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The AUDIT Alcohol Consumption Questions AUDIT-C

The AUDIT Alcohol Consumption Questions AUDIT-C - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


The AUDIT Alcohol Consumption
Questions (AUDIT-C)
An Effective Brief Screening Test for Problem Drinking
Kristen Bush, MPH; Daniel R. Kivlahan, PhD; Mary B. McDonell, MS; Stephan D. Fihn, MD, MPH;
Katharine A. Bradley, MD, MPH; for the Ambulatory Care Quality Improvement Project (ACQUIP)
Objective:To evaluate the 3 alcohol consumption ques-
tions from the Alcohol Use Disorders Identification Test
(AUDIT-C) as a brief screening test for heavy drinking
and/or active alcohol abuse or dependence.
Methods: Patients from 3 Veterans Affairs general medi-
cal clinics were mailed questionnaires. A random,
weighted sample of Health History Questionnaire re-
spondents, who had 5 or more drinks over the past year,
were eligible for telephone interviews (N = 447). Heavy
drinkers were oversampled 2:1. Patients were excluded
if they could not be contacted by telephone, were too ill
for interviews, or were female (n = 54). Areas under re-
ceiver operating characteristic curves (AUROCs) were
used to compare mailed alcohol screening question-
naires (AUDIT-C and full AUDIT) with 3 comparison
standards based on telephone interviews: (1) past year
heavy drinking (.14 drinks/week or $5 drinks/
occasion); (2) active alcohol abuse or dependence ac-
cording to the Diagnostic and Statistical Manual of Men-
tal Disorders, Revised Third Edition, criteria; and (3) either.
Results:Of 393 eligible patients, 243 (62%) completed
AUDIT-C and interviews. For detecting heavy drinking,
AUDIT-C had a higher AUROC than the full AUDIT
(0.891 vs 0.881; P = .03). Although the full AUDIT per-
formed better than AUDIT-C for detecting active alco-
hol abuse or dependence (0.811 vs 0.786; P<.001), the
2 questionnaires performed similarly for detecting heavy
drinking and/or active abuse or dependence (0.880 vs
0.881).
Conclusions: Three questions about alcohol consump-
tion (AUDIT-C) appear to be a practical, valid primary
care screening test for heavy drinking and/or active al-
cohol abuse or dependence.
Arch Intern Med. 1998;158:1789-1795
H
EAVY DRINKING and alco-
hol abuse and/or depen-
dence are common among
primary care patients,
1-3
and result in consider-
able suffering,
4-6
mortality,
4,5,7,8
and eco-
nomic costs.
9
The risk of alcohol-related
psychosocial, legal, and economic prob-
lems increases when drinking exceeds 14
drinks a week or 5 or more drinks per oc-
casion for men.
10,11
Referral to specialized
alcohol treatment is effective for alcohol-
dependent patients.
12,13
Over the last 10
years, primary care interventions with
heavy-drinking men have been shown to
decrease consumption, blood pressure, lev-
els of serum g-glutamyl transferase, and
days hospitalized.
14-17
Unfortunately, primary care patients
who might benefit from brief, alcohol-
related interventions or referral are often un-
recognized until serious complications of
drinking have developed.
2,3
Despite the
availability of standardized questionnaires
that effectively screen for heavy and prob-
lem drinking in primary care settings
18-20
and
compelling evidence of the benefits of
screening and intervention,
14-17,21-23
physi-
cians usually do not use these question-
naires in the absence of a clinicwide screen-
ing program.
2,24,25
A major obstacle to routine screen-
ing for heavy drinking and/or alcohol abuse
or dependence is the lack of a valid, prac-
tical screening test. The optimal screen-
ing test for problem drinking would be
brief and acceptable to both clinicians and
patients. It would also have excellent sen-
sitivity for heavy drinking that had not yet
resulted in adverse consequences, as well
as for active alcohol abuse or depen-
dence. To date, no screening question-
naire fully satisfies these criteria.
