Jeffrey R. Steinbauer

Ethnic and Sex Bias in Primary Care Screening Tests for Alcohol Use Disorders

Alcohol use is the third leading cause of preventable death in the United States [1], and alcohol-related morbidity is substantial [2]. For many persons with alcohol problems, a primary care provider is the first contact with the health care system [3]. Unfortunately, the problem often goes unrecognized until it has had significant consequences for physical health [4]. Many professional organizations recommend questioning patients about alcohol use [5-7]. The routine use of biochemical markers as the primary method for screening for alcohol problems in asymptomatic patients is discouraged by the U.S. Preventive Services Task Force because the accuracy of such tests is poor compared with that of self-report measures [6]. Many self-report screening tests have been developed to help identify patients with alcohol use disorders. Nevertheless, concern is growing over the lack of validation of these tests in patients who are female, elderly, or nonwhite [8]. Concerns about potential ethnic and sex bias in screening accuracy are particularly important because patterns of alcohol use [9, 10], the prevalence of alcohol use disorders [11, 12], and the consequences of alcohol consumption [2, 13] vary in men and women from different ethnic backgrounds in the United States. We tested for bias in the accuracy of three common self-report screening tests across sex and ethnic subgroups of primary care patients. The CAGE questionnaire was selected for evaluation because it is one of the most widely used screening tests for alcoholism. It was developed originally to identify the hidden alcoholic in hospital settings [14] and has also been evaluated in primary care settings [15, 16]. We also selected the Self-Administered Alcoholism Screening Test (SAAST), a self-administered version of the Michigan Alcoholism Screening Test, for evaluation (Appendix Figure 1). The SAAST was developed to screen for alcoholism in general medical patients and is available in a 9-item version with response options in a yes/no format. The final instrument selected for evaluation was the Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization [17] (Appendix Figure 2). The 10-item AUDIT was developed to detect persons with early alcohol use problems who do not necessarily meet the diagnostic criteria for alcohol dependence. In our study, the criterion variable was a current alcohol use disorder, including alcohol abuse and alcohol dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) [18]. Recommended methodologic standards for evaluating diagnostic tests guided this analysis [19]. Appendix Figure 1. Appendix Figure 2. Methods Patients and Procedures Participants were adult primary care patients presenting to the Family Practice Center at the University of Texas Medical Branch, Galveston, Texas. This family medicine clinic, which is a residency-training site, serves an ethnically diverse community and has an annual patient-visit volume in excess of 30 000; the patients are a mix of privately insured, managed care, Medicaid, Medicare, and uninsured patients. Faculty and resident practices are located at the Center, which has approximately 12 faculty physicians and 20 resident providers. The sampling strategy was designed to ensure adequate representation of minority and female patients. Adult family medicine patients were randomly selected from the Family Practice Center appointment lists. For each clinic session, a patient was selected at random by using a table of random numbers from among those patients who had appointment times within the first 60 minutes of the session. Thereafter, patients were selected according to appointment time at fixed intervals (for example, 45 minutes after the previously selected patient) to allow for a manageable flow of patients through the interview process. Patients were contacted about participating in the study by telephone on the day before their scheduled appointments. Patients who could not be reached by telephone (30%) were approached directly in the clinics waiting area on the day of their appointment. If a patient refused to participate in the study, the next patient on the appointment schedule was approached. Sampling continued until at least 100 men and 250 women in each ethnic group had participated. The sampling strategy is described in more detail elsewhere [20]. Data were collected between October 1993 and December 1994. While waiting to see their physicians, patients completed self-report questionnaires that included questions about sociodemographic indicators and the SAAST. After their office visits, patients participated in an interview that was administered by project interviewers and included the CAGE questionnaire, the AUDIT, and a diagnostic schedule used to determine the presence of an alcohol use disorder. Interviewers were not given the results of the diagnostic interview, which was scored by computer algorithm after the questionnaire and interview had been completed. All study materials were translated into Spanish, and Spanish-speaking interviewers were used with Mexican-American patients (30 patients selected Spanish administration). Patients were reimbursed

Item bias in the CAGE screening test for alcohol use disorders.

