Hostname: page-component-788cddb947-tr9hg Total loading time: 0 Render date: 2024-10-08T21:42:02.365Z Has data issue: false hasContentIssue false

Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis

Published online by Cambridge University Press:  02 January 2018

Alex J. Mitchell*
Affiliation:
Department of Psycho-oncology, Leicester Partnership Trust and Department of Cancer Studies & Molecular Medicine, Leicester Royal Infirmary, Leicester
Nick Meader
Affiliation:
National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research Unit, London and CORE, University College London, Research Department of Clinical, Educational and Health Psychology, London
Vicky Bird
Affiliation:
National Collaborating Centre for Mental Health, London, UK
Maria Rizzo
Affiliation:
National Collaborating Centre for Mental Health, London, UK
*
Alex J. Mitchell, Leicester General Hospital, Leicester Partnership Trust, Leicester LE5 4PW, UK. Email: alex.mitchell@leicspart.nhs.uk
Rights & Permissions [Opens in a new window]

Abstract

Background

Clinicians have considerable difficulty identifying and helping those people with alcohol problems but no previous study has looked at this systematically.

Aims

To determine clinicians' ability to routinely identify broadly defined alcohol problems.

Method

Data were extracted and rated by two authors, according to PRISMA standard and QUADAS criteria. Studies that examined the diagnostic accuracy of clinicians' opinion regarding the presence of alcohol problems as well as their written notation were evaluated.

Results

A comprehensive search identified 48 studies that looked at the routine ability of clinicians to identify alcohol problems (12 in primary care, 31 in general hospitals and 5 in psychiatric settings). A total of 39 examined alcohol use disorder, 5 alcohol dependence and 4 intoxication. We separated studies into those using self-report and those using interview. The diagnostic sensitivity of primary care physicians (general practitioners) in the identification of alcohol use disorder was 41.7% (95% CI 23.0–61.7) but alcohol problems were recorded correctly in only 27.3% (95% CI 16.9–39.1) of primary care records. Hospital staff identified 52.4% (95% CI 35.9–68.7) of cases and made correct notations in 37.2% (95% CI 28.4–46.4) of case notes. Mental health professionals were able to correctly identify alcohol use disorder in 54.7% (95% CI 16.8–89.6) of cases. There were limited data regarding alcohol dependency and intoxication. Hospital staff were able to detect 41.7% (95% CI 16.5–69.5) of people with alcohol dependency and 89.8% (95% CI 70.4–99.4) of those acutely intoxicated. Specificity data were sparse.

Conclusions

Clinicians may consider simple screening methods such as self-report tools rather than relying on unassisted clinical judgement but the added value of screening over and above clinical diagnosis remains unclear.

Type
Review Article
Copyright
Copyright © Royal College of Psychiatrists, 2012 

Alcohol problems are a significant public health problem. Reference Room, Babor and Rehm1,Reference Saitz2 Alcohol consumption has been estimated to cause 3.8% of all deaths and 4.6% of disability. Reference Rehm, Mathers, Popova, Thavorncharoensap, Teerawattananon and Patra3 Alcohol problems in general include alcohol use disorder, alcohol dependence and acute intoxication. Alcohol use disorders include a spectrum of excessive drinking often also described as alcohol abuse (DSM-IV), 4 hazardous drinking (WHO) 5 or harmful drinking (ICD-10) 6 (see Appendix 1). In the general population hazardous drinking is seen in 30–40%, Reference Compton, Conway, Stinson, Colliver and Grant7 with lifetime alcohol misuse or dependence found in about 10% compared with 16–36% of out-patients. Reference O'Connor and Schottenfeld8,9 In primary care approximately 7–30% of attendees have at-risk drinking or an alcohol use problem. Reference Saitz2,Reference Reid, Fiellin and O'Connor10Reference Fiellin, Reid and O'Connor12 In hospital settings the point prevalence of alcohol use disorder varies between 7 and 25% Reference Gerke, Hapke, Rumpf and John13Reference Santora and Hutton18 and approximately 4% have alcohol dependence. Reference Coder, Freyer-Adam and Bischof19 In psychiatric out-patients with serious mental illness, a recent meta-analysis showed rates of 10% (current use) and 20% (lifetime use) for alcohol use disorder. Reference Koskinen, Löhönen, Koponen, Isohanni and Miettunen20 The highest rates are seen in psychiatric in-patients where prevalence rates may be as high as 50%. Reference Barry, Fleming, Greenley, Widlak, Kropp and McKee21Reference McCloud, Barnaby, Omu, Drummond and Aboud23 In spite of these high prevalence rates it seems that only a minority of alcohol problems are detected and treated. Studies conducted in the USA, Australia, UK and Finland indicate that clinicians frequently do not screen for alcohol use disorder and fail to address the problem in at least a third to a half of cases even when the diagnosis is known. Reference Kaner, Heather, Brodie, Lock and McAvoy24Reference Rydon, Redman, Sanson-Fisher and Reid28 In most cases, diagnosis is made by clinical judgement without the use of scales, blood tests or reference to diagnostic criteria. Reference Berner, Zeidler, Kriston, Mundle, Lorenz and Härter29,Reference Aalto and Seppa30 Patient surveys suggest that only 30–40% are asked about their alcohol habits Reference Deitz, Rohde, Bertolucci and Dufour31Reference Edlund, Jürgen and Wells33 and a small percentage of those with alcohol problems report receiving advice to cut down. Reference Hasin, Grant, Dufour and Endicott34 Several effective treatment packages including brief alcohol interventions have been developed and are potentially effective. Reference Wallace, Cutler and Haines35Reference D'Onofrio and Degutis37 However, such interventions can only be effective when alcohol problems are recognised. Numerous studies of screening tools and biomarkers have been conducted but it is important to clarify how much improvement in the identification of alcohol problems occurs with their use above and beyond that achieved from routine clinical judgement alone. Reference Neumann, Gentilello, Neuner, Weiss-Gerlach, Schürmann and Schröder38 Early research suggests that about a third of individuals with alcohol problems are detected by their general practitioner. Reference Rydon, Redman, Sanson-Fisher and Reid28 The comparable detection rate from general hospital and psychiatric settings is unknown, although some previous work has suggested that hospital specialists detect most people with drinking problems at admission. Reference Nielsen and Gluud39

The aim of this study was to clarify accuracy of clinical judgement as well as clinical recording of clinicians working in (a) primary care, (b) general hospital and (c) psychiatric settings in identifying broadly defined alcohol problems. We hypothesised that mental health specialists would have the greatest success and primary care doctors the least success when working without assistance of scales or tools.