The 4-item CAGE is the briefest ef-
fective screening test for lifetime alcohol
abuse and/or dependence,
26
but it is in-
sensitive for detecting heavy drinking and
does not distinguish between active and
past problem drinking.
20,27,28
Moreover, al-
though physicians appear to know the 4
ORIGINAL INVESTIGATION
From Health Services Research
and Development (Mss Bush
and McDonell, and Drs Fihn
and Bradley), the Center of
Excellence for Substance Abuse
Treatment and Education
(Ms Bush and Dr Kivlahan),
and Medicine Service (Drs Fihn
and Bradley), VA Puget Sound
Health Care System, Seattle
Division, Wash; the
Departments of Medicine
(Drs Fihn and Bradley),
Psychiatry and Behavioral
Services (Ms Bush and
Dr Kivlahan), and Health
Services (Drs Fihn and
Bradley), University of
Washington, Seattle.
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CAGE questions, they seldom ask a patient all 4.
24
The
Alcohol Use Disorders Identification Test (AUDIT) was
developed specifically to identify patients with recent
heavy drinking, as well as alcohol dependence, and per-
formed significantly better than the CAGE as a screen for
heavy drinking and/or active alcohol abuse or depen-
dence in our study of Veterans Affairs (VA) general medi-
cal patients.
20
However, despite the AUDIT’s demon-
strated validity,
19,29,30
the AUDIT’s 10-question length
makes it unlikely that primary providers will incorpo-
rate it into routine patient interviews, or that it will be
embedded into general health history questionnaires.
Several 2- and 3-item alcohol screening question-
naires have been evaluated. A 3-item questionnaire about
alcohol consumption performed adequately for identi-
fication of active alcohol abuse or dependence but is un-
likely to be widely adopted because of its low face valid-
ity: drinking 6 or more drinks a week was the threshold
for a positive screening test.
31
An encouraging initial re-
port of a 2-question screening test has not been repli-
cated.
32-35
Other brief screening questionnaires have also
not been shown to have adequate sensitivity for heavy
drinking and/or active alcohol abuse or dependence in
primary care populations using standardized compari-
son standards.
36-39
We hypothesized that the third AUDIT question,
which asks about the frequency of drinking 6 or more
drinks on one occasion, might be an effective brief screen-
ing question for both heavy drinking and/or active alco-
hol abuse or dependence. Reports of drinking 5 or more
drinks on any occasion in the past year had a sensitivity
of 0.90 for last year alcohol abuse or dependence in men
and 0.77 in women, based on the National Health Inter-
view Survey.
40
The corresponding specificities were 0.53
and 0.77, inmen andwomen, respectively. Others
10,11
have
also found a strong association between heavy drinking
PATIENTS AND METHODS
SETTING
This study, conducted at 3 VAMedical Centers, was based
on data from questionnaire validation studies performed
as part of a larger study dealing with health status mea-
surement and feedback in general medical clinics. The al-
cohol validation studies are described in detail elsewhere
but are summarized briefly herein.
20
PATIENTS
Of 9513 general medical patients, 330 (3%) were ex-
cluded because of lack of an accurate mailing address or
other exclusion criteria such as residence in a nursing home
or participation in a conflicting study, and 9183weremailed
baseline Health History Questionnaires (HHQs). A subset
of 447 respondents who drank alcohol was selected for in-
terviews (see below). Selected patients were excluded if they
had no telephone (n = 24), did not answer calls over a 2-
week period (n = 19), were too ill or deaf to participate in
a telephone interview (n = 5), or were female (n = 6).
Women were excluded because alcohol screening ques-
tionnaires function differently in men and women,
29
and
we had an inadequate number of women on which to base
any conclusions regarding questionnaire performance.
