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Rapid Responses: Rapid Responses published:
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underutilization of the screening tools for alcohal use disorders in primary care practices.
- Dr Rajan Chawla (23 February 2006)
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Selection Bias was major limitation
- Rahul Rao (3 March 2006)
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Can I buy it??
- Declan P Fox (4 March 2006)
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AUDIT questionaire
- Bhupendra Patel, CF48 3LU (5 March 2006)
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Does routine alcohol screening lead to change in behaviour?
- Graham Lane (5 March 2006)
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Screen and screen and screen until I'm sick
- Bhanuprakash Kolla, Andrew J.McBride (17 March 2006)
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Opportunistic screening and the NHS
- Bhanu Kolla (18 March 2006)
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AUDIT once again
- Anders Beich (2 May 2006)
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Dr Rajan Chawla, clinical attache,dept of psychiatry city hospital,dept of psychiatry,hucknall road,nottingham,
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Dear Editor,I appreciate your research on the screening of alcohal use problems in primary care setup. Primary care practitioners are in a unique position to identify patients with potential alcohol problems and intervene when appropriate. Screening, the process by which practitioners can identify at-risk drinkers, can be followed by one-time or repeated short counseling sessions, known as brief interventions, which are designed to help the patient reduce drinking and minimize related problems. Varied levels of screening and brief intervention can be implemented in the primary care setting, depending on patient and physician factors. Although screening and brief intervention are valuable tools, they are underutilized in primary care practices. Strategies that may help increase physicians' use of these techniques in the primary care setting include skills-based role-playing, performance feedback, clinical protocols, clinic-based education, and training by credible experts. Some long-term objectives or expectations that would hopefully include making screening and brief intervention part of health care systems; helping people with potential alcohol problems recognize the value of early intervention; reducing the stigma associated with alcohol problems;raising the profile of alcohol problems in health practice, policy making and the media; making it easy and meaningful for people to seek help for alcohol problems; and mobilizing partners, e.g. NGOs and religious groups to work on alcohol problems collaboratively. References; world heath organisation review. Competing interests: None declared |
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Rahul Rao, Consultant/Senior Lecturer York Clinic, Guy's Hospital, London SE1
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Dear Editor In the brave new world of a National Health Service where 'value for money' is tantamount, the authors are to be commended for their methodology in using a number of valid clinical outcome measures for alcohol misuse and dependence and comparing these to more traditional biochemical variables that are commonly used in both primary and secondary care. However, some caution is required in interpreting the results in light of the methodology. Firstly, as the AUDIT is made up of questions that assess aspects of alcohol use such as quantity/frequency and dependence, it is hardly surprising that its internal validity when measured against outcomes such as binge drinking and alcohol dependence is high in ROC analyses. In fact, a more clinically meaningful outcome parameter that may of more relevance to primary care would be the presence of problems consequent upon drinking, which could have been ascertained using a rating scale such as the Drinking Problems Index (1). Secondly, the selection of male drinkers is a major source of bias, as it is known that traditional screening tools such as the AUDIT show low sensitivity in detecting alcohol misuse in women (2)and older people (3). This study would need further replication is both these populations, as well as in inner-city areas where populations show greater cultural diversity. Although a major contribution to detection and screening of alcohol use disorders in primary care, clinicians should be mindful of the wider population, otherwise the general public may be misinformed in the same way as they have with the public health message of alcohol and cardioprotection, which, again, only applies to a section of the population. REFERENCES (1) Finney, J.W., Moos, R.H. & Brennan, P.L. The Drinking Problems Index: A measure to assess alcohol-related problems among older adults. J Subst Abuse 1991;3:395-404 (2) Arndt, S., Schultz, S.K., Turvey, C., Petersen, A. Screening for Alcoholism in the Primary Care Setting: Are We Talking to the Right People? J Fam Prac 2002;51:41-6. (3) Morton, J.L., Jones, T.V., Manganaro, M.A. Performance of alcoholism screening questionnaires in elderly veterans. Am J Med 1996;101:153–159. Competing interests: None declared |
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Declan P Fox, Freelance physician N Ireland, Scotland, Canada
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The AUDIT questionnaire sounds good. Where can I find it? Do I buy it? How much? Could this sort of information be made more readily available? Declan Fox Competing interests: None declared |
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Bhupendra Patel, General Practitioner Merthyr Tydfil, CF48 3LU
