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Item bias in the CAGE screening test for alcohol use disorders

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Abstract

Objective

To 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 setting

Cross-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.

Patients

A probability sample of 1,333 adult primary care patients, with oversampling of female and minority (African-American and Mexican-American) patients.

Main results

Unadjusted 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 $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.

Conclusions

Despite 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.

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References

  1. Magruder HK, Durand AM, Frey KA. Alcohol abuse and alcoholism in primary health care settings. J Fam Pract. 1991;32:406–13.

    Google Scholar 

  2. Allen JP, Eckardt MJ, Wallen J. Screening for alcoholism: techniques and issues. Public Health Rep. 1988;103:586–92.

    PubMed  CAS  Google Scholar 

  3. Allen JP, Maisto SA, Connors GJ. Self-report screening tests for alcohol problems in primary care. Arch Intern Med. 1995;155: 1726–30.

    Article  PubMed  CAS  Google Scholar 

  4. Beresford TP, Blow FC, Brower KJ, Singer K. Clinical applications: screening for alcoholism. Prev Med. 1988;17:653–63.

    Article  PubMed  CAS  Google Scholar 

  5. Volk RJ, Steinbauer JR, Cantor SB, Holzer CE. Screening for “at risk” drinking in primary care patients of different racial/ethnic backgrounds. Addiction. 1997;92:197–206.

    Article  PubMed  CAS  Google Scholar 

  6. Ewing JA, Rouse BA. Identifying the hidden alcoholic. In: The 29th International Congress on Alcohol and Drug Dependence. Sydney, Australia: 1970.

  7. Ewing JA. Detecting alcoholism: the CAGE Questionnaire. JAMA. 1984;252:1905–7.

    Article  PubMed  CAS  Google Scholar 

  8. Grant BF, Hasin D. The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS), Rockville, Md: National Institute on Alcohol Abuse and Alcoholism: 1992.

    Google Scholar 

  9. Grant BF, Harford TC, Dawson DA, Chou PS, Pickering RP. The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample. Drug Alchol Depend. 1995;39:37–44.

    Article  CAS  Google Scholar 

  10. Cahalan DR, Roizen R. Room R. Alcohol problems and their prevention: public attitudes in California. In: Room R, Sheffield S, eds. The Prevention of Alcohol Problems: Report of a Conference. Sacramento Calif: Health and Welfare Agency, Office of Alcoholism; 1974:354–403.

    Google Scholar 

  11. Cherpitel CJS. Drinking patterns and problems associated with injury status in emergency room admissions. Alcohol Clin Exp Res. 1988;12:105–10.

    Article  PubMed  CAS  Google Scholar 

  12. Bush B, Shaw S, Cleary P, Delbanco TL, Aronson MD. Screening for alcohol abuse using the CAGE Questionnaire. Am J Med. 1987;82:231–87.

    Article  PubMed  CAS  Google Scholar 

  13. Caetano R. Acculturation, drinking and social settings among U.S. Hispanics. Drug Alcohol Depend. 1987;19:215–26.

    Article  PubMed  CAS  Google Scholar 

  14. Johnston LD, O’Malley PM, Bachman JG, National Survey, Results on Drug Use From the Monitoring the Future Study, 1975–1992. Vol 2: College Students and Young Adults. Rockville, Md: National Institute on Drug Abuse: 1993. NIH publication 93-3598.

    Google Scholar 

  15. Steinweg DL, Worth H. Alcoholism: the keys to the CAGE. Am J Med. 1993;94:520–3.

    Article  PubMed  CAS  Google Scholar 

  16. Wenrich MD, Paauw DS, Carline JD, Curtis JR, Ramsy PG. Do primary care physicians screen patients about alcohol intake using the CAGE questions? J Gen Intern Med. 1995;10:631–4.

    Article  PubMed  CAS  Google Scholar 

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Additional information

Supported by grants from the National Institute on Alcohol Abuse and Alcoholism (AA09496) and from the Bureau of Health Professions. Health Resources and Services Administration (d32-PE16033 and D32-PE10158).

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Volk, R.J., Cantor, S.B., Steinbauer, J.R. et al. Item bias in the CAGE screening test for alcohol use disorders. J GEN INTERN MED 12, 763–769 (1997). https://doi.org/10.1046/j.1525-1497.1997.07162.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.1997.07162.x

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