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Question Are alcohol screening questionnaires sensitive and specific for identifying heavy drinking or alcohol abuse or dependence in women in general clinical populations in the US?
English language studies were identified using Medline (1966 to July 1997) with a combination of the search terms alcoholism, alcohol drinking, screening, CAGE, BMAST, T-ACE, TACE, TWEAK, MAST, SMAST, SAAST, and AUDIT; Social Science and Science Citation Indexes; and bibliographies of relevant studies.
Studies were selected if they compared a brief alcohol screening questionnaire (≤10 items) with an appropriate criterion standard for alcohol abuse or dependence (ie, based on DSM-IV or ICD-10) or heavy drinking (ie, based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule or a timeline follow back interview) in a generalisable clinical population of women in the US.
Sensitivity, specificity, and area under receiver operating characteristic (ROC) curve.
13 of 759 studies met the inclusion criteria. They evaluated 8 screening questionnaires in various settings (emergency department, primary care, and obstetric clinic), in different populations (black, white, and Hispanic), and assessed test properties using various cutoff points. Data were not meta-analysed because of study heterogeneity. The table⇓ lists test properties for 7 tests. Test sensitivity varied by race or ethnicity and tended to be lower for women than for men at equivalent cutoff points.
Some brief alcohol screening questionnaires have acceptable test properties for women, although test sensitivities vary by race or ethnicity and tend to be lower for women than for men. Using lower than usual thresholds for a positive screen may therefore be appropriate when giving alcohol screening questionnaires to women.
Dozens of studies confirm the efficacy of brief interventions for alcohol problems.1 Translating this evidence into practice has been difficult, however, because of limited physician time and expertise and under recognition of alcoholism.2 Although the CAGE questions are almost 25 years old, screening tools have only recently been tested in women, minorities, and the elderly, and used to detect hazardous drinkers (people drinking detrimental amounts but with no consequences).3, 4
The systematic review by Bradley et al finds that alcohol screening questionnaires may be less sensitive for problem drinking in women than in men. The authors also point out that their conclusions should be viewed as tentative because, unfortunately, there were few studies to review.
Alcohol problems are more likely to be detected by standardised screening tools.2 For sex specific screening, the evidence supports using TWEAK (with questions about Tolerance, Worried, Eye openers, Amnesia, and Kut down) (2 points as a positive test) in women; it is brief, works in diverse populations, and detects current hazardous drinking (particularly important in women who are pregnant or considering pregnancy). If one instrument is used for all patients, we need a brief, sensitive test that is valid in diverse populations and identifies both current and past hazardous and problem drinking.
Sources of funding: Health Services Research and Development Field Program and Medicine Service and VA Puget Sound Health Care System.
For correspondence: Dr K A Bradley, Health Services Research and Development, VA Puget Sound Health Care System (Seattle Division), 1660 S Columbian Way, Mail Stop 152, Seattle, WA 98108, USA. Fax +1 206 764 2935.
Abstract and commentary also published in ACP Journal Club.
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