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1.  Alcohol misuse, genetics, and major bleeding among warfarin therapy patients in a community setting† 
Little is known about the impact of alcohol consumption on warfarin safety, or whether demographic, clinical, or genetic factors modify risk of adverse events. We conducted a case–control study to assess the association between screening positive for moderate/severe alcohol misuse and the risk of major bleeding in a community sample of patients using warfarin.
The study sample consisted of 570 adult patients continuously enrolled in Group Heath for at least 2 years and receiving warfarin. The main outcome was major bleeding validated through medical record review. Cases experienced major bleeding, and controls did not experience major bleeding. Exposures were Alcohol Use Disorders Identification Test Consumption Questionnaire (AUDIT-C) scores and report of heavy episodic drinking (≥5 drinks on an occasion). The odds of major bleeding were estimated with multivariate logistic regression models. The overall sample was 55% male, 94% Caucasian, and had a mean age of 70 years.
Among 265 cases and 305 controls, AUDIT-C scores indicative of moderate/severe alcohol misuse and heavy episodic drinking were associated with increased risk of major bleeding (OR = 2.10, 95% CI = 1.08–4.07; and OR = 2.36, 95% CI = 1.24–4.50, respectively). Stratified analyses demonstrated increased alcohol-related major bleeding risk in patients on warfarin for ≥1 year and in those with a low-dose genotype (CYP2C9*2/*3, VKORC1(1173G>A), CYP4F2*1), but not in other sub-groups evaluated.
Alcohol screening questionnaires, potentially coupled with genetic testing, could have clinical utility in selecting patients for warfarin therapy, as well as refining dosing and monitoring practices.
PMCID: PMC4478047  PMID: 25858232
warfarin; AUDIT-C; alcohol; CYP2C9; VKORC1; CYP4F2; major bleeding; pharmacoepidemiology
4.  An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration 
Addiction (Abingdon, England)  2014;109(9):1472-1481.
The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.
Observational, retrospective cohort study using secondary clinical and administrative data.
Thirty VA facilities.
Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9–15 months later (n = 6210; 28%).
Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).
Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42–52%] and 48% (95% CI = 42–54%) for patients with and without documented brief intervention, respectively (P = 0.50).
During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.
PMCID: PMC4257468  PMID: 24773590
Alcohol; brief intervention; implementation; unhealthy alcohol use; veterans
5.  Alcohol and Associated Characteristics among Older Persons Living with HIV on Antiretroviral Therapy 
Alcohol use, and particularly unhealthy alcohol use, is associated with poor HIV-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are under-described in this population. We describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to ART.
Participants were recruited from AIDS Service Organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C alcohol screen, socio-demographic characteristics, substance use and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into non-drinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1-3, 4-6, 7-12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers.
Among 447 participants, 57% reporting drinking alcohol in the past year, including 35%, 15% and 7% reporting low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively. Any drinking was most common among men and those who were LGBT, married/partnered, had received past-year alcohol treatment, and never used injection drugs (p-values all <0.05). Differences in race, employment status, past year alcohol treatment, and positive depression screening (p-values all <0.05) were observed across AUDIT-C categories.
In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.
PMCID: PMC4249664  PMID: 24625188
Alcohol; HIV; Older adults
6.  Costly reproductive competition between females in a monogamous cooperatively breeding bird 
In many cooperatively breeding societies, only a few socially dominant individuals in a group breed, reproductive skew is high, and reproductive conflict is common. Surprisingly, the effects of this conflict on dominant reproductive success in vertebrate societies have rarely been investigated, especially in high-skew societies. We examine how subordinate female competition for breeding opportunities affects the reproductive success of dominant females in a monogamous cooperatively breeding bird, the Southern pied babbler (Turdoides bicolor). In this species, successful subordinate reproduction is very rare, despite the fact that groups commonly contain sexually mature female subordinates that could mate with unrelated group males. However, we show that subordinate females compete with dominant females to breed, and do so far more often than expected, based on the infrequency of their success. Attempts by subordinates to obtain a share of breeding impose significant costs on dominant females: chicks fledge from fewer nests, more nests are abandoned before incubation begins, and more eggs are lost. Dominant females appear to attempt to reduce these costs by aggressively suppressing potentially competitive subordinate females. This empirical evidence provides rare insight into the nature of the conflicts between females and the resultant costs to reproductive success in cooperatively breeding societies.
PMCID: PMC3673060  PMID: 23677348
female competition; reproductive conflict; cooperative breeding; reproductive skew; Southern pied babbler; Turdoides bicolor
7.  Alcohol Screening Scores and 90 Day Outcomes in Patients with Acute Lung Injury 
Critical care medicine  2013;41(6):1518-1525.