Method

Inclusion and exclusion criteria

The principal inclusion criteria were studies that examined the clinical judgement and clinical recording of clinicians in the identification of those with alcohol problems. We defined alcohol problems broadly to give a representative picture of routine practice. We grouped these problems into alcohol use disorder with and without dependence. We allowed studies to use a self-report or interview-based criterion definition of alcohol use disorder. Although we did not specifically exclude ICD-10-based studies, all interview-based studies used DSM criteria (Appendix 1). In an attempt to minimise heterogeneity we looked at studies examining acute intoxication and alcohol dependence separately from alcohol use disorder without intoxication or dependence. We excluded studies that did not present data on alcohol use, were based on vignettes, had insufficient primary data or failed to employ an adequate criterion standard (e.g. studies based on self-reported alcohol use). Reference Ramsay, Vredenburgh and Gallagher40Reference Cheeta, Drummond, Oyefeso, Phillips, Deluca and Perryman46

Search and information sources

A systematic search, critical appraisal and meta-analysis were conducted. The following abstract databases were searched from inception to September 2011. In MEDLINE/Embase (266 hits) and PsycINFO (20 hits), relevant keywords, MESH terms, title terms and limits were applied (available from the author on request). In four full-text collections (Science Direct, Ingenta Select, Ovid Full text, Blackwell-Wiley Interscience) the search terms were used as a full text search and citation search (261 hits). The abstract databases SCOPUS (179 hits) and Web of Knowledge (113 hits) were searched, using relevant search terms as a text word search, and using key papers in a reverse citation search. Non-English language articles were searched and one relevant study was found. We also contacted several experts in the field for unpublished and very recently published work.

Data extraction and appraisal

We adhered to standards in the PRISMA guidelines for meta-analyses. Reference Moher, Liberati, Tetzlaff and Altman47 Data extraction was conducted independently by two authors using a data extraction form in Microsoft excel. The form was developed from previous systematic reviews of diagnostic accuracy according to principles of PRISMA and the Cochrane Collaboration (available from the author on request). Reference Elamin, Flynn, Bassler, Briel, Alonso-Coello and Karanicolas48 Variables extracted were country of study, setting (e.g. primary care, general hospital), patient characteristics (e.g. age, gender), reference standard (including cut-off if relevant), method used to determine clinician judgement, sample size, positive cases and negative cases (as identified by reference standard), sensitivity, specificity, true positives (i.e. clinician judgement and reference standard both suggest alcoholism), false positives (i.e. clinician judgement suggests alcoholism but reference standard does not), false negatives (clinician judgement indicates no alcoholism but reference standard suggests alcoholism) and true negatives (both clinician judgement and reference standard both judge no alcoholism). To establish validity of the data extraction for the primary outcomes, true positive, false positives, false negatives and true negatives extracted from papers were recalculated from prevalence, sensitivity and specificity data in order to identify any inconsistencies or errors in extraction. Any inconsistencies were resolved by double-checking data from the paper and discussion with one of the authors (A.J.M.). Appraisal of each article was conducted by all authors independently using QUADAS. Reference Whiting, Rutjes, Reitsma, Bossuyt and Kleijnen49 This is a standardised quality appraisal form and is the recommended tool for a number of organisations such as the Cochrane Collaboration and the National Institute for Health and Clinical Excellence.

Meta-analysis

Given high heterogeneity, we used random effects bivariate meta-analysis to synthesise the data and provide pooled estimates of sensitivity and specificity using the metandi commands in Stata 10 on Windows. This method fits a two-level model, with independent binomial distributions for the true positives and true negatives conditional on the sensitivity and specificity in each study, and a bivariate normal model for the logit transforms of sensitivity and specificity between studies. Reference Reitsma, Glas, Rutjes, Scholten, Bossuyt and Zwinderman50 A summary receiver operator characteristic (ROC) curve, where each data point represents a separate study, was then constructed using the bivariate model to produce a 95% confidence ellipse within ROC space. Heterogeneity was assessed using the I Reference Saitz2 statistic. Reference Higgins, Thompson, Deeks and Altman51 Partial verification bias, differential verification bias and incorporation bias was assessed for each study (online Table DS1). Finally, publication bias was assessed formally using Begg-Mazumdar’s test. Reference Begg and Mazumdar52

Results

Study description and methods

We identified 48 studies of clinical accuracy including 39 on alcohol use disorder, 4 concerning intoxication and 5 examining alcohol dependence (Fig. 1). The sample size of individual studies ranged from 35 to 3014 individuals (mean 490.6, s.d. = 644.7). Twenty-one studies identified alcohol use disorder on the basis of a structured interview, four intoxication studies used blood alcohol concentration and the remainder used self-report measures of alcohol use (online Table DS2). High heterogeneity was found for most analyses (I ranged from 92.0 to 94.5% depending on analysis). Publication bias was assessed using funnel plots but no evidence of bias was detected (Fig. 2).

We examined the prevalence of each type of alcohol problem according to setting. In primary care the pooled prevalence of alcohol use disorder was 16.7% (95% CI 10.0–24.6). It was 12.1% (95% CI 7.2–18.0) when identified by interview and 22.7% (95% CI 10.5–37.9) when identified by self-report. In hospital settings the prevalence of alcohol use disorder was 33.5% (95% CI 16.2–53.5%) (Martin et al Reference Martin, Heymann, Neumann, Schmidt, Soost and Mazurek53 was excluded from the prevalence calculation as the study pre-selected a high-risk sample). However, the prevalence was 43.4% (95% CI 5.1–87.5) when identified by interview and 28.1% (95% CI 20.5–36.5) when identified by self-report. In mental health settings the prevalence of alcohol use disorder was 21.7% (95% CI 10.4–35.7), with insufficient studies to stratify by self-report/interview. Finally, the prevalence of alcohol dependence was 12.1% (n = 4, 95% CI 9.3–15.1) in hospital settings, whereas the prevalence of intoxication reached 52% (n = 2, 95% CI 7.7–94.0) identified by analysing blood alcohol levels in emergency departments.