MEASURES
Demographic datawere obtained from theVADecentralized
HospitalComputingProgram.TheVADecentralizedHospi-
talComputingProgramdata onethnicitywasmissing for 34%
of participants.However, 89%of participantswithdata avail-
ablewerewhite. ThebaselineHHQ includedquestions about
alcohol consumption, beginning with, “Over the past year,
have you had a total of 5 or more drinks?”
The Drinking Practices Questionnaire (DPQ) in-
cluded the 10-item AUDIT, a retrospective drinking diary,
and questions about previous provider advice to decrease al-
cohol consumption or abstain, and readiness to change (full
questionnaire available from us). The DPQ began with the
3 following AUDIT consumption questions (AUDIT-C):
1. How often did you have a drink containing alcohol in the
past year? Consider a “drink” to be a can or bottle of beer, a
glass of wine, a wine cooler, or one cocktail or a shot of hard
liquor (like scotch, gin, or vodka). Response options were
never (0 points); monthly or less (1 point); 2 to 4 times a
month (2 points); 2 to 3 times a week (3 points); 4 to 5 times
a week (4 points); or 6 or more times a week (4 points).
2. How many drinks did you have on a typical day
when you were drinking in the past year? Response op-
tions were 0 drinks (0 points); 1 to 2 drinks (0 points); 3
to 4 drinks (1 point); 5 to 6 drinks (2 points); 7 to 9 drinks
(3 points); or 10 or more drinks (4 points).
3. How often did you have 6 or more drinks on one
occasion in the past year? Response options were never (0
points); less than monthly (1 point); monthly (2 points);
weekly (3 points); or daily or almost daily (4 points).
The AUDITwas scored in the traditional manner with
questions 1 to 8 scored 0 to 4 points, and questions 9 and
10 scored 0, 2, or 4 points. Possible scores ranged from
0 to 40. The AUDIT-C was scored in the same way, with
the scores summed for a possible score of 0 to 12. In ad-
dition, we evaluated the third AUDIT question as a 1-item
screening test with a possible score of 0 to 4. The AUDIT
was scored if 5 or more questions (at least half) were
answered.
Telephone interviews included a modified version of
the World Health Organization trilevel alcohol consump-
tion interview, followed by the computerized version of the
alcohol module of the Diagnostic Interview Schedule for
Diagnostic and Statistical Manual of Mental Disorders, Re-
vised Third Edition.
41,42
Interviews were performed by 1 of
5 interviewers who were experienced in alcohol-related in-
terviews and blinded to all questionnaire results.
Three comparison standards were defined based on tele-
phone interviews.We considered patients to be heavy drink-
ers if they drank more than 14 drinks a week or 5 or more
drinks on one occasion in the past or a typical month based
on the trilevel alcohol consumption interview. These crite-
ria were based on evidence that men who drink above these
levels have increased psychosocial and other adverse con-
sequences of drinking.
10,11
We considered patients to have
active alcohol abuse and/or dependence if they met criteria
for lifetime alcohol abuse and/or dependence and had 1
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on any recent occasion and the development of alcohol-
related problems. Preliminary analyses of our data from
VA general medical patients revealed that 35% of drink-
ers reported drinking 6 or more drinks at least once dur-
ing the past year, while only 19% scored positive on the
AUDIT at a screening threshold of 8 or more points.
20
The objective of the analyses reported herein was to evalu-
ate the performance of the third question of the AUDIT
combinedwith the preceding AUDIT questions about typi-
cal frequency and quantity of drinking, as a 3-item screen-
ing test for active alcohol abuse or dependence and/or
heavy drinking. We refer to this 3-item screening test as
AUDIT-C, short for AUDIT consumption questions.
RESULTS
Table 1 presents demographic and clinical character-
istics of the study participants and nonparticipants. Based
on responses to the baseline HHQ, the 243 patients in
the study drank less often (P = .005), tended to drink less
per drinking day (P = .06), and smoked fewer cigarettes
(P = .02), compared with 204 nonparticipants (Kendall
t-b). Among the 243male patients included in these analy-
ses, 86 (35%) met interview criteria for heavy drinking,
52 (21%) met criteria for active alcohol abuse or depen-
dence, and 100 (41%) met criteria for either or both.
