Alcohol problems are common in primary care with between 7% and 30% of attendees having at-risk drinking or an alcohol-use disorder.1–3 In a meta-analysis of five in primary care studies the pooled prevalence of lifetime problem drinking was 19.8%.4 Many authors have therefore suggested that GPs are well positioned to identify and manage alcohol problems.5,6 Several effective treatment packages called ‘brief alcohol interventions’ have been developed and tested.7,8 Clearly these interventions require adequate initial identification of alcohol problems, yet only about one-third of such individuals are detected by their GP.9–12 Studies conducted in the US, UK, Australia, and Finland indicate that clinicians frequently do not screen for problem drinking, and fail to address the problem in at least one-third to one-half of cases even when the diagnosis is known.9,13–18 A recent meta-analysis found that GPs had a clinical detection sensitivity of 42% but alcohol problems were recorded correctly in the notes only 27.3% of the time.19
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.20–23 In order to screen for problem drinking, the US NIAAA and the US Preventive Services Task Force (USPSTF) recommend population screening; that is, physicians 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.24 In 2004, the USPSTF recommended screening is accompanied by behavioural counselling interventions to reduce alcohol misuse by adults in primary care settings.25 The NIAAA also recommends targeted screening (case-finding) in that all patients who drink alcohol should be screened with the four CAGE questions.21 In the UK, the Primary Care Service Framework prefers the 10 AUDIT questions; in fact, it recommends an algorithm approach whereby either the Single Alcohol Screening Question (SASQ) (1 item), Fast Alcohol Screening Test (FAST) (4 items), Alcohol-use disorders Identification Test (AUDIT)-C (3 items) or AUDIT-PC (5 items) is applied as an initial first step, followed by the remaining AUDIT questions given to those who initially score positive on the screening test.26 Yet choice of the initial steps is not yet clear,27 and no evidence has yet been presented for algorithm approaches.
How this fits in
Screening for alcohol misuse in primary care is important because it is common and because brief interventions can be effective. However, the most useful simple screening questions to ask remain to be defined. In a meta-analysis of their use, it appears that both 1- and 2-item screening questions have value, and that they should be followed by a second, more detailed assessment to determine the need for intervention or referral.
In reality, many GPs have difficulty applying routine alcohol screening, although most state that they often inquire about drinking behaviours.21,28 Indeed observational studies have shown that screening for alcohol problems is far from routine in primary care.18,29–32 In the UK, alcohol screening sometimes occurs at patient registration but is usually opportunistic.33 Investigations into alcohol screening practices have consistently found that most physicians ask patients about consumption, but few go beyond an initial inquiry.31,34 Most alcohol discussions last less than 1 minute.35 D’Amico et al examined primary care physician practices in over 7000 visits; practitioners asked only 29% of all attendees about their drinking over the course of 1 year, although they asked 44% of problem drinkers about their drinking. Of those individuals with problem drinking, 49% received relevant advice.36
Lessons from screening studies for depression suggest that ultra-short methods consisting of one or two questions might be valuable in some circumstances.37 However such methods often have low positive predictive value.38 The aim of this study was to find out whether very simple one and two question screening might prove an accurate and acceptable screening method in primary care using quantitative meta-analysis. It was hypothesised that one question might have good rule-in but poor rule-out performance when used alone.