Identification by primary care physicians

Alcohol use disorder

Across 12 studies, involving 10 997 people with problem drinking, primary care physicians recorded alcohol problems in medical records in 27.3% (95% CI 16.9–39.1), but actually recognised alcohol use disorder in 41.7% (95% CI 23.0–61.7) using clinical judgement (Table 1). In studies relying on interview-based gold standard detection the sensitivity was 44.0% (95% CI 21.4–68.0). There were only two studies with specificity data, both based on clinical judgement, and primary care physicians correctly reassured 93.1% (95% CI 86.7–97.6) of people without a drinking problem (detection specificity). At a prevalence of 20%, the positive predictive value would be 60.2% and the negative predictive value 86.5%. Thus, a primary care practitioner would typically identify 8 cases, missing 12. They would correctly identify 75 non-drinkers, falsely diagnosing 5. Thus the fraction correctly identified would be 83%.

Fig. 1 QUOROM overview of studies.

AUD, alcohol use dependence. Sample size refers to raw data extracted.

TABLE 1 Meta-analytic summary of results

Alcohol use disorder Alcohol dependence Alcohol intoxication
Professional group Sensitivity % (95% CI) Specificity % (95% CI) Sensitivity % (95% CI) Specificity % (95% CI) Sensitivity % (95% CI) Specificity % (95% CI)
Clinical judgement
    Primary care physicians 41.7 (23.0–61.7) 93.1 (86.7–97.6) No studies No studies No studies No studies
    Hospital specialists 52.4 (35.9–68.7) 88.2 (80.9–93.9) No studies No studies 89.8 (70.4–99.4) 61.4 (11.4–98.7)
    Mental health professionals 54.7 (16.8–89.6) 83.6 (56.3–98.8) No studies No studies No studies No studies
Clinical recording (chart notation)
    Primary care physicians 27.3 (16.9–39.1) No studies No studies No studies No studies No studies
    Hospital specialists 37.2 (28.4–46.4) 95.2 (94.2–96.1) 41.7 (16.5–69.5) No studies 75.6 (68.1–82.3). No studies
    Mental health professionals 28.2 (15.0–44.9) a No studies No studies No studies No studies No studies

a Based on one study only.

Fig. 2 Bias assessment plot.

Begg-Mazumdar: Kendall’s tau = 0.15415, P = 0.3194; Egger: bias 0.504955 (95% CI –2.05 to 2.98), P = 0.7333.

Alcohol dependence and alcohol intoxication

No studies were found.

Identification by hospital staff in medical settings

Alcohol use disorder

Across 23 studies involving 10 837 people with alcohol use disorder, health professionals correctly recorded alcohol problems in 37.2% (95% CI 28.4–46.4) of case notes. Based on clinical judgement, at interview they correctly identified 52.4% (95% CI 35.9–68.7). There was no difference in detection sensitivity when stratified by gold standard (robust clinical interview) 41.2% (95% CI 28.8–54.2) v. self-report 42.7% (95% CI 31.1–54.6). In nine studies reporting specificity, hospital staff identified 93.1% (95% CI 89.1–96.3) of those without problem drinking with no difference by case ascertainment or outcome method.

At a prevalence of 20%, the positive predictive value would be 52.5% and the negative predictive value 88.2%. Thus, hospital doctors would typically identify 10 cases, missing 10. Hospital doctors would typically correctly identify 71 non-drinkers, falsely diagnosing 9. Thus, the fraction correctly identified would be 81%.

Alcohol dependence and alcohol intoxication

There were four studies assessing the identification of alcohol dependence in hospital settings. Hospital staff accurately recorded 41.7% (95% CI 16.5–69.5) of such cases in medical notes. However, no data were reported on specificity in these settings.

Four studies examined the ability of doctors and nurses working in trauma centres to identify acute alcohol intoxication (defined by a high blood alcohol concentration). Health professionals were able to identify intoxication in 89.8% (95% CI 70.4–99.4) of cases based on clinical judgement and recorded this in the notes in 75.6% (95% CI 68.1–82.3). However, their specificity (based on clinical judgement) was low at 61.4% (n = 2, 95% CI 11.4–98.7).

Identification by mental health professionals

Alcohol use disorder

We located four studies involving a small sample of 784 patients, but as there was only one study using a chart review method (showing a sensitivity of 28.2%), we were only able to pool studies

Fig. 3 Hierarchical summary receiver operator characteristic (HSROC) curve for clinical identification of alcohol use disorder.

Sampled data from Gentilello et al Reference Gentilello, Villaveces, Ries, Nason, Daranciang and Donovan55 only includes detection of alcohol use disorder by doctors.

of clinical judgement, reducing the sample size to 384. Mental health professionals identified 54.7% (95% CI 16.8–89.6) of those with alcohol use disorder. Based on clinical judgement, their detection specificity was 83.6% (95% CI 56.3–98.8). At a prevalence of 20%, the positive predictive value would be 45.4% and negative predictive value 88.1%. Thus, a mental health professional would typically identify 11 cases, missing 9. They would correctly identify 67 non-drinkers, falsely diagnosing 13. Thus, the fraction correctly identified would be 78%.

Alcohol dependence and alcohol intoxication

Only one small study was found. Rienzi Reference Rienzi54 reported that mental health practitioners had a sensitivity of 82.9% (95% CI 67.3–91.9) when looking for self-reported alcohol dependency (defined using the Michigan Alcoholism Screening Test (MAST)).

Figure 3 shows the results for the hierarchical summary ROC curve analysis for clinical identification of alcohol use disorder.

Discussion

Main findings

We found 39 studies examining the clinical identification of alcohol use disorder, 5 studies involving alcohol dependence and 4 involving acute alcohol intoxication, with a total sample of 23 472 participants. Although the overall sample size was large there was sparse data on dependence and intoxication, especially in mental health settings (Table 1). Our findings indicate that all healthcare professionals have considerable difficulty with the identification of problem drinking in clinical practice, identifying about half of those with alcohol use disorder based on clinical judgement and correctly recording alcohol use disorder in the notes in only one in three cases. It should be noted that this data were based on single assessments to inform clinical opinion. Only one study examined the effect of cumulative assessment, finding that detection sensitivity improved from 16 to 34% after three consultations. Reference Kip, Neumann, Jugel, Kleinwaechter, Weiss-Gerlach and Guill56 Previous studies have found that clinicians have most difficulty identifying individuals with milder alcohol problems and better success with dependence but we found no significant difference. Reference Cheeta, Drummond, Oyefeso, Phillips, Deluca and Perryman46 The most successful group were emergency department specialists who were able to identify acute alcohol intoxication in nine out of ten people. This is in itself important, as at least 33% of people seen in the emergency department for trauma have evidence of legal intoxication. Reference Gentilello, Villaveces, Ries, Nason, Daranciang and Donovan55,Reference Reyna, Hollis and Hulbus57 However, even here emergency department specialists made a significant number of false positive errors.