The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury (ALI) have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test (AUDIT) that correspond to past year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with ALI.
Secondary analysis.
The Acute Respiratory Distress Syndrome (ARDS) network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multi-center clinical trials in patients with acute lung injury.
Patients meeting consensus criteria for ALI enrolled in one of three recent ARDS network clinical trials.
Measurements and Main Results
Of 1,133 patients enrolled in one of three ARDS network studies, 1,037 patients had an AUDIT score available for analysis. Alcohol misuse was common with 70 (7%) of patients having AUDIT scores in zone 3 and 129 (12%) patients in zone 4. There was a u-shaped association between validated AUDIT zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients in AUDIT zone 4 when compared to those in zone 2 (adjusted OR 1.70; 95% CI 1.00, 2.87; p = 0.048).
Severe, but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in ALI patients.
PMCID: PMC4048714  PMID: 23538449
alcohol use disorders identification test; acute lung injury; alcohol use disorder; alcohol misuse; unhealthy alcohol use
8.  When Quality Indicators Undermine Quality: Bias in a Quality Indicator of Follow-up for Alcohol Misuse 
Valid quality indicators are needed to monitor and incentivize identification and management of mental health and substance use conditions (“behavioral conditions”). Because behavioral conditions are frequently under-identified, quality indicators often evaluate the proportion of patients who screen positive for a condition who have appropriate follow-up care documented. However, these “positive-screen-based” quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality (“denominator bias”) and could reward identification of fewer patients with the behavioral condition(s) of interest.
To evaluate denominator bias in the performance of Veterans Health Administration (VA) networks on a quality indicator of follow-up for alcohol misuse that used patients with positive alcohol screens as the denominator.
The performance of 21 VA networks on a positive-screen-based quality indicator of follow-up for alcohol misuse was compared to the networks' performance on a population-based quality indicator (proportion of eligible patients who had alcohol misuse identified and follow-up documented) using medical record reviews (n=219,119).
Results of the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7%, 65.4%) even though one identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% vs 7.4% respectively).
A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.
PMCID: PMC3959120  PMID: 23852137
quality improvement; alcohol counseling; alcohol screening
9.  Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples 
The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice.
This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C.
Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking.
This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens.
Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.
PMCID: PMC3946205  PMID: 24468406
AUDIT-C; Brief intervention; Unhealthy alcohol use; Alcohol screening; Heavy episodic drinking
10.  Association between Alcohol Screening Scores and Mortality in Black, Hispanic, and White Male Veterans 
AUDIT-C alcohol screening scores are associated with mortality, but whether or how associations vary across race/ethnicity is unknown.
Self-reported black (n=13,068), Hispanic (n=9,466), and white (n=182,688) male VA outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1–4, 5–8, and 9–12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity.
Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1–4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p=0.0022). Hispanic and white patients with scores of 0, 5–8, and 9–12 had significantly increased risk of death compared to those with scores of 1–4; Hispanic ORs: 1.93, 95% CI 1.50–2.49; 1.57, 1.07–2.30; 1.82, 1.04–3.17, respectively; white ORs: 1.34, 95% CI 1.29–1.40; 1.12, 1.03–1.21; 1.81, 1.59–2.07, respectively. Black patients with scores of 0 and 5–8 had increased risk relative to scores of 1–4 (ORs 1.28, 1.06–1.56 and 1.50, 1.13–1.99), but there was no significant increased risk for scores of 9–12 (ORs 1.27, 0.77–2.09). Post-hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity.
Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically-tailored feedback regarding medical consequences of drinking.
PMCID: PMC3443543  PMID: 22676340
alcohol; race; ethnicity; mortality; AUDIT-C
11.  Environmental factors influence both abundance and genetic diversity in a widespread bird species 
Ecology and Evolution  2013;3(14):4683-4695.
Genetic diversity is one of the key evolutionary variables that correlate with population size, being of critical importance for population viability and the persistence of species. Genetic diversity can also have important ecological consequences within populations, and in turn, ecological factors may drive patterns of genetic diversity. However, the relationship between the genetic diversity of a population and how this interacts with ecological processes has so far only been investigated in a few studies. Here, we investigate the link between ecological factors, local population size, and allelic diversity, using a field study of a common bird species, the house sparrow (Passer domesticus). We studied sparrows outside the breeding season in a confined small valley dominated by dispersed farms and small-scale agriculture in southern France. Population surveys at 36 locations revealed that sparrows were more abundant in locations with high food availability. We then captured and genotyped 891 house sparrows at 10 microsatellite loci from a subset of these locations (N = 12). Population genetic analyses revealed weak genetic structure, where each locality represented a distinct substructure within the study area. We found that food availability was the main factor among others tested to influence the genetic structure between locations. These results suggest that ecological factors can have strong impacts on both population size per se and intrapopulation genetic variation even at a small scale. On a more general level, our data indicate that a patchy environment and low dispersal rate can result in fine-scale patterns of genetic diversity. Given the importance of genetic diversity for population viability, combining ecological and genetic data can help to identify factors limiting population size and determine the conservation potential of populations.
