Physicians Frequently Miss Alcohol Problems

Joanna Broder

January 14, 2013

Clinical intuition alone misses most patients with alcohol problems compared with a standard screening instrument, according to a study published in the January/February issue of the Annals of Family Medicine.

"Our study affirms that systems need to be in place, possibly through team-based care, to screen systematically for alcohol problems with a validated question or series of questions and to address this health threat using evidence-based approaches," write Daniel Vinson, MD, MSPH, from the Department of Family and Community Medicine, University of Missouri, Columbia, and colleagues.

The researchers designed the cross-sectional study to evaluate the effectiveness of clinical judgment in the identification of patients with alcohol problems.

The team recruited 94 primary care physicians in 40 practices. They asked both physicians and their eligible patients to complete short surveys after the appointment. The patient survey included 5 alcohol-related questions drawn from the Alcohol Use Disorders Identification Test-Consumption or adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The physician surveys asked whether the clinician thought a particular patient had problems with alcohol.

The authors then compared results from the patient questionnaires with those from physicians' questionnaires, controlling for patient sex, age, educational attainment, race/ethnicity, and clustering by clinician.

Of the 1699 patients who filled out exit questionnaires, 171 (10.1%) screened positive for hazardous drinking and 64 (3.8%) screened positive for harmful drinking. The difference between "hazardous" and "harmful" drinking is based on how the patient scored on various questionnaires.

When physicians thought a patient had an alcohol problem, they had a reasonable chance of being right. Physicians sensed that 81 patients had problems with alcohol; the positive predictive value of clinician suspicion was 62%.

Physicians, however, were much more likely to accurately identify patients who did not have alcohol problems (the specificity of clinician suspicion of either hazardous or harmful drinking was 98%) than to accurately identify patients with alcohol problems (the sensitivity of clinician suspicion of either hazardous or harmful drinking was 27%).

According to the authors, physicians often do not identify alcohol problems during a routine office visit. However, "[w]hen alcohol problems are detected and addressed by clinicians, patients can be helped to reduce consumption."

Results from this study support the routine use of screening to supplement clinician judgment, according to the authors.

Although incorporating routine screening into primary care is not easy, there are ways to make it simpler, according to the authors. "To increase the feasibility of screening for alcohol problems in practice, a validated single screening question can be used. For example, for the question, 'When was the last time you had more than X drinks in one day?' where X is 4 for women and 5 for men, an answer of any time in the past 3 months was 86% sensitive and 86% specific in detecting alcohol problems compared with a structured, researcher-administered interview."

This study was supported by the Robert Wood Johnson Foundation. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2013;11:53-59. Full text