Using clinical judgement primary care physicians identified about four in ten of attendees with alcohol use disorder, although their medical records were accurate in less than three out of ten. This is in line with previous work suggesting that most of those presenting in primary care are not detected routinely. Reference Rydon, Redman, Sanson-Fisher and Reid28 Recognition by hospital specialists and mental health professionals has been much less discussed. Reference Freimuth44 Hospital staff also had difficulty with recognition with about half of people with alcohol use disorder identified. This is important because alcohol use disorder can exacerbate severity of illness and prognosis in people with several mental disorders such as schizophrenia and depression. Reference Potvin, Sepehry and Stip58Reference Dixon60 Our finding of lower accuracy in indentifying problems among mental health professionals may be surprising but it has been previously found that alcohol problems are often not discussed even in mental health settings. Reference Lubman, Hides, Jorm and Morgan61,Reference Weisner and Matzger62 Further, most mental health practitioners are not expert in alcohol problems, rarely use standardised instruments for alcohol problems and have variable access to dedicated specialist alcohol services. 63Reference Berner, Langlotz, Kriston and Härter65

Barriers to the recognition of alcohol problems

Many factors have been cited as barriers to appropriate and prompt recognition. These include clinician confidence as to what constitutes alcohol misuse, Reference Rush, Ellis, Crowe and Powell66 inadequate training, Reference Cornuz, Ghali, Di Carlantonio, Pecoud and Paccaud67 lack of contractual incentives, Reference Wilson, Lock, Heather, Cassidy, Christie and Kaner68 lack of time, Reference Aira, Kauhanen, Laricaara and Rautio69 fear of labelling due to the stigma associated with substance misuse Reference Bander, Goldman, Schwartz, Rabinowitz and English70 and a belief that patients will not honestly disclose their drinking practices. Reference Beich, Gannik and Malterud71Reference Ferguson, Ries and Russo73 In most cases patients accept being questioned about their drinking habits. Reference Miller, Thomas and Mallin74,Reference Makela, Havio and Seppa75 Our data on the similar prevalence of alcohol problems by self-report compared with interview and lack of substantial diagnostic differences by criterion reference do not support the hypothesis that people will not disclose their drinking history if asked in a sensitive manner. Therefore we suggest that the most significant modifiable predictor remains the willingness of the clinician to ask about alcohol habits appropriately. Reference Rush, Powell, Crowe and Ellis76 In self-report surveys, health professionals report that they often enquire about drinking behaviours. Reference Herbert and Bass7779 Yet they also express the belief that clinical questions will not be answered honestly by patients Reference Bander, Goldman, Schwartz, Rabinowitz and English70 and are concerned that asking about drinking might harm the patient–provider relationship. Reference Thom and Tellez72,Reference Arborelius and Thakker80

Observational studies of clinician enquiry show that, in general, screening for alcohol problems is not routine in primary care Reference Berner, Zeidler, Kriston, Mundle, Lorenz and Härter29,Reference Aalto and Seppa30,Reference Bradley, Curry, Koepsell and Larson81,Reference Wenrich, Paauw, Carline, Curtis and Ramsey82 or in specialist settings. Reference Huang, Yu, Chen, Chen, Shen and Chen83 Several studies found that clinicians discuss alcohol use in about 10–15% of consultations but few discussions are specifically prompted by concerns over drinking habits. Reference Vinson, Elder, Werner, Vorel and Nutting84Reference Arndt, Schultz, Turvey and Petersen86,Reference Huang, Yu, Chen, Chen, Shen and Chen83 On videotaped or observed interviews, alcohol-related discussions were often superficial and yielded little information regarding patients’ drinking practices. Reference Wenrich, Paauw, Carline, Curtis and Ramsey82,Reference Larsson, Saljo and Aronsson87,Reference Lawner, Doot, Gausas, Doot and See88 Interviews where at-risk drinking discussions took place typically lasted only 1–2 min. Reference Bradley, Epler, Bush, Sporleder, Dunn and Cochran89,Reference Vinson, Galliher, Reidinger and Kappus90 Of those clinicians that look for alcohol problems, nearly all prefer asking quantity–frequency questions, about a third say they use the CAGE questions, and 15% cite use of biochemical markers. Reference Huang, Yu, Chen, Chen, Shen and Chen83,Reference Reid, Tinetti, Brown and Concato91,Reference Spandorfer, Israel and Turner92 D’Amico et al examined the practices of physicians towards over 7000 individuals visiting them. Reference D'Amico, Paddock, Burnam and Kung93 The practitioners asked 29% about their drinking (and 44% of problem drinkers about their drinking) over 1 year. Of those asked about alcohol problems, only 21% received advice (49% in the case of problem drinkers). Reference D'Amico, Paddock, Burnam and Kung93 Clinicians are least likely to raise the subject of problem drinking with White people, women and widows, Reference Arndt, Schultz, Turvey and Petersen86 prioritising discussion with healthier, younger males who misuse tobacco and alcohol. Reference Bertakis and Azari94 Less studied is the issue of whether clinicians may also find distinguishing problematic alcohol use from non-problematic use difficult.