PMCID: PMC3867904  PMID: 24363897
Animals; conservation; molecular ecology; population genetics
15.  Alcohol Screening Scores and the Risk of New-Onset Gastrointestinal Illness or Related Hospitalization 
Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.
To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.
Retrospective cohort study.
Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.
Alcohol Use Disorder Identification Test—Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0–12 points).
Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5–8 and 9–12 (OR 1.54, 95% CI = 1.27–1.86; and OR 3.27; 95% CI = 2.62–4.09 respectively), and women with AUDIT-C scores of 9–12 (OR 6.84, 95% CI = 1.85 – 25.37). Men with AUDIT-C scores of 5–8 and 9–12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30–1.71; and OR 2.82, 95% CI = 2.38–3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05–1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9–12 was also increased (OR 2.14; 95% CI = 1.54–2.97).
Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1688-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3138581  PMID: 21455813
alcohol; AUDIT; gastrointestinal; hospitalization; new-onset; women
16.  Quality Concerns with Routine Alcohol Screening in VA Clinical Settings 
Alcohol screening questionnaires have typically been validated when self- or researcher-administered. Little is known about the performance of alcohol screening questionnaires administered in clinical settings.
The purpose of this study was to compare the results of alcohol screening conducted as part of routine outpatient clinical care in the Veterans Affairs (VA) Health Care System to the results on the same alcohol screening questionnaire completed on a mailed survey within 90 days and identify factors associated with discordant screening results.
Cross sectional.
A national sample of 6,861 VA outpatients (fiscal years 2007–2008) who completed the AUDIT-C alcohol screening questionnaire on mailed surveys (survey screen) within 90 days of having clinical AUDIT-C screening documented in their medical records (clinical screen).
Alcohol screening results were considered discordant if patients screened positive (AUDIT-C ≥ 5) on either the clinical or survey screen but not both. Multivariable logistic regression was used to estimate the prevalence of discordance in different patient subgroups based on demographic and clinical characteristics, VA network and temporal factors (e.g. the order of screens).
Whereas 11.1% (95% CI 10.4-11.9%) of patients screened positive for unhealthy alcohol use on the survey screen, 5.7% (5.1- 6.2%) screened positive on the clinical screen. Of 765 patients who screened positive on the survey screen, 61.2% (57.7-64.6%) had discordant results on the clinical screen, contrasted with 1.5% (1.2-1.8%) of 6096 patients who screened negative on the survey screen. In multivariable analyses, discordance was significantly increased among Black patients compared with White, and among patients who had a positive survey AUDIT-C screen or who received care at 4 of 21 VA networks.
Use of a validated alcohol screening questionnaire does not—by itself—ensure the quality of alcohol screening. This study suggests that the quality of clinical alcohol screening should be monitored, even when well-validated screening questionnaires are used.
PMCID: PMC3043188  PMID: 20859699
alcohol screening; brief alcohol counseling; validation
17.  Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery 
Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.
To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire—up to a year before surgery—were associated with the risk of postoperative complications.
This is a cohort study.
Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA’s Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.
One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.
Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8–6.6%) in patients with AUDIT-C scores 1–4, to 7.9% (6.3–9.7%) in patients with AUDIT-Cs 5–8, 9.7% (6.6–14.1%) in patients with AUDIT-Cs 9–10 and 14.0% (8.9–21.3%) in patients with AUDIT-Cs 11–12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1–5.7%) in patients with AUDIT-C scores 1–4, to 6.9% (5.5–8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0–11.3%) among those with AUDIT-Cs 9–10.
AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1475-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3019325  PMID: 20878363
alcohol screening; surgical outcomes; AUDIT-C
18.  Risk of future trauma based on alcohol screening scores: A two-year prospective cohort study among US veterans 
Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender.
Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1–4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed.
Having an AUDIT-C score of 9–12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men ≤50 years, those with AUDIT-C scores ≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1–4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR = 1.24; 95% confidence interval [CI], 1.03–1.50). For men ≥65 years with average comorbidity and education, those with AUDIT-C scores of 5–8 (adjusted prevalence, 7.9% versus 7.4%; OR = 1.16; 95% CI, 1.02–1.31) and 9–12 (adjusted prevalence 11.1% versus 7.4%; OR = 1.68; 95% CI, 1.30–2.17) were at significantly increased risk for trauma compared with men ≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women.
