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A Systematic Review

David A. Fiellin, MD; M. Carrington Reid, PhD, MD; Patrick G. O'Connor, MD, MPH

Arch Intern Med. 2000;160:1977-1989.

Background  Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.

Objective  To evaluate the accuracy of screening methods for alcohol problems in primary care.

Methods  We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results.

Results  Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated. The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%), while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%). These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions. The studies inconsistently adhered to methodological standards for diagnostic test research: 3 (8%) provided a full description of patient spectrum (demographics and comorbidity), 30 (79%) avoided workup bias, 12 (of 34 studies [35%]) avoided review bias, and 21 (55%) performed an analysis in pertinent clinical subgroups.

Conclusions  Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care. Future research in this field will benefit from increased adherence to methodological standards for diagnostic tests.

From the Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn (Drs Fiellin, Reid, and O'Connor); and the Clinical Epidemiology Unit, Veterans Affairs Connecticut Healthcare System, West Haven (Dr Reid).

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