In response to these concerns the Institute of Medicine, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the American Medical Association and the American Society of Addiction Medicine have all recommended that clinicians routinely ask patients about alcohol use. 79,9597 However, the Scottish Intercollegiate Guidelines Network advocates clinical assessment with judicious use of questionnaires only where there is suspicion of alcohol problems. 98 The NIAAA and the US Preventive Services Task Force (USPSTF) recommend population screening to identify problem drinking; that is, clinicians should ask all attendees whether they drink, and assess the specific quantity, frequency and pattern of consumption, but they did not recommend a specific tool. 99 In 2004 the USPSTF recommended that screening should be accompanied by behavioural counselling interventions to reduce alcohol misuse by adults in primary care settings. 100 The NIAAA also recommended targeted screening (case finding) in that all patients who drink alcohol should be screened with the CAGE questions. 101 To date, variations of the AUDIT (Alcohol Use Disorder Identification Test), CAGE and MAST have been the most common questionnaires for alcohol problems but these tools are difficult to use in a primary care practice. Reference Thom and Tellez72,79,Reference Wenrich, Paauw, Carline, Curtis and Ramsey82,Reference Beich, Thorsen and Rollnick102,Reference Phelps and Johnson103 No single laboratory test or combination of tests has been shown to be appropriate for screening. Reference Hoeksema and De Bock104,Reference Reynaud, Schwan, Loiseaux-Meunier, Albuisson and Deteix105

Limitations

The main limitation in this data synthesis is lack of data from some settings and a lack of consistency in terminology for alcohol use disorder. Reference Kunda106,Reference Morse and Flavin107 It is disappointing that few studies were conducted in Europe, and none in the UK. Some problems in terminology are to be anticipated given we have examined studies spanning more than 25 years of clinical practice. A second limitation is the reliance on self-report criterion methods such as the CAGE, AUDIT and MAST in some studies. However, we adjusted for this by examining both interview-based and self-report standards separately. In primary care and medical settings there was no difference in sensitivity or specificity but in mental health settings, in studies relying on an interview-based gold standard, detection sensitivity was significantly lower 36.0% (95% CI 16.5–58.2) compared with self-report 79.8% (95% CI 70.0–88.1). In addition, we found no statistically significant difference in the prevalence of alcohol use disorder whether defined by interview or self-report.

Implications

Given the clear findings that most, if not all health professionals struggle to accurately identify those with alcohol problems (including dependency) is there any evidence that interventions improve recognition rates? There is some evidence that education programmes can improve diagnostic habits. Reference Seale, Shellenberger, Boltri, Okosun and Barton108 A meta-analysis of 15 methods in 12 trials aimed at increasing primary care practitioner rates of screening for, and giving advice about, hazardous and harmful alcohol consumption concluded it is possible to increase the engagement of physicians although effects of identification of alcohol problems were unclear. Reference Anderson, Laurant, Kaner, Wensing and Grol109 There is an urgent need to trial combined screening, education and brief alcohol interventions in adequate samples in both mental health and general hospital settings. We suggest that such trials specifically measure detection sensitivity and detection specificity as well as patient outcomes. We also suggest that such trials compare the performance of screening against unassisted clinical accuracy in order to clarify which methods most help clinicians identify people with problem drinking.

Appendix

Definitions of alcohol problems

Our catagorisation Source definition
Alcohol use disorder Hazardous use (WHO) 5
Alcohol abuse (DSM-IV-TR) 4
Alcoholism or alcoholic (primary authors’ own definition, from original publications, see online Table DS2)
Risky drinking or at-risk drinking (primary authors’ own definition, from original publications, see online Table DS2)
Alcohol use disorder with dependence Alcohol dependence (DSM-IV-TR) 4

Acknowledgements

Thanks to the staff of the postgraduate library, Leicester General Hospital. Thanks also to Alex Sutton, Professor of Medical Statistics, University of Leicester for statistical advice.

Footnotes

Declaration of interest

None.