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As a General Practitioner, I am quite interested in the conclusion of this research but as as opportunistic reader, I could not find the details of The Alcohol Use Disorders Identification Test questionnaire ( AUDIT questionaire/screening test) in the reference of the printed article nor in the eBMJ. It would be more appropriate if these details are provided as it will help many GPs like myself to start implementing the conclusion from this research. Incidently, I managed to get the details by conducting a 'Google' search and now am in posssesion of the 10 AUDIT questions. Competing interests: None declared |
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Graham Lane, Service Director Central Coast Youth Health Service, Northern Sydney Central Coast Health, Wyong NSW 2259, Australia
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How effective is routine screening in leading to change in behaviour, with reduced or ceased alcohol use? How sustained is this change? How effective is it in work with young people less than 18 years of age? Competing interests: None declared |
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Bhanuprakash Kolla, Senior House Officer SCAS Rectory Centre, Rectory Road, Oxford OX4 1BU, Andrew J.McBride
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Dear Editor Opportunistic screening for alcohol use disorders in primary care: comparative study Simon Coulton, Colin Drummond, Darren James, Christine Godfrey, J Martin Bland, Steve Parrott, Timothy Peters the Stepwice Research Team BMJ 2006; 332: 511-517 This interesting study confirms that questions are better than tests for identifying alcohol related risk. As presented it raises a number of issues. The authors do not describe or discuss the number of patients who were offered a questionnaire but declined to fill it in or failed to complete it. A second linked issue is the information provided to the participants. The number of honestly and satisfactorily completed forms returned will have been inflated if the participants were told that the information was confidential and for research purposes only, as distinct from screening information that might lead the GP to take some action (1). A further methodological problem is that the research interviewers who established the diagnosis of alcohol dependence were already aware of the participants’ alcohol consumption, which may have biased their assessments. The authors’ final assertion, that the NHS should consider routine alcohol screening of all attendees in primary care, is not a question that can legitimately be addressed by the study. GPs willing to take part in such research are sceptical (2), and we know of no alcohol screening study in primary care where the screening outlived the researchers’ presence. AM spoke recently, on this very subject, with an audience of more than 100 UK GPs, many of whom show a practical interest in addiction work through shared care, and not one supported the idea of alcohol screening. REFERENCES (1) Angove, R. and McBride, A. J. Swimming upstream: how and why alcohol misuse screening and intervention using the AUDIT can have limited impact in primary care Journal of Substance Use 2001; 6: 670-74 (2) Beich, A., Gannik, D. and Malterud, K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners British Medical Journal 2002; 325: 870 COMPETING INTEREST None Bhanu Kolla Senior House Officer Andrew McBride Consultant Psychiatrist Specialist Community Addictions Service,
The Rectory Centre,
Rectory Road,
Oxford
OX4 1BU
Competing interests: None declared |
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Bhanu Kolla, Senior House Officer-Addiction Psychiatry City Clinic,Oxford,OX4 1BU
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Dear Editor Opportunistic screening for alcohol use disorders in primary care: comparative study Simon Coulton, Colin Drummond, Darren James, Christine Godfrey, J Martin Bland, Steve Parrott, Timothy Peters the Stepwice Research Team The stepwice research team tell us in their discussion that they recognise that their study is limited by its focus on male attendees only. But another important limitation which is the number of patients who were offered the questionnaire, the number who refused to complete it and if they were significantly different form those who did is not made clear. The other important point is if the male attendees were informed of the purpose of the questionnaire and were informed of the possibility of a more detailed assessment at a later date. This has been shown to affect the numbers declining to fill it out, returning it and what they say in it (1). The research team, which established the diagnosis of alcohol dependence by the composite international diagnostic interview was already aware of their alcohol status, as they were the ones administering the timeline, follow back. Their final comments that the NHS should consider routine screening of all attendees in primary care, though well accepted is not supported by the results of the study. (1) R.Angove and A.J.McBride, Swimming upstream: how and why alcohol misuse screening and intervention using the AUDIT can have limited impact in primary care 2001; 670-74 Competing interests: None declared |
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Anders Beich, Dr Research Unit for General Practice, University of CPH, DK-1014 Copenhagen K
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Editor, The AUDIT questionnaire is once again promoted for alcohol screening in health care. It is found to be better for identifying hazardous drinking than some laboratory tests that are aimed at identifying consequences / impact rather than risk. No big surprise. The content of the paper by Coulton et al. does in no way support their statement: “Routine screening of all attendees in primary care should be considered throughout the NHS”. No reliable evidence is supporting that screening should be a productive way to identify unhealthy drinking in the health care system. In the primary health care setting we found screening by use of AUDIT to be detrimental to the GPs ability to establish rapport with the patient subsequently (1). Anders Beich (1) Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ 2002; 325: 870-2 Competing interests: None declared |
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