Receiver operating characteristic curves are de-
picted in the Figure, with AUROCs and 95% confi-
dence intervals in Table 2. For detection of heavy drink-
ing, AUDIT-C performed better than the entire AUDIT
(P = .03), whereas the full AUDIT had a higher AUROC
for detection of active alcohol abuse and/or dependence
(P,.001). For detection of either heavy drinking and/or
active alcohol abuse or dependence, the AUDIT-C had
an AUROC equivalent to that of the full 10-item AUDIT
(P = .83).
or more alcohol-related symptom(s) in the last year accord-
ing to the computerized version of the alcohol module of
the Diagnostic Interview Schedule.
31
We chose this defini-
tion, previously used by Buchsbaum and colleagues,
31
in-
stead of requiring 3 symptoms in the past year as required
forDiagnostic and Statistical Manual of Mental Disorders, Re-
vised Third Edition, criteria for last year abuse or depen-
dence, because we believe that primary care providers should
intervene with patients with lifetime alcohol abuse and de-
pendence who have even 1 recent symptom. The third com-
parison standard was a composite of the first 2, including
patients who met criteria for either heavy drinking and/or
active alcohol abuse and/or dependence.
SURVEY DESIGN
The baseline HHQwas returned by 6116 (67%) of 9183 eli-
gible patients, and the DPQwas subsequentlymailed to 2875
HHQ respondents who reported drinking 5 or more drinks
over the past year (“drinkers”). A random weighted sample
of 447 drinkers was selected for interviews from amongHHQ
respondents, with “heavy drinkers” oversampled 2:1 to al-
low validation of questionnaire measures in adequate num-
bers of heavy drinkers. Heavy drinkers were those who re-
ported drinking 14 or more drinks per typical week or 5 or
more drinks per typical day on the HHQ. Eligible patients
were called for interviews either immediately before themail-
ing of the DPQ or within 3 weeks of its return. Although pa-
tients randomized to be interviewed before theDPQweremore
likely to return the DPQ, timing of interviews was not asso-
ciatedwith any significant differences in DPQ responses; thus,
the groups were combined for analyses.
20
Of 393 eligible patients, 110 (28%) did not return the
DPQ and 18 (5%) did not complete AUDIT-C. Twenty-
two (6%) of all 393 eligible individuals refused interviews
or did not complete telephone interviews. The analyses be-
low are based on 243 patients who completed AUDIT-C
and interviews.
ANALYSES
Sensitivity, specificity, and positive and negative likeli-
hood ratios were calculated for the full AUDIT, AUDIT-C
and AUDIT question 3 alone, for each comparison stan-
dard (heavy drinking, active alcohol abuse or depen-
dence, and either or both).
43,44
Sensitivity (true-positive
rate) is the percentage of all patients with heavy drink-
ing and/or active alcohol abuse or dependence based on
interview criteria who score above a threshold score on a
screening questionnaire; specificity (true-negative rate)
is the proportion of patients who do not meet criteria
based on interviews who score below the threshold
score. One minus specificity is the false-positive rate.
Positive likelihood ratios are the sensitivity divided by
(1 − specificity), whereas negative likelihood ratios are
(1 − sensitivity) divided by specificity.
44
Likelihood
ratios allow clinicians to calculate the postscreening
probability that a patient who screens positive (or nega-
tive) actually drinks heavily or has active alcohol abuse
or dependence, depending on the estimated prevalence
in the screened population.
