OBJECTIVE: We evaluated the Alcohol Use Disorders Identification Test (AUDIT), the first 3 questions of the AUDIT (AUDIT-C), the third AUDIT question (AUDIT-3), and quantity-frequency questions for identifying hazardous drinkers in a large primary care sample.
STUDY DESIGN: Cross-sectional survey.
POPULATION: Patients waiting for care at 12 primary care sites in western Pennsylvania from October 1995 to December 1997.
OUTCOMES MEASURED: Sensitivity, specificity, likelihood ratios, and predictive values for the AUDIT, AUDIT-C, and AUDIT-3.
RESULTS: A total of 13,438 patients were surveyed. Compared with a quantity-frequency definition of hazardous drinking (Ž16 drinks/week for men and Ž12 drinks/week for women), the AUDIT, AUDIT-C, and AUDIT-3 had areas under the receiver-operating characteristic curves (AUROC) of 0.940, 0.949, and 0.871, respectively. The AUROCs of the AUDIT and AUDIT-C were significantly different (P=.004). The AUROCs of the AUDIT-C (P <.001) and AUDIT (P <.001) were significantly larger than the AUDIT-3. When compared with a positive AUDIT score of 8 or higher, the AUDIT-C (score Ž3) and the AUDIT-3 (score Ž1) were 94.9% and 99.6% sensitive and 68.8% and 51.1% specific in detecting individuals as hazardous drinkers.
CONCLUSIONS: In a large primary care sample, a 3-question version of the AUDIT identified hazardous drinkers as well as the full AUDIT when such drinkers were defined by quantity-frequency criterion. This version of the AUDIT may be useful as an initial screen for assessing hazardous drinking behavior.
Hazardous drinkers consume enough alcohol to be at risk for adverse consequences but do not meet criteria for alcohol abuse or dependence. They are, however, are at risk for more harmful alcohol abuse.1-5 Such drinking behavior has been defined by quantity and frequency criteria.6 It is estimated that up to 20% of primary care patients are at least hazardous drinkers.7-9 Effective interventions to reduce alcohol consumption exist in primary care settings, so it is important for care providers to reliably and efficiently identify patients who are hazardous drinkers.1,10,11 Traditionally,12-14 care providers are poor at identifying such drinkers, and as many as 72% escape their detection.15-17 This ineffectiveness may be because of a lack of brief and simple questions that aid in patient identification.18-20
Formal screening instruments have been promoted to aid in identification of patients with alcohol problems. The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization (WHO) and consists of 2 distinct instruments: a 10-item AUDIT core questionnaire and a clinical screening procedure.1,9,21 The AUDIT core questions can detect hazardous drinkers and have been used alone as a screening instrument.22 The AUDIT questions address intake, dependence, and adverse consequences of drinking,23 emphasize drinking in the past year,5,24 and are indifferent to sex or ethnicity.4,25 It is most useful at detecting drinkers who do not meet criteria for alcohol abuse or dependence.26 Because of its ability to detect less severe alcohol drinkers, the AUDIT seems to have practical value in primary care settings.4,15,21,26
Because of trends toward shorter patient visits, the 10-question AUDIT may be too lengthy to be clinically useful in primary care settings.5,27,28 The shorter CAGE questionnaire, therefore, is often recommended for use in limited time situations.18,20 However, although the CAGE is a valuable tool for identifying alcohol abuse and dependence, it is not as useful for identifying less serious behaviors, such as hazardous drinking.5,28-32
A shorter version of the AUDIT may prove beneficial for use by the busy physician for identifying hazardous drinking behavior. The AUDIT-C (consisting of the first 3 questions of the AUDIT) was shown to be as effective as the full AUDIT in detecting hazardous drinking in a population of veterans.33 Also, the AUDIT-3 (the third question of the AUDIT) may be effective for identifying hazardous drinkers.5,34
We investigated the performance of the AUDIT, AUDIT-C, and AUDIT-3 in detecting such drinkers in a large primary care sample. We also compared the AUDIT-C and the AUDIT-3 to the full AUDIT. We hypothesized that the abbreviated instruments would be comparable with the AUDIT for detecting hazardous drinkers as defined by a quantity-frequency standard.
Methods
Design
We based our study on screening data obtained as part of a large randomized clinical trial of brief interventions for hazardous drinkers (the Early Lifestyle Modification [ELM] Study). Screening forms were administered at 12 primary care sites in the western Pennsylvania area from October 1995 to December 1997. The institutional review board at the University of Pittsburgh and equivalent review groups from each primary care setting approved the ELM study and screening protocol.
Setting
The 12 primary care sites included a Veterans Affairs Medical Center internal medicine clinic, a university-based internal medicine clinic, 2 university-affiliated community care clinics, 3 health maintenance organization clinics, 3 university-affiliated family medicine clinics, and 2 private practice family medicine clinics. All clinics were staffed by physicians. The Veterans Administration and university-based clinics had internal medicine residents participating in patient care. Also, physician assistants and nurse practitioners were involved with primary care at some sites.