ABSTRACT
BACKGROUND
Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings.
OBJECTIVE
The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results.
DESIGN
Cross sectional.
PARTICIPANTS
A national sample of 6,861 VA outpatients (fiscal years 2007–2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen).
MAIN MEASURES
Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens).
KEY RESULTS
Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks.
CONCLUSION
Use of a validated alcohol screening questionnaire does not—by itself—ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.
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REFERENCES
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596–607.
Room R, Babor T, Rehm J. Alcohol and public health. Lancet. 2005;365(9458):519–530.
Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–568.
Kaner E, Beyer F, Dickinson H, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2):CD004148.
Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2):143–152.
Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am. J. Manag. Care. 2006;12(10):597–606.
Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased documented brief alcohol interventions with a performance measure and electronic decision support. Med. Care. In Press.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol use disorders identification test. Arch Intern Med. 1998;158(16):1789–1795.
Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med. 2003;16(7):821–829.
Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208–1217.
Frank D, DeBenedetti AF, Volk RJ, Williams EC, Kivlahan DR, Bradley KA. Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups. J Gen Intern Med. 2008;23(6):781–787.
Aertgeerts B, Buntinx F, Ansoms S, Fevery J. Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Br J Gen Pract. 2001;51(464):206–217.
Rumpf HJ, Hapke U, Meyer C, John U. Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires. Alcohol Alcohol. 2002;37(3):261–268.
Hawkins EJ, Kivlahan DR, Williams EC, Wright SM, Craig T, Bradley KA. Examining quality issues in alcohol misuse screening. Subst Abus. 2007;28(3):53–65.
Goulet JL, Erdos J, Kancir S, et al. Measuring performance directly using the veterans health administration electronic medical record: a comparison with external peer review. Med Care. 2007;45(1):73–79.
Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med. 2006;21(Suppl 3):S26–S32.
Bradley KA, McDonell MB, Bush K, Kivlahan DR, Diehr P, Fihn SD. The AUDIT alcohol consumption questions: reliability, validity, and responsiveness to change in older male primary care patients. Alcohol Clin Exp Res. 1998;22(8):1842–1849.
Dybek I, Bischof G, Grothues J, et al. The reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a German general practice population sample. J Stud Alcohol. 2006;67(3):473–481.
Bradley KA, Williams EC, Achtmeyer CE, et al. Measuring performance of brief alcohol counseling in medical settings:a review of the options and lessons from the Veterans Affairs (VA) health care system. Subst Abus. 2007;28(4):133–149.
Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res. 2004;28(3):448–455.
Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcohol Clin Exp Res. 2007;31(3):443–451.
Harris AH, Bryson CL, Sun H, Blough D, Bradley KA. Alcohol screening scores predict risk of subsequent fractures. Subst Use Misuse. 2009;44:1055–1069.
Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Ann Intern Med. 2008;149(11):795–804.
Stata Statistical Software: Release Special Edition 11.1 [computer program]. College Station TX: Stata Corporation; 2007.
Kinder LS, Bryson CL, Sun H, Williams EC, Bradley KA. Alcohol screening scores and all-cause mortality in male Veterans Affairs patients. J Stud Alcohol Drugs. 2009;70(2):253–260.
McCambridge J, Day M. Randomized controlled trial of the effects of completing the Alcohol Use Disorders Identification Test questionnaire on self-reported hazardous drinking. Addiction. 2008;103(2):241–248.
Kypri K, Langley JD, Saunders JB, Cashell-Smith ML. Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking. Addiction. 2007;102(1):62–70.
Moos RH. Context and mechanisms of reactivity to assessment and treatment. Addiction. 2008;103(2):249–250.
Davis CG, Thake J, Vilhena N. Social desirability biases in self-reported alcohol consumption and harms. Addict. Behav. Nov 10 2009.
Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. 1998;13(6):379–388.
Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am. J. Manag. Care. 2009;15(9):e71–e87.
Helzer JE, Rose GL, Badger GJ, et al. Using interactive voice response to enhance brief alcohol intervention in primary care settings. J Stud Alcohol Drugs. 2008;69(2):251–258.
Babor TF, Stephens RS, Marlatt A. Verbal report methods in clinical research on alcoholism: response bias and its minimization. J Stud Alcohol. 1987;48:410–424.
Del Boca FK, Darkes J. The validity of self-reports of alcohol consumption: state of the science and challenges for research. Addiction. 2003;98(Suppl 2):1–12.
Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004;291(20):2466–2470.
Kaner E, Bland M, Cassidy P, et al. Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol. BMC Public Health. 2009;9:287.
Brown RL, Saunders LA, Bobula JA, Mundt MP, Koch PE. Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes. Alcohol Clin Exp Res. 2007;31(8):1372–1379.
Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 1999;159(16):1946–1952.
Willenbring ML. Medications to treat alcohol dependence: adding to the continuum of care. JAMA. 2007;298(14):1691–1692.
Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003–2017.
Acknowledgements
The authors greatly appreciate the VA Office of Quality and Performance for sharing their data for use in this study and feedback on several drafts of the manuscript.
The research reported here was supported by Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. The manuscript was specifically produced with support from the Veterans Affairs Substance Use Disorders Quality Enhancement Research Initiative (SUB 98-000). Data for this study were provided by the VA Office of Quality and Performance.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the University of Washington.
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None disclosed.
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Bradley, K.A., Lapham, G.T., Hawkins, E.J. et al. Quality Concerns with Routine Alcohol Screening in VA Clinical Settings. J GEN INTERN MED 26, 299–306 (2011). https://doi.org/10.1007/s11606-010-1509-4
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DOI: https://doi.org/10.1007/s11606-010-1509-4