Receiver operating characteristic curves plot sensitiv-
ity vs (1 − specificity). Curves toward the upper left-hand
corner of a receiver operating characteristic graph repre-
sent stronger screening tests. The areas under receiver op-
erating characteristic curves (AUROCs) are useful for choos-
ing which screening test offers the optimal combination of
sensitivity and specificity overall. The higher the AUROC,
the stronger the performance of a screening test. Areas un-
der receiver operating characteristic curves higher than 0.80
are generally considered excellent. Receiver operating char-
acteristic curves comparing the 3 screening tests with each
comparison standard are presented graphically with areas
under the curves and SEs depicted on the graph; 95% con-
fidence intervals (95%CIs) are the AUROC ± (1.963 SE).
To compare AUROCs, we used the z statistic corrected to
account for the correlation of curves derived from the same
population.
45
HUMAN SUBJECTS
This study was approved by the institutional review boards
at the 3 VAmedical centers fromwhich patients were drawn
(Seattle,Wash;White River Junction, Vt; and Boston,Mass),
and the VA Center for Cooperative Studies in Health Ser-
vices Research, Hines, Ill.
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Sensitivities and specificities are given in Table 3,
and demonstrate the tradeoff between sensitivity and speci-
ficity at each cutoff. In general, sensitivity should take pri-
ority over specificity for alcohol screening in primary care
settings, since further assessment by primary care provid-
ers is relatively easy and inexpensive. The AUDIT-C was
more sensitive and specific for heavy drinking than for ac-
tive alcohol abuse or dependence at each cutoff. However,
the AUDIT-C was nevertheless sensitive for active alcohol
abuse or dependence. Using a cutoff of 3, of a total of 12
points, the AUDIT-C would identify 90% of patients with
active alcohol abuse or dependence and 98% of patients
with heavy drinking, although the specificity was only 60%
(false-positive rate 40%). For a more specific test, a cutoff
of 4 or more identified 86% of patients with heavy drink-
ing and/or active alcohol abuse or dependence (sensitiv-
ity), with a specificity of 72%.
Although the third question of the AUDIT alone
did not perform as well overall as the full AUDIT or the
AUDIT-C, this single question had acceptable sensitiv-
ity and excellent specificity. A report of ever drinking
6 or more drinks on any occasion in the last year iden-
tified 79% of heavy drinkers and 81% of patients with
active alcohol abuse or dependence. Only 17% of pa-
tients who did not drink heavily and/or have active al-
cohol abuse or dependence screened falsely positive.
Positive likelihood ratios for the AUDIT-C ranged
from 2.38 to 26.46 for identifying heavy drinking and/or
active alcohol abuse or dependence (Table 2). The posi-
tive likelihood ratio is multiplied by the prescreening odds
of a condition, to arrive at the postscreening odds of the
condition given a patient with a positive screen. The pre-
screening odds that a patient has a condition is the esti-
mated prevalence divided by (1 − estimated preva-
lence). For instance, if the prevalence of heavy drinking
and/or active alcohol abuse or dependence in our screened
population of male drinkers is estimated at 33%,
18,46-48
the
prescreening odds would be 1:2. Given this prevalence,
a score of 4 or more points on the AUDIT-C (positive
likelihood ratio, 3.07) would result in postscreening odds
that the patient truly was a heavy drinker or had active
alcohol abuse or dependence of about 3:2 (1:23 3.07),
and a postscreening probability of about 60%. If, how-
ever, a patient responded to the third question of the AU-
DIT indicating that he drank 6 or more drinks at least
monthly (positive likelihood ratio, 11.0), his postscreen-
ing odds of meeting interview criteria for heavy drink-
ing or active alcohol abuse and/or dependence would be
11:2 (85% probability). Negative likelihood ratios can
similarly be used to predict the postscreening probabil-
ity that a patient who screens negative drinks heavily or
has active alcohol abuse and/or dependence.
COMMENT
We found that the 3 questions of the AUDIT dealing with
alcohol consumption (AUDIT-C)performedbetter than the
full AUDIT for identification of heavy drinkers whomight
benefit frombrief primary care interventions.
