We found that a majority of AUDIT-positive patients recalled a discussion about alcohol problems by their resident physician. The majority of the discussions consisted of advice to decrease use and much less often involved a specific recommendation for more traditional treatment. Nevertheless, there appeared to be a modest reduction in patient alcohol consumption over 6 months.
Our finding of a 78% discussion rate in screen-positive patients was comparable to that in a previous study. Schorling et al. screened patients of categorical internal medicine, primary care internal medicine, and family medicine residents for alcohol abuse using the Michigan Alcoholism Screening Test and showed that 60% to 80% of positive patients recalled a discussion of alcohol abuse by their physician in the past year.29
In our study, resident intervention consisted mostly of advice to “cut down” in 58% of AUDIT-positive patients, but referral to other therapy occurred in less than 25%. This finding is lower than that found in the inpatient setting, where Moore noted that when the diagnosis of alcohol abuse was made, treatment was instituted 50% to 75% of the time.30
If outpatients are more likely problem drinkers, then they may lack clinical evidence of an alcohol-related problem and physicians might be less likely to offer other, more intensive traditional treatment.
Newly diagnosed patients in our study were less likely to recall a discussion, and physicians were less likely to note an alcohol-related problem. These patients may be problem drinkers who lack the “clinical” evidence of an alcohol-related problem. In a similar study, Buchsbaum et al. administered the alcohol module of the Diagnostic Interview Schedule to patients in a medical clinic at an urban university teaching hospital staffed by interns and residents and studied patient and physician characteristics that influence detection of problem drinking.15
Resident physicians, unaware of the interview results, noted alcohol problems in the chart of 49% of patients who met criteria for current alcohol abuse or dependence. Previous medical record reference of alcohol problems, number of concurrent medical problems, patient gender, and gastrointestinal problems were associated with detection of alcohol problems by residents. Our notation rate of 58% resulted when physicians were made aware of a current problem. We also found that prior medical record notation was the strongest predictor of current notation in the chart. The association of prior medical record notation in both studies support the theory that residents depend on prior labeling with alcohol diagnoses in making current alcohol-related diagnoses.
Six months after screening, patients reported a decrease in alcohol consumption and were less likely to drink in the problem range. This was due primarily to decreased consumption among the AUDIT-positive group and problem drinkers. However, screen-positive patients who recalled a discussion about alcohol with their doctor or for whom physicians made a note in the chart had a similar decrease in their alcohol consumption compared with those without a reported discussion or notation. The rate of utilization of alcohol-related and non-alcohol-related health care services was low in all patients and did not explain the decrease in consumption.
These overall findings suggest that a simple screening program may act as a brief intervention for problem drinkers. A simple screen or reminder has been shown to reduce consumption and adverse outcomes from drinking in a number of studies.31
Wallace et al., screening general practitioners' practices, found an overall reduction of 24% in the proportion of patients who reported excessive levels of consumption at 12 months.10
Most recently, Fleming et al. reported a 20% reduction in alcohol use among control patients in a study evaluating the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers.12
Patients in our study who were AUDIT-negative but consumed alcohol in the problem range also had a significant decrease in their consumption although we did not specifically identify them to their physicians. The reasons for these reductions include regression to the mean, historical changes in alcohol use, and the intervention effect of the screen and the data collection procedures independent of physician involvement.
There are several limitations to our study. First, the patient sample was derived from a single VA hospital, which may limit the generalizability of our results. Veterans may possess unique medical and psychosocial comorbidities that increase the prevalence of alcohol problems or make their diagnosis difficult to establish. Our prevalence, although low, is in the range of earlier studies, as is our rate of physician recognition.14, 28
Our lower rate of alcohol problems and higher rate of nondrinkers may be a reflection of the older age of our population. Patients who were heavier drinkers may have succumbed from complications associated with drinking or other comorbid conditions. Residents cared for the patients in our study so these results may not be applicable to other health care providers. The issue of alcohol abuse and early treatment, however, should be more salient during training and thus resident rates of discussion might be higher than with physicians in practice. Residents are also caring for fewer patients per clinical session.
We used a quantity-frequency method to assess average level of consumption. Such methods may underestimate consumption especially when patients have days of excessive or heavy alcohol use that deviate substantially from their average daily consumption.32
However, when average consumption was sought, this method produced results similar to those of a study using a more sensitive time-line method.32
Finally, we used a telephone-based screen that may have biased patient responses. Prior comparisons between telephone interviews and face-to-face interviews found that women tended to underreport consumption in face-to-face interviews, but no difference was seen in men.33
Despite these limitations, we believe our study has important implications. First, we showed that given the knowledge of a positive alcohol screen, residents discussed alcohol problems in a majority of patients, however, this occurred less often for patients without a prior history of alcohol abuse. Second, a simple screen for alcohol problems may be enough of an intervention to decrease alcohol consumption in patients. This last finding contributes to the growing body of literature supporting the importance of a brief intervention. Given these findings, clinic directors should consider implementing a systematic screening program to identify alcohol problems and decrease overall drinking rates in their patients.