10 for their time. Written informed consent was obtained from each patient, and the project was approved by our institutional review board. Instruments CAGE The acronym CAGE represents four brief questions: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? The CAGE was developed as a device to screen for alcoholism in hospital settings, where high rates of alcohol abuse are often seen [14]. It is also widely used in clinical settings and community-based studies and is considered an indirect measure of alcoholism because it addresses the consequences of drinking (with the exception of the eye-opener question) rather than alcohol consumption per se [21]. The CAGE can be used during the clinical interview (self-administered) or as part of a broader assessment of alcohol use (as was done in this study). A yes answer to two or more questions is generally considered a positive result [21], although an approach that uses likelihood ratios has also been proposed [15]. The time frame for the CAGE is lifetime. Self-Administered Alcoholism Screening Test The SAAST [22-24] is a modified, self-administered version of the Michigan Alcoholism Screening Test. In our study, we used the 9-item version of the SAAST (completed by patients before the diagnostic interview) because its reduced length is more amenable to primary care settings [25]. The Michigan Alcoholism Screening Test is a structured, 25-item questionnaire that has been used to detect alcoholism in many groups, including persons suspected of driving while under the influence of alcohol [26]. The 9-item version of the SAAST was developed for use in medical settings and has shown consistency in U.S. and Mexican samples [27]. Three items are similar to the annoyed, eye-opener, and cut down questions from the CAGE; the rest address the consequences of drinking and indicators of dependence. The instrument is scored by summing responses to the questions (the annoyed and cut-down questions each receive a weight of 2, and all others receive a weight of 1), and a score of 3 or more is considered a positive result [25]. The time frame for the SAAST is lifetime. Alcohol Use Disorders Identification Test The AUDIT is a 10-item, self-report screening test that identifies patients at risk for alcohol use disorders by using procedures appropriate for the variety of health care facilities in developed and developing counties [17, 28, 29]. The AUDIT was developed by the World Health Organization (WHO) for the express purpose of avoiding ethnic and cultural bias. An extensive, multinational instrument development study of primary health care patients was coordinated by WHO (the WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption) to eliminate such bias [17]. The AUDIT has three important advantages over other screening tests: It 1) identifies at-risk alcohol users who do not meet criteria for alcohol dependence, 2) includes both consumption-based indicators of alcohol problems and indicators of harmful use and dependence, and 3) uses both current (defined as within the past month) and lifetime time frames. Response options range from 0 to 4, and a positive result is a score of 8 or more [28] (alternative cut-points and approaches using likelihood ratios have been suggested [20, 30, 31]). The instrument can be self-administered or given orally (as was done in our study). Alcohol Use Disorders Diagnostic Schedule The patient interview included the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS), a structured diagnostic schedule developed for use in the National Longitudinal Alcohol Epidemiologic Survey, which was started in 1992 by the National Institute on Alcohol Abuse and Alcoholism [32]. The AUDADIS has shown reliability in clinical and general population studies, applicability for cross-cultural research, and concordance with other diagnostic instruments [33-36]. It was designed to be administered by trained lay interviewers, as was done in our study. We used the AUDADIS Alcohol Experiences module to determine the presence of alcohol abuse or dependence according to the DSM-IV criteria [18]. Alcohol dependence, as defined by DSM-IV, is a maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by three or more of the following criteria: increased tolerance, withdrawal, impaired control, neglect of activities, increased time spent drinking, and drinking despite problems.

Stress perceptions in community clinic: a pilot survey of patients and physicians.

ObjectiveTo explore potential item bias in the CAGE questions (mnemonic for cut-down, annoyed, guilty, and eyeopener) when used to screen for alcohol use disorders in primary care patients.Design and settingCross-sectional study, conducted in a university-based, family practice clinic, with the presence of an alcohol use disorder determined by structured diagnostic interview using the Alcohol Use Disorder and Associated Disabilities Interview Schedule.PatientsA probability sample of 1,333 adult primary care patients, with oversampling of female and minority (African-American and Mexican-American) patients.Main resultsUnadjusted analyses showed marked differences in the sensitivity and specificity of each CAGE question against a lifetime alcohol use disorder, across patient subgroups. Women, Mexican-American patients, and patients with annual incomes above

Geriatric Care Issues: An American and an International Perspective

40,000 were consistently less likely to endorse each CAGE question “yes”, after adjusting for the presence of an alcohol use disorder and pattern of alcohol consumption. In results from logistic regression analyses predicting an alcohol use disorder, cut-down was the only question retained in models for each of the subgroups. The guilty question did not contribute to the prediction of an alcohol use disorder; annoyed and eye-opener were inconsistent predictors.ConclusionsDespite its many advantages, the CAGE questionnaire is an inconsistent indicator of alcohol use disorders when used with male and female primary care patients of varying racial and ethnic backgrounds. Gender and cultural differences in the consequences of drinking and perceptions of problem alcohol use may explain these effects. These biases suggest the CAGE is a poor “rule-out” screening test. Brief and unbiased screens for alcohol use disorders in primary care patients are needed.

The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different racial/ethnic backgrounds

This pilot survey of 103 patients and 17 physicians in an urban family medicine clinic gathered information pertinent to the design of a feasible stress intervention for patients bothered by stress, but who did not have a psychiatric diagnosis. Among patients, 45% reported being excessively bothered by stress in the preceding month, with the chief stressors being job (70 reporting), financial worries (58%) and family concerns (50%). Patients reported a variety of problems perceived to be related to stress, such as headaches, insomnia, eating control, and gastrointestinal symptoms. Although about 80% reported using positive coping methods (e.g., talking, exercising, and relaxing), 42% reported using alcohol, and 10% used non-prescribed drugs to cope with stress. Only 37% of patients had sought help for stress from their physician. The wide variety of responses from the physicians reflected a lack of standardized approaches, inadequate training, and a reluctance to engage patients about their stress problems. About 42% of the physicians reported routinely asking patients about stress, and 77% felt that dealing with patient stress was a significant burden on their practice of medicine. Overall, the findings indicate that opportunities are being missed for helping patients to deal with stress constructively, and that a standardized stress self-management program might be one solution.

Alcohol use disorders, consumption patterns, and health-related quality of life of primary care patients

As the global population ages, there is an opportunity to benefit from the increased longevity of a healthy older adult population. Healthy older individuals often contribute financially to younger generations by offering financial assistance, paying more in taxes than benefits received, and providing unpaid childcare and voluntary work. Governments must address the challenges of income insecurity, access to health care, social isolation, and neglect that currently face elderly adults in many countries. A reduction in disparities in these areas can lead to better health outcomes and allow societies to benefit from longer, healthier lives of their citizens.