Screening for Alcoholism in the Primary Care Setting

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Original Research

Screening for Alcoholism in the Primary Care Setting

J Fam Pract. 2002 January;51(1):41-46

By

Stephan Arndt, PhD

Are We Talking to the Right People?

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References

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ABSTRACT

BACKGROUND: This study assessed which demographic groups were most likely to consume alcohol excessively, and which groups had received inquiries and discussion about alcohol use from their physicians compared with discussions about other health risks.

STUDY DESIGN: This was a cross-sectional study using data from the Centers for Disease Control Behavioral Risk Factors Surveillance System 1997 data set that represents a stratified random sample in the United States.

POPULATION: We selected 23,349 adults who reported a routine physical examination within the last 3 years.

OUTCOMES MEASURED: The main variables involved responses to questions about alcohol intake and whether the respondent’s physician had initiated discussions about drinking.

RESULTS: Physicians spoke to patients about alcohol use much less frequently than about other health-related behaviors. Discussions were roughly targeted to groups with the largest intake. However, physicians were least likely to speak with white patients, women, and widows who drank significantly.

CONCLUSIONS: Regularly asking patients about alcohol use could substantially reduce the under-recognition of alcoholism. Since brief counseling is effective, negative consequences of excessive alcohol intake may be avoided.

KEY POINTS FOR CLINICIANS

Alcohol screening occurs less frequently than screening about other health-related behaviors.
There were no demographic groups in which the prevalence of excessive drinking was so low that general screening was not appropriate.
Physicians frequently miss the opportunity to discuss alcohol use with patients in certain groups, such as white patients and women (widows, in particular).

Physicians and related health care workers are well positioned to detect possible alcohol-related problems during routine patient visits, provided the appropriate screening procedures are implemented.^2-4 Ideally, the primary care clinician should be the most prominent source of alcohol abuse screening and referrals, rather than the provider of treatment after an alcohol-related incident.

Although screening for alcoholism adds another step to an already over-worked health care system, it can result in substantial benefits by reducing the burden of overall health care costs. According to recent information, alcohol abuse costs our society $184.6 billion.⁵ In 1997, an estimated 1.3 million hospital discharges reported an alcohol-related diagnosis.⁶ And an estimated 12,870 alcohol-related traffic fatalities accounted for nearly one third of all traffic deaths in that same year.⁷ Even when individuals reamin socially functional and do not meet the formal criteria for an alcohol-related disorder, excessive use of alcohol is associated with a variety of medical problems. Although cardioprotective effects have been reported with moderate use (ie, 1 to 2 drinks per day), the list of medical complications associated with longstanding alcoholism (hypertension, cardiomyopathy, cirrhosis, erosive gastris, pancreatitis, and esophageal varices, for example) account for considerable morbidity and mortality.^8,9 Increased alcohol consumption over a 1-year period is also associated with accidents and injuries necessitating emergency services.¹⁰

Because the primary care physician is in a unique position to influence the preventive care of the community they serve, our study examined alcohol screening in the primary care setting. The following 2 questions were asked: (1) Which patients were assessed for excessive alcohol use, and what patient characteristics predicted the assessment? and (2) How often did discussions about alcohol occur compared with other health risk discussions (eg, eating habits or smoking)?

Methods

Subjects

This is a secondary analysis of data from an epidemiologic telephone interview conducted by the Behavioral Risk Factors Surveillance System (BRFSS)¹ involving a random stratified sample of people living within the United States. In the 1997 interviews, all state interviews included questions about alcohol consumption. Alaska, Colorado, Idaho, Louisiana, Missouri, New York, North Carolina, Oklahoma, Pennsylvania, Virginia, and Wyoming included a counseling module that asked, “Has a doctor or other health professional ever talked with you about alcohol use?”

The 1997 BRFSS data set represents 135,582 interviews. The sample reported here includes only respondents who reported a routine physical examination within the last 3 years and who were asked questions from the counseling module (n = 23,349), as well as questions about other health habits. There were 9106 men (mean age = 45.82 years; SD = 16.86) and 14,203 women (mean age = 46.90; SD = 17.44) who responded.

Excessive drinking was defined as consuming 60 alcoholic beverages per month or 5 on a single occasion (binge drinking) in the month prior to the interview (n = 2772). The 60 beverages per month threshold follows recommendations by the National Institute for Alcohol Abuse and Alcoholism and the US Department of Health and Human Services’ Dietary Guidelines for Americans.^11,12

Statistical analysis

Analysis used the sampling weights provided by the Centers for Disease Control. The data were weighted so that the summary statistics, standard errors, and test statistics took into account the sampling design and represented estimates in the total US. population. We used the procedures described by Levy and Lemeshow,¹³ and implemented them using STATA.¹⁴ These included simple chi-square tests, logistic regression with F- or t-approximations. The F- and t-approximations for the logistic regression were necessary to adjust for the complex survey design.¹³ Hierarchical (protected) testing procedures helped correct for multiple comparisons. We used omnibus tests for variables with multiple options (eg, marital status), and only considered follow-up tests when the overall test result was significant. Furthermore, a conservative threshold for significance (P < .01) was a compromise to the Bonferroni correction for multiple comparisons.