Study Suggests Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
A National Commission on Prevention Priorities designated alcohol screening and brief alcohol interventions the third highest U.S. adult prevention priority. The VA healthcare system implemented routine screening for alcohol misuse in 2004, and since 2006 has required that the Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) be used for screening. Nationwide, more than 90% of VA outpatients are screened with the AUDIT-C, and rates of brief alcohol counseling in VA are increasing. The AUDIT-C has been validated when interviewer-administered – and when completed as a mailed questionnaire with results shared with primary care providers – but little is known about its performance when implemented as part of routine clinical care. This study evaluated the quality of clinical alcohol screening among 6,861 VA outpatients from 2007-2008 by comparing AUDIT-C results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Investigators also evaluated factors associated with discordance between the results of clinical and survey alcohol screens.
- Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings.
- Overall, 11% of Veterans screened positive on the survey screen vs. only 5.7% on the clinical screen.
- Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens.
- Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
- Mailed surveys may not be the optimal comparison standard, e.g. compared to in-depth interviews.
- The study sample was too small to evaluate facility-level variations. Also, data were not collected on alcohol screening procedures across VA networks, so investigators could not determine whether differences in alcohol screening implementation accounted for differences in discordance.
- Findings suggest that mandating the clinical use of a validated alcohol screening questionnaire may not ensure high-quality screening, and that many Veterans who could benefit from brief alcohol counseling are being missed.
This study was funded through VA’s Substance Use Disorders Quality Enhancement Research Initiative (SUD-QUERI). Dr. Bradley is co-Clinical Coordinator for SUD-QUERI.
Bradley K, Lapham G, Hawkins E, et al. Quality Concerns with Routine Alcohol Screening in VA Clinical Settings. Journal of General Internal Medicine September 22, 2010;e-pub ahead of print.