References

1 Room, R, Babor, T, Rehm, J. Alcohol and public health. Lancet 2005; 365: 519–30.Google Scholar
2 Saitz, R. Clinical practice. Unhealthy alcohol use. New Engl J Med 2005; 352: 596607.Google Scholar
3 Rehm, J, Mathers, C, Popova, S, Thavorncharoensap, M, Teerawattananon, Y, Patra, J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009; 373: 2223–33.Google Scholar
4 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn, revised) (DSM-IV-TR). APA, 2000.Google Scholar
5 World Health Organization. Lexicon of Alcohol and Drug Terms Published by the World Health Organization. WHO, 2012.Google Scholar
6 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.Google Scholar
7 Compton, WM, Conway, KP, Stinson, FS, Colliver, JD, Grant, BF. Prevalence, correlates, and comorbidity of DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2005; 66: 677–85.CrossRefGoogle ScholarPubMed
8 O'Connor, PG, Schottenfeld, RS. Patients with alcohol problems. New Engl J Med 1998; 338: 592602.Google Scholar
9 National Institute on Alcohol Abuse and Alcoholism. Tenth Special Report to the US Congress on Alcohol and Health. NIH Publication No. 00-3769. Department of Health and Human Services, 2000.Google Scholar
10 Reid, MC, Fiellin, DA, O'Connor, PG. Hazardous and harmful alcohol consumption in primary care. Arch Intern Med 1999; 159: 1681–9.Google Scholar
11 Buchsbaum, DG, Buchanan, RG, Lawton, MJ, Schnoll, SH. Alcohol consumption patterns in a primary care population. Alcohol Alcohol 1991; 26: 215–20.CrossRefGoogle Scholar
12 Fiellin, DA, Reid, MC, O'Connor, PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med 2000; 160: 1977–89.Google Scholar
13 Gerke, P, Hapke, U, Rumpf, HJ, John, U. Alcohol-related diseases in general hospital patients. Alcohol Alcohol 1997; 32: 179–84.Google Scholar
14 John, U, Rumpf, H-J, Hapke, U. Estimating prevalence of alcohol abuse and dependence in one general hospital: an approach to reduce sample selection bias. Alcohol Alcohol 1999; 34: 786–94.CrossRefGoogle ScholarPubMed
15 Jarque-López, A, González-Reimers, E, Rodríguez-Moreno, F, Santolaria-Fernández, F, López-Lirola, A, Ros-Vilamajo, R, et al. Prevalence and mortality of heavy drinkers in a general medical hospital unit. Alcohol Alcohol 2001; 36: 335–8.Google Scholar
16 Smothers, BA, Yahr, HT, Sinclair, MD. Prevalence of current DSM-IV alcohol use disorders in short-stay, general hospital admissions, United States, 1994. Arch Intern Med 2003; 163: 713–9.CrossRefGoogle ScholarPubMed
17 Roche, AM, Freeman, T, Skinner, N. From data to evidence, to action: findings from a systematic review of hospital screening studies for high risk alcohol consumption. Drug Alcohol Depend 2006; 83: 114.Google Scholar
18 Santora, PB, Hutton, HE. Longitudinal trends in hospital admissions with co-occurring alcohol/drug diagnoses, 1994-2002. J Subst Abuse Treat 2008; 35: 112.Google Scholar
19 Coder, B, Freyer-Adam, J, Bischof, G. Alcohol problem drinking among general hospital inpatients in northeastern Germany. Gen Hosp Psychiatry 2008; 30: 147–54.Google Scholar
20 Koskinen, J, Löhönen, J, Koponen, H, Isohanni, M, Miettunen, J. Prevalence of alcohol use disorders in schizophrenia - a systematic review and meta-analysis. Acta Psychiatr Scand 2009; 120: 8596.Google Scholar
21 Barry, KL, Fleming, MF, Greenley, J, Widlak, P, Kropp, S, McKee, D. Assessment of alcohol and other drug disorders in the seriously mentally ill. Schizophr Bull 1995; 21: 313–21.Google Scholar
22 Hulse, GK, Saunders, JB, Roydhouse, RM, Stockwell, TR, Basso, MR. Screening for hazardous alcohol use and dependence in psychiatric in-patients using the AUDIT questionnaire. Drug Alcohol Rev 2000; 19: 291–8.Google Scholar
23 McCloud, A, Barnaby, B, Omu, N, Drummond, C, Aboud, A. Relationship between alcohol use disorders and suicidality in a psychiatric population. In-patient prevalence study. Br J Psychiatry 2004; 184: 439–45.CrossRefGoogle Scholar
24 Kaner, EF, Heather, N, Brodie, J, Lock, CA, McAvoy, BR. Patient and practitioner characteristics predict brief alcohol intervention in primary care. Br J Gen Pract 2001; 51: 822–7.Google ScholarPubMed
25 Aalto, M, Pekuri, P, Seppa, K. Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project. Drug Alcohol Depend 2003; 69: 914.Google Scholar
26 Richmond, RL, Anderson, P. Research in general practice for smokers and excessive drinkers in Australia and the UK. III. Dissemination of interventions. Addiction 1994; 89: 4962.Google Scholar
27 Kaner, EF, Lock, CA, McAvoy, BR, Heather, N, Gilvarry, E. An RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. Br J Gen Pract 1999; 49: 699703.Google Scholar
28 Rydon, P, Redman, S, Sanson-Fisher, RW, Reid, AL. Detection of alcohol-related problems in general practice. J Stud Alcohol 1992; 53: 197202.Google Scholar
29 Berner, MM, Zeidler, C, Kriston, L, Mundle, G, Lorenz, G, Härter, M. Diagnostic and treatment approaches to alcohol-related disorders. Results of a survey in general practices [in German]. Fortschr Neurol Psychiatr 2006; 74: 157–64.Google Scholar
30 Aalto, M, Seppa, K. Use of laboratory markers and the audit questionnaire by primary care physicians to detect alcohol abuse by patients. Alcohol Alcohol 2005; 40: 520–3.CrossRefGoogle ScholarPubMed
31 Deitz, D, Rohde, F, Bertolucci, D, Dufour, M. Prevalence of screening for alcohol use by physicians during routine physical examinations. Alcohol Health Res World 1994; 18: 162–8.Google ScholarPubMed
32 Taira, DA, Safran, DG, Seto, TB, Rogers, WH, Tarlov, AR. The relationship between patient income and physician discussion of health risk behaviors. JAMA 1997; 278: 1412–7.CrossRefGoogle ScholarPubMed
33 Edlund, MJ, Jürgen, U, Wells, KB. Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities. Med Care 2004; 42: 1158–66.Google Scholar
34 Hasin, DS, Grant, BF, Dufour, MG, Endicott, J. Alcohol problems increase while physician attention declines. 1967 to 1984. Arch Intern Med 1990; 150: 397400.Google Scholar
35 Wallace, P, Cutler, S, Haines, A. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988; 297: 663–8.Google Scholar
36 Bertholet, N, Daeppen, JB, Wietlisbach, V, Fleming, M, Burnand, B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med 2005; 165: 986–95.Google Scholar
37 D'Onofrio, G, Degutis, LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med 2002; 9: 627–38.Google Scholar
38 Neumann, T, Gentilello, LM, Neuner, B, Weiss-Gerlach, E, Schürmann, H, Schröder, T, et al. Screening trauma patients with the alcohol use disorders identification test and biomarkers of alcohol use. Alcohol Clin Exp Res 2009; 33: 970–6.Google Scholar