14
In addition,
therewasno significant difference between the 2 screening
questionnaires for identificationofpatientswithheavydrink-
ing and/or active alcohol abuse or dependence. For identi-
fication of active alcohol abuse and/or dependence alone,
however, the full AUDITperformed slightly better than the
AUDIT-C. However, the AUDIT-C performed better than
thecommonly recommendedCAGEscreen(AUROC,0.717),
which identified only 56% of patients in the same popula-
tion with heavy drinking and/or active alcohol abuse or
dependence using the standard cutoff of 2 or more.
20
This study had several limitations. We studied pre-
dominantly white, male veterans (mean age, 67 years) with
multiple medical problems. Analyses were restricted to
drinkers who responded to a mailed DPQ and we mea-
sured statistically significant response bias; nonpartici-
pants smoked more cigarettes and drank alcohol more
often than participants. Some patients may have beenmis-
classified by questionnaires or interviews. We evaluated
mailed questionnaires that were sometimes completed by
proxy respondents.We also could not assure privacy dur-
ing completion of questionnaires or telephone inter-
views, possibly leading to social desirability bias. Finally,
this report evaluates a hypothesis that was generated af-
ter data were reviewed and therefore has all the potential
weaknesses of posthoc analyses.
For these reasons, it will be essential to confirm our
findings in other, less biased populations. Future re-
search should also evaluate the third AUDIT questionmodi-
fied to reflect recent sex-specific data. For men, 5 or more
drinks has been associatedwith symptoms related to drink-
ing, whereas for women, 4 or more drinks per occasion
has been found to increase the risk of alcohol-related prob-
lems.
10,11
Future studies should also evaluate the use of
asking the third question of the AUDIT alone, outside the
context of the complete AUDIT.
49-51
Despite the limitations of our study, several factors
lead us to believe that our findings will be replicated in
other settings and populations. Our finding of a strong
association between episodic heavy drinking and alcohol-
Table 1. Demographic and Clinical Characteristics
of Participants and Nonparticipants*
Characteristic
Participants
(n = 243)
Nonparticipants
(n = 204)
Male 243 (100) 198 (97)
Age, y
,50 22 (9) 24 (12)
50-59 20 (8) 38 (19)
60-69 94 (39) 78 (38)
$70 106 (44) 64 (31)
Cigarette use
Nonsmoker 141 (58) 112 (55)
,1 pack per day 32 (13) 31 (15)
$1 pack per day 36 (15) 43 (21)
Alcohol use
Frequency, more than once a week 125 (51) 121 (59)
Quantity .2 drinks per typical day 94 (39) 94 (46)
Medical conditions
Hypertension 133 (55) 108 (53)
Diabetes 45 (19) 42 (21)
Coronary artery disease 91 (37) 83 (41)
Chronic obstructive lung disease 55 (23) 50 (25)
Depression 60 (25) 55 (27)
*Based on the Veterans Affairs Decentralized Hospital Computing Program
and Health History Questionnaires. All values are number (percentage).
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related symptoms or dependence is supported by sev-
eral other studies.
10,11,40
In fact, we likely underesti-
mated the sensitivity of alcohol screening questionnaires,
resulting in conservative estimates of AUROCs. Unlike
most studies of such questionnaires, we did not admin-
ister screening questionnaires and interviews at the same
sitting to avoid consistency response bias that can in-
flate the performance of screening questionnaires. Ex-
cluding nondrinkers
30
and using self-administered ques-
tionnaires
20
may also have lowered the performance of
screening questionnaires in our study. Because re-
sponse bias probably exists in all screening and inter-
vention studies relating to heavy drinking, it is a strength
of this study that we were able to measure it.
52,53
We suspect the AUDIT-C will gain increasing ac-
ceptance as a screening test among clinicians given the
straightforwardness of the questions and evidence link-
ing frequency of heavy drinking to alcohol abuse or de-
pendence.
