Quality concerns with routine alcohol screening in VA clinical settings

Abstract

Background: 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.

Objective: 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.

Design: Cross sectional.

Participants: 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).

Main measures: 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).

Key results: 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.

Conclusion: 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.

Figure 1

Study sample. The prevalence of positive survey screens among all of 427,612 survey respondents who completed the AUDIT-C was 13.4% (95% CI 13.3-13.5) and the prevalence of positive clinical screens in all 207,181 patients who had AUDIT-C results abstracted from the medical records was 6.4% (95% CI 6.3-6.5). These were higher than in the study sample, as expected, likely due to greater survey non-response in younger patients and heavier drinkers.

Figure 2

Among patients with each AUDIT-C score based on clinical screens (Panel a) or survey screens (Panel b), the percent with discordant results on the other screen (N = 6,861). Alcohol screening results are considered discordant if a patient screened positive on the clinical or survey screen but not the other. Panel a: The percent of patients with each AUDIT-C score (0–12 points) on the clinical screen who had discordant survey screen results. Panel b: The percent of patients with each AUDIT-C score (0–12 points) on the survey screen who had discordant clinical screen results.