, relative to cutoff scores on the 10-item AUDIT for at-risk, high-risk, and likely dependent drinkers. Receiver operating characteristic (ROC) curve analyses were conducted to measure the detection characteristics of AUDIT-C and AUDIT-3 for the three categories of risk. Results The areas under the receiver operating characteristic (AUROC) curves were high for drinkers classified as being at-risk, high-risk, and likely dependent. Conclusions Recommended cutoff scores for Aboriginal Australians are as follows: at-risk drinkers AUDIT-C ≥ 5, AUDIT-3 ≥ 1; high-risk drinkers AUDIT-C ≥ 6, AUDIT-3 ≥ 2; and likely dependent drinkers AUDIT-C ≥ 9, AUDIT-3 ≥ 3. Adequate sensitivity and specificity were achieved for recommended cutoff scores. AUROC curves were above 0.90.
    Full-text · Article · Sep 2014 · Addiction science & clinical practice
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    • "suggesting that clinicians document perceived problem drinking in less than 25% of cases. Significant underdocumentation of alcohol disorders has been noted in several other previous studies [15,44,45], pointing out an important methodological flaw in many previous studies which have presumed that problem drinkers are "undiagnosed" based on chart review data [9-12]. This finding suggests that future studies assessing clinician recognition and intervention rates should utilize more sensitive measures such as clinician or patient exit interviews or direct observation, and that future training efforts should address documentation of alcohol disorders in the medical record. "
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    ABSTRACT: Many hazardous and harmful drinkers do not receive clinician advice to reduce their drinking. Previous studies suggest under-detection and clinician reluctance to intervene despite awareness of problem drinking (PD). The Healthy Habits Project previously reported chart review data documenting increased screening and intervention with hazardous and harmful drinkers after training clinicians and implementing routine screening. This report describes the impact of the Healthy Habits training program on clinicians' rates of identification of PD, level of certainty in identifying PD and the proportion of patients given advice to reduce alcohol use, based on self-report data using clinician exit questionnaires. 28 residents and 10 faculty in a family medicine residency clinic completed four cycles of clinician exit interview questionnaires before and after screening and intervention training. Rates of identifying PD, level of diagnostic certainty, and frequency of advice to reduce drinking were compared across intervention status (pre vs. post). Findings were compared with rates of PD and advice to reduce drinking documented on chart review. 1,052 clinician exit questionnaires were collected. There were no significant differences in rates of PD identified before and after intervention (9.8% vs. 7.4%, p = .308). Faculty demonstrated greater certainty in PD diagnoses than residents (p = .028) and gave more advice to reduce drinking (p = .042) throughout the program. Faculty and residents reported higher levels of diagnostic certainty after training (p = .039 and .030, respectively). After training, residents showed greater increases than faculty in the percentage of patients given advice to reduce drinking (p = .038), and patients felt to be problem drinkers were significantly more likely to receive advice to reduce drinking by all clinicians (50% vs. 75%, p = .047). The number of patients receiving advice to reduce drinking after program implementation exceeded the number of patients felt to be problem drinkers. Recognition rates of PD were four to eight times higher than rates documented on chart review (p = .028). This program resulted in greater clinician certainty in diagnosing PD and increases in the number of patients with PD who received advice to reduce drinking. Future programs should include booster training sessions and emphasize documentation of PD and brief intervention.
    Full-text · Article · Dec 2005 · BMC Family Practice
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    • "The mixed reports regarding the detrimental effects and potential benefits of alcohol use may confuse clinicians who debate whether to recommend reduction in consumption for older adults who do not meet criteria for abuse/dependence and, perhaps, even for those who do. Conigliaro et al. (1998) surveyed patients in all age groups who were identified as " problem drinkers " and recently had a primary care visit. The majority of the patients remembered having a discussion with their doctor about drinking, but only half remembered being advised to reduce consumption . "
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    ABSTRACT: Suicide is among the leading causes of death in the United States, ranking 10th to 12th annually, depending on the year. Rates of suicide increase markedly among Americans over age 75, especially among white men. After age 85, rates are >5-fold higher in this group than in the general population. The relationship between alcohol use and later-life suicide is complex and currently ill defined. Substance use disorders, particularly alcohol abuse and dependence, are the second most common category of axis I disorders associated with completed suicide among adults aged 65 and older, following only depression. The co-occurrence of alcohol use disorders and depression heightens suicide risk. Most studies that have evaluated the effects of alcohol in geriatric suicide have focused on older adults who met DSM criteria for abuse and/or dependence. However, the majority of older adults who are experiencing problems related to their alcohol use do not meet alcohol abuse/dependence criteria. Therefore, the role of at-risk and problem alcohol use in geriatric suicide may be underestimated. Drinking among elders elevates suicide risk through interactions with other factors that are more prevalent in this age group, such as depressive symptoms, medical illness, negatively perceived health status, and low social support. This article reviews the literature related to alcohol use and suicide among older adults. Clinical and research recommendations for addressing this problem are also presented.
    Preview · Article · May 2004 · Alcoholism Clinical and Experimental Research
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