40,54
Recent studies reveal that many clini-
cians still do not ask about alcohol use,
25,55
or recognize
and refer patients with heavy drinking or alcohol abuse
and/or dependence.
2
We believe that the most effective
approaches to screening will not involve primary care cli-
nicians, but will rely instead on the use of surveys or an-
cillary staff to screen patients for multiple high-risk be-
haviors including heavy and dependent drinking. The
AUDIT-C is easily integrated into general health history
questionnaires for use in such programs.
For medical interviews, the third question of the
AUDIT alone is potentially a more practical screen for
identification of active drinking problems than the
AUDIT-C, as response options and scoring for the latter
may be difficult for clinicians to remember. Patients could
be asked how often in the last year they had a drink con-
taining alcohol. For patients who responded “never,”
screening would be complete. However, if patients re-
ported any drinking in the last year, clinicians could then
ask howmuch they typically drank as a lead-in to, “How
often in the past year have you had 6 or more drinks on
one occasion?” Ever drinking 6 or more drinks should
be considered a positive screening test.
In summary, for themany clinicians who do not cur-
rently use a validated alcohol screening questionnaire,
it is reasonable to begin asking patients who drink ques-
tions about typical frequency and quantity of drinking,
and the frequency of drinking 6 or more drinks on one
occasion. Previous research has demonstrated a strong
association between the frequency of heavy drinking and
alcohol dependence, and in our population, the AUDIT
question about frequency of heavy drinking alone per-
formed better than the CAGE and almost as well as the
10-question AUDIT for identification of heavy drinking
and/or active alcohol abuse or dependence. Although sen-
sitivities and specificities need to be confirmed in other
populations, until that time our findings suggest appro-
priate thresholds for a positive AUDIT-C. A score of 3
or more points on the AUDIT-C, or a report of drinking
6 or more drinks on one occasion ever in the last year,
should lead to a more in-depth assessment of drinking
and related problems. Based on in-depth assessments, pa-
tients can be offered brief interventions or referrals as
appropriate.
56,57
Accepted for publication January 27, 1998.
This research was supported by the Department of
Veterans Affairs, Cooperative Studies in Health Services
1.0
0.8
0.6
0.4
0.2
0
0 0.2 0.4 0.6 0.8 1.0
S
e
n
s
i
t
i
v
i
t
y
1 – Specificity
1.0
0.8
0.6
0.4
0.2
0
0 0.2 0.4 0.6 0.8 1.0
1 – Specificity
1.0
0.8
0.6
0.4
0.2
0
0 0.2 0.4 0.6 0.8 1.0
1 – Specificity
AUDIT Nos. 1-10 0.881 (0.007)
Questionnaire AUROC (SE)
AUDIT Nos. 1-3 0.891 (0.0073)
AUDIT No. 3 0.827 (0.015)
AUDIT Nos. 1-10 0.811 (0.011)
Questionnaire AUROC (SE)
AUDIT Nos. 1-3 0.786 (0.012)
AUDIT No. 3 0.795 (0.020)
AUDIT Nos. 1-10 0.880 (0.0066)
Questionnaire AUROC (SE)
AUDIT Nos. 1-3 0.881 (0.0072)
AUDIT No. 3 0.831 (0.014)
A B C
AUDIT Nos. 1 to 10 refers to the full 10-item Alcohol Use Disorders Identification Test; AUDIT Nos. 1 to 3, AUDIT consumption questions (AUDIT-C); AUDIT No. 3,
the third question of the AUDIT alone; AUROC, areas under the receiver operating characteristic curves; A, heavy drinking; B, active alcohol abuse or dependence;
and C, active alcohol abuse or dependence and/or heavy drinking. Comparison standards are defined in the “Methods” section of the text.
