Of 441 male patients who returned Health History Questionnaires and were selected for interviews, 48 (10.9%) were ineligible due to being too ill or deaf to be interviewed (n= 5), having no telephone (n= 24), or not answering repeated telephone calls over a 3-week period (n = 19). Of the remaining 393 patients, 110 (28.0%) did not return Drinking Practices Questionnaires, and 22 (5.6%) refused interviews. A total of 261 patients (66.4% of eligible) completed interviews and returned Drinking Practices Questionnaires ().
)describes demographic and screening characteristics of the entire population of Health History Questionnaire respondents, drinkers mailed the Drinking Practices Questionnaire and respondents to that questionnaire, and participants and nonparticipants in the interview study. Unfortunately, VA Decentralized Hospital Computing Program data on ethnicity were frequently missing. The underlying clinical populations were, however, predominantly white (89.9% of the 65% with ethnicity reported). Answers to a question at the end of the Health History Questionnaire revealed that about 80% of questionnaires were completed by patients themselves; 12% were filled out by patients and their spouses or partners; and 6% were filled out by patients' spouses or someone else.
Characteristics of Health History Questionnaire (HHQ) Respondents, Drinkers Who Were Mailed and Responded to the Drinking Practices Questionnaire (DPQ), and Drinkers Randomly Selected for the Interview Study*
Of 261 study participants, 127 (49%) met interview criteria for lifetime alcohol abuse or dependence, 56 (22%) met criteria for active alcohol abuse and dependence, 89 (34%) met criteria for heavy drinking, and 105 (40%) met our criteria for “heavy drinking and/or active alcohol abuse or dependence.” Among the 261 study participants, 39% indicated on the AUDIT having had 6 or more drinks in a day in the past year (), a much higher proportion than reported more than 14 drinks in a typical week.
Comparison of AUROCs () shows that for identification of active or lifetime alcohol abuse or dependence (), the augmented CAGE performed better than the CAGE alone or the AUDIT (p < .0001). For detection of heavy drinking ( c), however, the AUDIT was a superior screening test to the augmented CAGE (p < .0001), which in turn performed significantly better than the CAGE alone (p < .0001). For identifying heavy drinking and active alcohol abuse or dependence ( d), the AUDIT performed better than either the CAGE (p < .0001) or the augmented CAGE (p < .0001). Again the augmented CAGE performed significantly better than the CAGE alone (p < .0001).
Areas Under Receiver Operating Characteristic Curves (AUROCs)
Figure 2 Comparison of AUROCs for identification of active or lifetime alcohol abuse or dependence: (a) Active alcohol abuse and dependence; (b) lifetime alcohol abuse and dependence; (c) heavy drinking; (d) heavy drinking and/or active alcohol abuse or dependence. (more ...)
All screening questionnaires were more sensitive for active than for lifetime alcohol abuse or dependence ( However, using traditional cutpoints, the CAGE (≥2) missed 47% of patients with heavy drinking or active alcohol abuse or dependence, and the AUDIT (≥8) missed 45%; the augmented CAGE (≥2) only missed 28%. Using lower cutpoints, however, the CAGE and augmented CAGE (≥1) had sensitivities of 77% and 87%, respectively, and the AUDIT (≥4) also had a sensitivity of 87%.
Sensitivity, Specificity, and Positive Likelihood Ratios for Questionnaire Screens Compared with Each Interview Comparison Standard
The AUDIT had higher specificity for heavy drinking or active alcohol abuse or dependence (). Using traditional cutpoints, patients without heavy drinking or active alcohol abuse or dependence in the past year, according to the interviews, were much less likely to screen positive on the AUDIT (4%), than on the CAGE or augmented CAGE (19% or 25%, respectively). This advantage is reflected in the AUDIT's higher positive likelihood ratios. Even with a CAGE or augmented CAGE score of 4 or more, the positive likelihood ratios for these questionnaires were lower than for an AUDIT score of 6 or more.