David G. Buchsbaum

Screening for Alcohol Abuse Using CAGE Scores and Likelihood Ratios

OBJECTIVE To assess the performance of the CAGE (acronym referring to four questions, see below) questionnaire in discriminating between medicine outpatients with and without an alcohol abuse or dependence disorder. DESIGN A cross-sectional design of a sample of consecutive patients who received both the alcohol module of the diagnostic interview schedule and the CAGE (Cut down, Annoyed, Guilty, Eye-opener) screening questionnaire. SETTING The outpatient medical practice of an urban university teaching hospital. PATIENTS All patients 18 years or older who signed a consent form approved by the universitys institutional review board. MEASUREMENT Calculation of the sensitivity, specificity, receiver operating characteristic (ROC) curve, and likelihood ratio for CAGE scores of 0 to 4. RESULTS Thirty-six percent of the sample group met criteria for a history of alcohol abuse or dependence. A CAGE score of 2 or more was associated with a sensitivity and specificity of 74% and 91%. The calculated area under the ROC curve was 0.89, whereas the likelihood ratios for CAGE scores of 0 to 4 were 0.14, 1.5, 4.5, 13, and 100, respectively. These ratios were associated with posterior probabilities for an abuse or dependence disorder of 7%, 46%, 72%, 88%, and 98%, respectively. CONCLUSION Clinicians can improve their ability to estimate a patients risk for an alcohol abuse or dependence disorder using likelihood ratios for CAGE scores.

Screening for Drinking Disorders in the Elderly Using the CAGE Questionnaire

To assess the performance of the CAGE questionnaire in identifying elderly medicine outpatients with drinking problems.

Physician detection of drinking problems in patients attending a general medicine practice

Objective:To assess the patient and physician characteristics that influence physicians’ detection of problem drinking in their medical patients.Setting:The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents.Design:Cross-sectional study of a rendomly chosen subsample of consecutive patients.Measurement:Univariate and multivariate analysis with calculated adjusted odds ratios of factors associated with physician detection of drinking problems. A problem was diagnosed according to the patient’s results on the alcohol module of the Diagnostic Interview Schedule (DIS).Results:Physicians detected 22% of 189 presumably inactive problems and 49% of 92 current problems, i.e., those that have occurred within the preceding year. Multivariate correlates of detection of active problems included male patient gender, presence of gastrointestinal complications of excessive drinking, number of concurrent medical disorders, and previous medical record reference to alcohol (p<0.05). Physician gender and year of training were not associated with detection.Conclusion:Our physicians appear to rely on specific patient characteristics as well as the patient’s medical record to detect drinking problems in their ambulatory patients. Their reliance upon these factors may hinder their detection of drinking problems in women patients and less seriously impaired individuals.

Why physicians don't pursue abnormal laboratory tests: an investigation of hypercalcemia and the follow-up of abnormal test results.

For unknown reasons, physicians often ignore unsolicited clinical data. This is thought to impair the quality of medical care and the efficacy of screening programs. To investigate this problem the authors followed 156 consecutive hypercalcemic patients for nine to 15 months. Twenty-eight were lost to follow-up, and the hypercalcemia was ignored in 26. Calcium tests were repeated for 102, and hypercalcemia was confirmed in 53. Of these, 39 were and 14 were not further investigated. Analysis by logistic regression revealed a highly significant relationship between the degree of hypercalcemia and the likelihood that calcium testing would be repeated or that abnormal levels would be further investigated. The authors conclude that, contrary to common opinion, when physicians ignore abnormal laboratory values they are making complex clinical judgments based on the degree of abnormality, the likelihood that further investigation will affect therapy, and the cost of the risk associated with further investigation. Evaluation and attempts to modify this behavior should take into account the complexity of these decisions.

House officer attitudes, beliefs, and recording behavior associated with prescribing minor tranquilizers

Because benzodiazepines are frequently and often inappropriately prescribed by internists, we wished to examine the attitudes, beliefs, and recording behavior of internal medicine house staff who prescribe these medications to patients attending a general medicine clinic. Over a 5‐month period, we reviewed the medical records of patients prescribed both a benzodiazepine and a nonbenzodiazepine for clinical information related to prescribing these medications. At the close of the collection, all house staff completed a series of 12 questions about the management and treatment of hypertension and anxiety. Forty‐five house staff were included in our study. As a group, these house staff omitted information significantly more often for benzodiazepines than for nonbenzodiazepines and endorsed attitudes that were significantly less favorable toward prescribing the former. In summary, inconsistency in house officer recording of benzodiazepine prescriptions can be explained in part by their unfavorable attitudes t...

Underdocumentation of benzodiazepine prescriptions in a general medicine clinic

During a three-month period the authors reviewed the charts of patients prescribed benzodiazepine and non-benzodiazepine medications by 73 housestaff practicing in an ambulatory medical clinic. Compared with non-benzodiazepine prescriptions, benzodiazepine name (p<0.001), instructions (p<0.001), and targeted problems (p<0.0001) were significantly underrectorded. In 11% of the records reviewed there was no indication that a mood disorder had been identified or a benzodiazepine prescribed (p<0.0001). Problems targeted for benzodiazepine management were found less frequently in the records of elderly patients than in those of patients <65 years of age (p<0.05). The authors conclude that many houseofficers significantly underdocument the prescriptions they write for benzodiazepine medications and that this may be a marker of their regard for managing mood disorders with benzodiazepines.