Men with severe alcohol misuse (AUDIT-C 9–12) demonstrate an increased risk of trauma. Men ≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5–8 and 9–12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.
PMCID: PMC3414833  PMID: 22966411
Alcohol; Trauma; Fracture; AUDIT-C; Age; Gender; Screening; Women
21.  Feedback from recently returned veterans on an anonymous web-based brief alcohol intervention 
Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are at increased risk for alcohol misuse, and innovative methods are needed to improve their access to alcohol screening and brief interventions (SBI). This study adapted an electronic SBI (e-SBI) website shown to be efficacious in college students for OEF/OIF veterans and reported findings from interviews with OEF/OIF veterans about their impressions of the e-SBI.
Outpatient veterans of OEF/OIF who drank ≥3 days in the past week were recruited from a US Department of Veterans Affairs (VA) Deployment Health Clinic waiting room. Veterans privately pretested the anonymous e-SBI then completed individual semistructured audio-recorded interviews. Their responses were analyzed using template analysis to explore domains identified a priori as well as emergent domains.
During interviews, all nine OEF/OIF veterans (1 woman and 8 men) indicated they had received feedback for risky alcohol consumption. Participants generally liked the standard-drinks image, alcohol-related caloric and monetary feedback, and the website’s brevity and anonymity (a priori domains). They also experienced challenges with portions of the e-SBI assessment and viewed feedback regarding alcohol risk and normative drinking as problematic, but described potential benefits derived from the e-SBI (emergent domains). The most appealing e-SBIs would ensure anonymity and provide personalized transparent feedback about alcohol-related risk, consideration of the context for drinking, strategies to reduce drinking, and additional resources for veterans with more severe alcohol misuse.
Results of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.
PMCID: PMC3507636  PMID: 23186354
Internet; Alcohol; Brief intervention; Feedback; Iraq war; Veteran
23.  Associations Between AUDIT-C and Mortality Vary by Age and Sex 
Population Health Management  2010;13(5):263-268.
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1–4, 5–8, 9–12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9–12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5–8 and 9–12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or “vital sign” that might facilitate the detection and management of alcohol-related risks and problems. (Population Health Management 2010;13:263–268)
PMCID: PMC3135896  PMID: 20879907
24.  Physical Health and Drinking among Medical Inpatients with Unhealthy Alcohol Use: A Prospective Study 
Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a “teachable moment” that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.
Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n=341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.
Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were non-dependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03 – 0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13 – 0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.
Among medical inpatients with non-dependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.
PMCID: PMC2911969  PMID: 20477765
25.  Estimating Risk of Alcohol Dependence Using Alcohol Screening Scores* 
Drug and alcohol dependence  2009;108(1-2):29-36.
Brief alcohol counseling interventions can reduce alcohol consumption and related morbidity among non-dependent risky drinkers, but more intensive alcohol treatment is recommended for persons with alcohol dependence. This study evaluated whether scores on common alcohol screening tests could identify patients likely to have current alcohol dependence so that more appropriate follow-up assessment and/or intervention could be offered. This cross-sectional study used secondary data from 392 male and 927 female adult family medicine outpatients (1993–1994). Likelihood ratios were used to empirically identify and evaluate ranges of scores of the AUDIT, the AUDIT-C, two single-item questions about frequency of binge drinking, and the CAGE questionnaire for detecting DSM-IV past-year alcohol dependence. Based on the prevalence of past-year alcohol dependence in this sample (men: 12.2%; women: 5.8%), zones of the AUDIT and AUDIT-C identified wide variability in the post-screening risk of alcohol dependence in men and women, even among those who screened positive for alcohol misuse. Among men, AUDIT zones 5–10, 11–14 and 15–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 18–87%, and AUDIT-C zones 5–6, 7–9 and 10–12 were associated with probabilities ranging from 22–75%. Among women, AUDIT zones 3–4, 5–8, 9–12 and 13–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 6–94%, and AUDIT-C zones 3, 4–6, 7–9 and 10–12 were associated with probabilities ranging from 9–88%. AUDIT or AUDIT-C scores could be used to estimate the probability of past-year alcohol dependence among patients who screen positive for alcohol misuse and inform clinical decision-making.
PMCID: PMC2835806  PMID: 20042299
Alcohol dependence; alcohol screening; stratum specific likelihood ratio; risk stratification; assessment; treatment

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