Three Questions Can Detect Hazardous Drinkers

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Original Research

Three Questions Can Detect Hazardous Drinkers

J Fam Pract. 2001 April;50(4):313-320

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Patients

Patients were eligible for the study if they were in the waiting rooms of one of the clinic sites during the screening period, were approached by a research assistant in the waiting room, and agreed to answer the screening questionnaire. Screening of eligible patients occurred from October 1995 to December 1997.

Screening Instruments

In the primary care clinics, patients self-administered an 8-page survey consisting of questions about lifestyle habits. Research assistants approached as many patients in the waiting rooms of the primary care sites as possible. The survey included questions about stress management (8 questions), smoking habits (8), the AUDIT (10), and quantity-frequency questions (3). In initial surveys, just before the alcohol-related questions patients were instructed not to answer alcohol questions if they responded “never” to the following question: “How often do you have a drink containing alcohol (for example: beer, wine, wine coolers, sherry, gin, vodka, or other hard liquor)?” This question was removed in later surveys, because it limited the number of people responding to the alcohol instruments under comparison. We also asked for categorical responses to questions about age, sex, education background, race, marital status, and occupation. We did not compensate patients for completing this questionnaire, and their responses were anonymous.

Alcohol Screening Instruments

The AUDIT consists of 10 questions Figure 1. The AUDIT-C includes the following first 3 questions of the AUDIT: How often do you have a drink containing alcohol? How many drinks containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more drinks on one occasion? The AUDIT-3 is the third question alone. Each individual question is scored from 0 to 4 points on a Likert scale, with higher numbers indicating more severe drinking behavior. For AUDIT questions with only 3 possible answers (questions 9 and 10), the scores were 0, 2, and 4. Thus, the range of possible scores on the AUDIT are from 0 to 40, the AUDIT-C from 0 to 12, and the AUDIT-3 from 0 to 4.

Our quantity-frequency questionnaire consisted of the questions: “If you drink, how many days per week do you have a drink?” (answers: 1 through 7); “If you drink less than once a week, how many days per month do you drink?” (answers: 1 or less, 2, 3, or 4 or more); and “How many drinks containing alcohol do you have on a typical day when you are drinking?” (answers: 1 through 10 or more). The number of average drinks per week was computed for analysis, and if the answer was “or more” we used the maximum number indicated in the question (4 or 10).

Outcome Measures and Analysis

The main outcome measures concerned the accuracy of the full AUDIT, AUDITC, and AUDIT-3. For comparative purposes, patients with missing responses were not used in subsequent statistical analyses.

The AUDIT, AUDIT-C, and AUDIT-3 were compared with a hazardous drinking criterion defined by the quantity-frequency questions. This criterion was 16 or more drinks per week for men and 12 or more drinks per week for women.⁶ Clinically, quantity-frequency assessment is often used to determine hazardous drinking behavior.¹⁶ The area under the receiver-operating characteristic curve (AUROC) was used to compare each instrument’s diagnostic ability.³⁵ AUROC is an indication of the ability of a test to discriminate between false positives and false negatives. A score approaching 1 will be more sensitive and specific over a range of cutoff points than a score of 0.5, which is a nondiscriminating test. To calculate and compare the AUROCs we used published standards developed by Hanley and McNeil^36,37 for curves derived by same cases. We performed chi-square analysis on comparisons of categorical data.

We then compared the AUDIT-C and AUDIT-3 with a score of the full AUDIT as a criterion for hazardous drinking. An AUDIT result of 8 or higher was accepted as a criterion for hazardous drinking. We measured the sensitivity and specificity of the AUDIT-C, using a cutoff score of 3 or higher and AUDIT-3 cutoff score of 1 or higher compared with the criterion of hazardous drinking defined by the full AUDIT.³⁸

Results

At least 1 question on the screening survey was answered by 13,438 patients. Overall, 13,198 (98%) either answered that they currently drink or never drank alcohol. Not all questions were answered by each individual. Of patients who indicated that they currently drink alcohol, the full AUDIT was completed by 7035 (52%). The AUDIT-C was completed by 7190 (54%) patients, and the AUDIT-3 was answered by 7303 (54%) patients. Both the entire AUDIT and quantity-frequency questions were answered by 6954 (52%) patients. Of the 13,438 patients, 36% indicated no alcohol consumption. The majority of the surveyed sample were men, white, married, employed, high school graduates, and younger than 60 years Table 1.