39 Nielsen, SD, Gluud, C. Physician's information about alcohol problems at hospitalisation of alcohol misusers. Alcohol Alcohol 1992; 27: 659–65.Google Scholar
40 Ramsay, A, Vredenburgh, J, Gallagher, RM 3rd. Recognition of alcoholism among patients with psychiatric problems in a family practice clinic. J Fam Pract 1983; 17: 829–32.Google Scholar
41 Indig, D, Copeland, J, Conigrave, KM, Rotenko, I. Why are alcohol-related emergency department presentations under-detected? An exploratory study using nursing triage text. Drug Alcohol Rev 2008; 27: 584–90.Google Scholar
42 Hadida, A, Kapur, N, Mackway-Jones, K, Guthrie, E, Creed, F. Comparing two different methods of identifying alcohol related problems in the emergency department: a real chance to intervene? Emerg Med J 2001; 18: 112–5.Google Scholar
43 Gammeter, R, Nay, C, Bissery, A, Leutwyler, J, Bonsack, C, Besson, J, et al. Frequency of alcohol use disorders in patients admitted in a psychiatric hospital according to admission diagnosis. Schweizer Archiv Neurol Psychiatrie 2006; 157: 290–6.Google Scholar
44 Freimuth, M. Another missed opportunity? Recognition of alcohol use problems by mental health providers. Psychotherapy 2008; 45: 405–9.CrossRefGoogle ScholarPubMed
45 Vinson, DC, Kruse, RL, Seale, JP. Simplifying alcohol assessment: two questions to identify alcohol use disorders. Alcohol Clin Exp Res 2007; 31: 1392–8.Google Scholar
46 Cheeta, S, Drummond, C, Oyefeso, A, Phillips, T, Deluca, P, Perryman, K, et al. Low identification of alcohol use disorders in general practice in England. Addiction 2008; 103: 766–73.Google Scholar
47 Moher, D, Liberati, A, Tetzlaff, J, Altman, DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535.Google Scholar
48 Elamin, MB, Flynn, DN, Bassler, D, Briel, M, Alonso-Coello, P, Karanicolas, PJ, et al. Choice of data extraction tools for systematic reviews depends on resources and review complexity. J Clin Epidemiol 2009; 62: 506–10.Google Scholar
49 Whiting, P, Rutjes, AW, Reitsma, JB, Bossuyt, PM, Kleijnen, J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003; 3: 25.Google Scholar
50 Reitsma, JB, Glas, AS, Rutjes, AWS, Scholten, RJPM, Bossuyt, PM, Zwinderman, AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 2005; 58: 982–90.Google Scholar
51 Higgins, JPT, Thompson, SG, Deeks, JJ, Altman, DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–60.Google Scholar
52 Begg, CB, Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088–101.CrossRefGoogle Scholar
53 Martin, MJ, Heymann, C, Neumann, T, Schmidt, L, Soost, F, Mazurek, B, et al. Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract. Alcohol Clin Exp Res 2002; 26: 836–40.Google Scholar
54 Rienzi, BM. Prevalence of undetected alcohol dependence in the mental health diagnostic interview. Psychol Rep 1992; 70: 913–4.Google Scholar
55 Gentilello, LM, Villaveces, A, Ries, RR, Nason, KS, Daranciang, E, Donovan, DM, et al. Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma 1999; 47: 1131–5.Google Scholar
56 Kip, MJ, Neumann, T, Jugel, C, Kleinwaechter, R, Weiss-Gerlach, E, Guill, MM, et al. New strategies to detect alcohol use disorders in the preoperative assessment clinic of a German University Hospital. Anesthesiology 2008; 109: 171–9.Google Scholar
57 Reyna, TM, Hollis, HW, Hulbus, RC. Alcohol-related trauma: the surgeon's responsibility. Ann Surg 1985; 201: 194–7.CrossRefGoogle ScholarPubMed
58 Potvin, S, Sepehry, AA, Stip, E. A meta-analysis of negative symptoms in dual diagnosis schizophrenia. Psychol Med 2006; 36: 431–40.Google Scholar
59 Potvin, S, Sepehry, A, Stip, E. Meta-analysis of depressive symptoms in dual-diagnosis schizophrenia. Aust N Z J Psychiatry 2007; 41: 792–9.Google Scholar
60 Dixon, L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res 1999; 35 (suppl): 93100.Google Scholar
61 Lubman, DI, Hides, L, Jorm, AF, Morgan, AJ. Health professionals' recognition of co-occurring alcohol and depressive disorders in youth: a survey of Australian general practitioners, psychiatrists, psychologists and mental health nurses using case vignettes. Aust N Z J Psychiatry 2007; 41: 830–5.Google Scholar
62 Weisner, C, Matzger, H. Missed opportunities in addressing drinking behavior in medical and mental health services. Alcohol Clin Exp Res 2003; 27: 1132–41.Google Scholar
63 National Audit Office. Reducing Alcohol Harm: Health Services in England for Alcohol Misuse. National Audit Office, 2008 (http://www.nao.org.uk/publications/0708/reducing_alcohol_harm.aspx).Google Scholar
64 Booth, BM, McLaughlin, YS. Barriers to and need for alcohol services for women in rural populations. Alcohol Clin Exp Res 2000; 24: 1267–75.Google Scholar
65 Berner, MM, Langlotz, M, Kriston, L, Härter, M. Diagnostics and treatment of alcohol-related disorders: results of a representative study in psychiatric and psychotherapeutic practices [in German]. Fortschr Neurol Psychiatr 2007; 75: 1825.Google Scholar
66 Rush, B, Ellis, K, Crowe, T, Powell, L. How general practitioners view alcohol use: clearing up the confusion. Can Fam Physician 1994; 40: 1570–8.Google Scholar
67 Cornuz, J, Ghali, WA, Di Carlantonio, D, Pecoud, A, Paccaud, F. Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits. Fam Pract 2000; 17: 535–40.CrossRefGoogle ScholarPubMed
68 Wilson, GB, Lock, CA, Heather, N, Cassidy, P, Christie, MM, Kaner, EFS. Intervention against excessive alcohol consumption in primary health care: a survey of GPs' attitudes and practices in England 10 years on. Alcohol Alcohol 2011; 46: 570–7.Google Scholar
69 Aira, M, Kauhanen, J, Laricaara, P, Rautio, P. Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Fam Pract 2003; 20: 270–5.Google Scholar
70 Bander, KW, Goldman, DS, Schwartz, MA, Rabinowitz, E, English, JT. Survey of attitudes among three specialties in a teaching hospital toward alcoholics. J Med Educ 1987; 62: 1724.Google Scholar
71 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: 15.Google Scholar
72 Thom, B, Tellez, C. A difficult business: detecting and managing alcohol problems in general practice. Br J Addict 1986; 81: 405–18.Google Scholar
73 Ferguson, L, Ries, R, Russo, J. Barriers to identification and treatment of hazardous drinkers as assessed by urban/rural primary care doctors. J Addict Dis 2003; 22: 7990.Google Scholar
74 Miller, PM, Thomas, SE, Mallin, R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol 2006; 41: 306–10.Google Scholar
75 Makela, P, Havio, M, Seppa, K. Alcohol-related discussions in health care-a population view. Addiction 2011; 106: 1239–48.Google Scholar
