To our knowledge, this is the first study to derive a short form of the AUDIT (brief AUDIT) and compare the performance of it with that of well known AUD screening questionnaires, CAGE, and NAST, in the primary care setting in Korea.
The new brief AUDIT consists of 4 items: frequency of heavy drinking (item 3), impaired control over drinking (item 4), increased salience of drinking (item 5), and alcohol-related injury (item 9), with a scoring range from 0 to 16. The brief AUDIT discriminated AUD very well. The cut-off point was 5 to detect any AUD (sensitivity 80.4%, specificity 69.4%), and 9 for alcohol dependence (sensitivity 87.5%, specificity 90.8%). The brief AUDIT's AUROC curve for alcohol-use disorder was 0.87 ± 0.04 (SE), and for alcohol dependence was 0.97 ± 0.01 (SE). The brief AUDIT had a greater AUROC curve than either CAGE 0.76 ± 0.05 (SE), or NAST 0.82 ± 0.04 (SE) for Any AUD, and greater than either NAST 0.93 ± 0.02 (SE) or CAGE 0.93 ± 0.03 (SE) for alcohol dependence. As we targeted primary outpatient setting, we put weight for higher sensitivity to detect any AUD and higher specificity for alcohol dependence.
AUDIT was originally designed for practitioners to screen problem drinkers, i.e., drinking problems less severe than diagnosable disorders of AUD as well as AUD. The full 10-item AUDIT with its multidimensional scoring for each item has been called "cumbersome" for use in some settings where rapidity of scoring, as well as accuracy, is important.21)
Many abbreviated versions of AUDIT were generated and tested to meet this practical need. AUDIT-C, the most commonly tested derived AUDIT, consists of the first 3 items of the AUDIT (the consumption factor items). AUDIT-C was reported useful to screen problem drinkers, and AUD in western countries. FAST is a 4-item scale consisting of item 3 (modified for men by increasing the number of drinks from 1 occasion to 8) as well as items 5, 8, and 10 from the original AUDIT. Unfortunately, these researchers validated the abbreviated scale only against the full AUDIT rather than also against an independent, formal alcohol diagnosis or hazardous drinking criterion.22)
Drinking behavior of the western population may be quite different from that of Korea. Heavy drinking is very popular because alcohol is accepted generously and quite often, and is socially forced in work-related gatherings, especially for men. This consumption factor might not be enough to discriminate AUD, however it is the main reason we decided to derive a short version for Koreans rather than using the existing one. We compared the performance of the brief AUDIT with the AUDIT-C and FAST. The AUROC against AUD was 0.868 for the brief AUDIT, 0.739 for the AUDIT-C, and 0.898 for FAST. The AUROC for alcohol dependence was 0.972 for the brief AUDIT, 0.664 for the AUDIT-C, and 0.942 for FAST (data not presented). The performance of the brief AUDIT was about equal to FAST, and better than the AUDIT-C. The performance of the AUDIT-C to detect AUD against formal alcohol diagnosis need to be further evaluated for Koreans.
The AUDIT questionnaire is measured consistently over time and is particularly useful in detecting recent problem drinking. Investigators in a six-country World Health Organization project developed the AUDIT to screen patients in primary health care settings for hazardous or harmful drinking and serve as a basis for discussion with patents in brief therapy.12)
Hazardous drinkers are individuals at high risk for alcohol-related damage to physical or psychological health; harmful drinkers already experience such problems.23)
The original cut-off point to detect hazardous drinker is 8, yielding a sensitivity of 0.90 s, and specificity of 0.80 s. To find the hazardous drinking cut-off point, the gold standard criteria need to be multidimensional: heavy consumption (i.e., 14 or more drinks per week), laboratory results or clinical diagnosis like alcoholic hepatitis, as well as diagnosis of AUD. The performance of AUDIT against those criteria needs to be evaluated further to make the AUDIT more practical, and at the same time, accurate for Koreans. Also, further study to evaluate the performance of the abbreviated version of the AUDIT against other criteria than AUD might be useful to detect problem drinkers.
Limitations of this study were as follows. Firstly, the study subjects were not representative of the entire population. Women were excluded, and the age range of study subjects was 32 to 63. Cut-off points could be different for different populations, as alcohol affects women differently. Women were excluded because alcohol screening questionnaires function differently in men and women19)
and we could not recruit an adequate number of women through which to base any conclusions regarding questionnaire performance. Also we collected 15% of study subjects from the psychiatric ward and not only from primary outpatient clinics for the same reason. Secondly, performance of the brief AUDIT on criteria of problem drinking was not measured as mentioned above. Thirdly, test-retest was not evaluated. Lastly, we used the same population to derive and validate the brief AUDIT.
The brief AUDIT was short and performed well to screen alcohol-use disorders in middle-aged men. It will facilitate screening for alcohol problems where significant constraints on time exist. Further research to evaluate performance of the brief AUDIT against criteria of problem drinking in large populations including other age groups and women are needed to verify its effectiveness.