Comfortably engaging: which approach to alcohol screening should we use?

PURPOSE: We wanted to compare 2 screening instruments for problem drinking, the CAGE and a single question, assessing frequency of use, patient and clinician comfort, and patient engagement in change. METHODS: The study was a crossover, cluster-randomized clinical trial with 31 clinicians in Missouri and 13 in the American Academy of Family Physicians (AAFP) National Network for Family Practice and Primary Care Research; 2,800 patients provided data. The clinician was the unit of randomization. Clinicians decided whether to screen each patient; if they chose to screen, they used the screening approach assigned for that block of patients. The clinician and patient separately completed questionnaires immediately after the office visit to assess each one's comfort with screening (and any ensuing discussion) and the patient's engagement in change. RESULTS: Missouri clinicians screened more patients when assigned the single question (81%) than the CAGE (69%, P = .001 in weighted analysis). There was no difference among AAFP network clinicians (96% of patients screened with the CAGE, 97% with the single question). Eighty percent to 90% of clinicians and 70% of patients reported being comfortable with screening and the ensuing discussion, with no difference between approaches in either network. About one third of patients who were identified as problem drinkers reported thinking about or planning to change their drinking behavior, with no difference in engagement between screening approaches. CONCLUSIONS: Clinicians and patients reported similar comfort with the CAGE questions and the single-question screening tools for problem drinking, and the 2 instruments were equal in their ability to engage the patient. In Missouri, the single question was more likely to be used.

Factors affecting the validity of a Timeline Follow-Back interview.

OBJECTIVE: The Timeline Follow-Back (TLFB) interview is a calendar-prompted, retrospective measure of alcohol consumption. This report examines limitations of the TLFB's validity by examining change in reported consumption going back in time. METHOD: This report analyzes data from a case-control study. Cases (N = 2,517; 56.9% men) were patients presenting for care of an acute injury to one of three emergency departments in Boone County, MO. Two control groups were recruited. Community controls (N = 1,856; 51.1% men) were recruited by random-digit dialing and interviewed by telephone (response rate, 46.5%); medical patients (N = 2,103; 50.9% men) presenting for care of a noninjury illness were interviewed in person and, a few months later, by telephone (complete data obtained on 2,082). A 28-day TLFB interview was conducted with cases and community controls and an 8-day TLFB was done twice with medical controls. RESULTS: A linear regression analysis was done on each individual's drinking over the 28 or 8 days. Averaging participants' regression slopes, cases as a group showed a significant decay in self-reported consumption (0.011 drink per day for each day going back in time). Among community controls, the decay was significantly greater (0.018 drink per day). Analyzing only the 8 days prior to the day of interview, medical controls showed more evidence of bias than either cases or community controls. CONCLUSIONS: The smaller decay in cases' reporting is consistent with an effect of motivation (e.g., engagement in the interview process). Whether the interview is conducted in person (cases and first interviews with medical controls) or by telephone (community controls and second interviews with medical controls) may be relatively less important.

A population-based case-crossover and case-control study of alcohol and the risk of injury.

OBJECTIVE: This study investigated the relationship between alcohol and the risk of acute injury, examining both short-term (drinking over a few hours) and long-term exposures (past-month hazardous drinking and current alcohol use disorders). METHOD: The study was a case-crossover and population-based case control study. Cases (N = 2,517; 1,432 men) were injured patients recruited from all three emergency departments in Boone County, Missouri. Each case's alcohol consumption in the 6 hours prior to injury was compared to his or her consumption the day before in a case-crossover analysis. Community controls (N = 1,856; 948 men) were recruited by telephone and matched to cases by age, gender, day of week and hour. Case-control analyses examined recent alcohol consumption (past 6 hours), past-month hazardous drinking and past-year alcohol use disorders. RESULTS: The odds ratios (ORs) for injury associated with short-term alcohol exposure were similar, whether cases were compared with themselves (case-crossover analyses) or with others (case-control analyses). After 1 or 2 drinks in a 6-hour interval, the ORs were 1.8 (95% confidence interval [CI]: 1.3-2.6) and 1.5 (0.96-2.2), respectively. Similar dose-response curves were seen in the two comparisons, with ORs of 6.2 and 3.7, respectively, after 3 or 4 drinks and 9.5 and 13.5 after 5 or 6 drinks. For past-month hazardous drinking, the OR was 1.7 (95% CI: 1.2-2.3). Current alcohol dependence was associated with injury (OR = 1.9; 95% CI: 1.5-2.6), but alcohol abuse was not (OR = 0.9; 95% CI: 0.8-1.1). CONCLUSIONS: Alcohol's effect on injury risk is related more strongly to acute exposure than to measures of long-term exposure. The risk is significant even at low levels of consumption.