76 Rush, BR, Powell, LY, Crowe, TG, Ellis, K. Early intervention for alcohol use: family physicians' motivations and perceived barriers. CAMJ 1995; 152: 863–9.Google Scholar
77 Herbert, C, Bass, F. Early at-risk alcohol intake. Definitions and physicians' role in modifying behavior. Can Fam Phys 1997; 43: 639–44.Google Scholar
78 Holmqvist, M, Bendtsen, P, Spak, F, Rommelsjö, A, Geirsson, M, Nilsen, P. Asking patients about their drinking. A national survey among primary health care physicians and nurses in Sweden. Addicti Behav 2008; 33: 301–14.Google Scholar
79 National Institute on Alcohol Abuse and Alcoholism. The Physician's Guide to Helping Patients with Alcohol Problems. NIH publication 95–3769. National Institutes of Health, 1995.Google Scholar
80 Arborelius, E, Thakker, KD. Why is it so difficult for general practitioners to discuss alcohol with patients? Fam Pract 1995; 12: 419–22.Google Scholar
81 Bradley, KA, Curry, SJ, Koepsell, TD, Larson, EB. Primary and secondary prevention of alcohol problems: U.S. internist attitudes and practices. J Gen Intern Med 1995; 10: 6772.Google Scholar
82 Wenrich, MD, Paauw, DS, Carline, JD, Curtis, JR, Ramsey, PG. Do primary care physicians screen patients about alcohol intake using the CAGE questions? J Gen Intern Med 1995; 10: 631–4.Google Scholar
83 Huang, M-C, Yu, C-H, Chen, C-T, Chen, C-C, Shen, WW, Chen, C-H. Prevalence and identification of alcohol use disorders among severe mental illness inpatients in Taiwan. Psychiatry Clin Neurosci 2009; 63: 94100.Google Scholar
84 Vinson, DC, Elder, NC, Werner, JJ, Vorel, LA, Nutting, PA. Alcohol-related discussions in primary care: a report from ASPN. J Fam Pract 2000; 49: 2833.Google Scholar
85 Stange, KC, Zyzanski, SJ, Jaen, CR, Callahan, EJ, Kelly, RB, Gillanders, WR, et al. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract 1998; 46: 377–89.Google Scholar
86 Arndt, S, Schultz, SK, Turvey, C, Petersen, A. Screening for alcoholism in the primary care setting are we talking to the right people? J Fam Pract 2002; 51: 41–6.Google Scholar
87 Larsson, US, Saljo, R, Aronsson, K. Patient-doctor communication on smoking and drinking: lifestyles in medical consultations. Soc Sci Med 1987; 25: 1129–37.Google Scholar
88 Lawner, K, Doot, M, Gausas, J, Doot, J, See, C. Implementation of CAGE alcohol screening in a primary care practice. Fam Med 1997; 29: 332–5.Google Scholar
89 Bradley, KA, Epler, AJ, Bush, KR, Sporleder, JL, Dunn, CW, Cochran, NE, et al. Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking. J Gen Intern Med 2002; 17: 315–26.Google Scholar
90 Vinson, DC, Galliher, JM, Reidinger, C, Kappus, JA. Comfortably engaging: which approach to alcohol screening should we use? Ann Fam Med 2004; 2: 398404.Google Scholar
91 Reid, MC, Tinetti, ME, Brown, CJ, Concato, J. Physician awareness of alcohol use disorders among older patients. J Gen Intern Med 1998; 13: 729–34.Google Scholar
92 Spandorfer, JM, Israel, Y, Turner, BJ. Primary care physicians' views on screening and management of alcohol abuse: inconsistencies with national guidelines. J Fam Pract 1999; 48: 899902.Google Scholar
93 D'Amico, EJ, Paddock, SM, Burnam, A, Kung, FY. Identification of and guidance for problems drinking by general medical providers. Results from a National Survey. Med Care 2005; 43: 229–36.Google Scholar
94 Bertakis, KD, Azari, R. Determinants of physician discussion regarding tobacco and alcohol abuse. J Health Commun 2007; 12: 513–25.Google Scholar
95 Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems: Report of a Study by a Committee of the Institute of Medicine, Division of Mental Health and Behavioral Medicine. National Academy Press, 1990.Google Scholar
96 Council on Scientific Affairs, American Medical Association. AMA Guidelines For Physician Involvement In The Care Of Substance Abusing Patients. American Medical Association, 1979.Google Scholar
97 American Society of Addiction Medicine. Public Policy Statement on Screening for Addiction in Primary Care Settings. ASAM 1997.Google Scholar
98 Scottish Intercollegiate Guidelines Network (SIGN). The Management of Harmful Drinking and Alcohol Dependence in Primary Care. National Clinical Guidelines, 2003.Google Scholar
99 US Preventive Services Task Force. Guide to Clinical Preventive Services (2nd edn). International Medical Publishing, 1998.Google Scholar
100 US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med 2004; 140: 554–6.Google Scholar
101 US Dept of Health and Human Services. The Physicians' Guide to Helping Patients With Alcohol Problems. US Dept of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995.Google Scholar
102 Beich, A, Thorsen, T, Rollnick, S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 2003; 327: 536–42.Google Scholar
103 Phelps, GL, Johnson, NP. Bright light in dark places: physician recognition of alcoholism. J S C Med Assoc 1990; 86: 17–8.Google ScholarPubMed
104 Hoeksema, HL, De Bock, GH. The value of laboratory tests for the screening and recognition of alcohol abuse in primary care patients. J Fam Pract 1993; 37: 268–76.Google Scholar
105 Reynaud, M, Schwan, R, Loiseaux-Meunier, M-N, Albuisson, E, Deteix, P. Patients admitted to emergency services for drunkenness: moderate alcohol users or harmful drinkers? Am J Psychiatry 2001; 158: 96–9.Google Scholar
106 Kunda, S. Actual problems of clinical classification and terminology of alcoholism. Alcoholism 1996; 32: 7993.Google Scholar
107 Morse, RM, Flavin, DK. The definition of alcoholism. JAMA 1992; 268: 1012–4.Google Scholar
108 Seale, JP, Shellenberger, S, Boltri, JM, Okosun, IS, Barton, B. Effects of screening and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- post-intervention assessment. BMC Family Pract 2005; 6: 46.Google Scholar
109 Anderson, P, Laurant, M, Kaner, E, Wensing, M, Grol, R. Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol 2004; 65: 191–9.Google Scholar
Figure 0

Fig. 1 QUOROM overview of studies.AUD, alcohol use dependence. Sample size refers to raw data extracted.

Figure 1

TABLE 1 Meta-analytic summary of results

Figure 2

Fig. 2 Bias assessment plot.Begg-Mazumdar: Kendall’s tau = 0.15415, P = 0.3194; Egger: bias 0.504955 (95% CI –2.05 to 2.98), P = 0.7333.

Figure 3

Fig. 3 Hierarchical summary receiver operator characteristic (HSROC) curve for clinical identification of alcohol use disorder.Sampled data from Gentilello et al55 only includes detection of alcohol use disorder by doctors.

Supplementary material: PDF

Mitchell et al. supplementary material

Supplementary Material

Download Mitchell et al. supplementary material(PDF)
PDF 61.5 KB
Submit a response

eLetters

No eLetters have been published for this article.