Table 2. AUROCs and Corresponding Statistics*
Heavy Drinking
Active Alcohol Abuse
or Dependence
Heavy Drinking and/or
Active Alcohol Abuse
or Dependence
AUDIT Questions 1-10 0.881 (0.007) (0.867-0.895) 0.811 (0.011) (0.789-0.833) 0.880 (0.007) (0.866-0.893)
AUDIT-Consumption Questions (AUDIT-C) 0.891 (0.007) (0.877-0.904) 0.786 (0.012) (0.762-0.810) 0.881 (0.007) (0.867-0.984)
AUDIT Question 3 alone 0.827 (0.015) (0.792-0.856) 0.795 (0.020) (0.795-0.834) 0.831 (0.014) (0.804-0.858)
*All values are areas under receiver operating characteristic curves (SE) and 95% confidence intervals. AUDIT indicates Alcohol Use Disorders Identification
Test.
ARCH INTERN MED/VOL 158, SEP 14, 1998
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Research No. 91-007, and Health Services Research and De-
velopment, SD No. 96-002, Ambulatory Care Quality Im-
provement Project (ACQUIP); a grant from the University
of Washington Alcohol and Drug Abuse Institute; and the
HSR&D Field Program and Medicine Service, Seattle Di-
vision, VA Puget Sound Health Care System, Seattle, Wash.
Corresponding author: Kristen Bush, MPH, Health Ser-
vices Research and Development, Mailstop-152, VA Puget
Table 3. Performance of Screening Questionnaires Compared With 3 Comparison Standards*
Questionnaire Scores Sensitivity, % Specificity, % +LR (95% CIs) −LR (95% CIs)
Heavy Drinking
AUDIT Questions 1-10
$4 94 66 2.75 (2.20-3.45) 0.09 (0.04-0.21)
$5 85 81 4.39 (3.14-6.12) 0.19 (0.11-0.31)
$6 72 88 5.88 (3.78-9.14) 0.32 (0.23-0.45)
$7 64 90 6.20 (3.79-10.12) 0.40 (0.30-0.54)
$8 59 91 6.57 (3.87-11.15) 0.45.(0.34-0.58)
$9 55 94 8.47 (4.51-15.90) 0.48.(0.38-0.61)
AUDIT Consumption Questions (AUDIT-C)
$3 98 57 2.26 (1.88-2.71) 0.04 (0.01-0.16)
$4 91 70 2.99 (2.33-3.83) 0.13 (0.07-0.26)
$5 73 88 6.31 (4.01-9.92) 0.30 (0.21-0.43)
$6 57 93 8.03 (4.41-14.6) 0.46 (0.36-0.59)
$7 48 95 10.56 (4.95-22.50) 0.55 (0.45-0.67)
$8 40 97 12.26 (4.98-30.18) 0.62 (0.53-0.74)
AUDIT Question 3 Alone
$Ever 79 79 3.83 (2.76-5.31) 0.26 (0.17-0.40)
$Monthly 58 93 8.19 (4.51-14.89) 0.45 (0.35-0.58)
$Weekly 41 95 9.01 (4.18-19.42) 0.62 (0.52-0.74)
Daily or almost 21 99 16.22 (3.86-68.25) 0.80 (0.72-0.89)
Active Alcohol Abuse or Dependence
AUDIT Questions 1-10
$4 85 52 1.78 (1.47-2.14) 0.29 (0.15-0.56)
$5 81 68 2.49 (1.95-3.18) 0.28 (0.16-0.50)
$6 75 77 3.33 (2.45-4.53) 0.32 (0.20-0.52)
$7 71 82 4.00 (2.82-5.67) 0.35 (0.23-0.54)
$8 71 85 4.85 (3.31-7.12) 0.34 (0.22-0.52)
$9 65 88 5.43 (3.53-8.36) 0.39 (0.27-0.57)
AUDIT-C
$3 90 45 1.64 (1.41-1.92) 0.21 (0.09-0.50)
$4 79 56 1.77 (1.43-2.19) 0.38 (0.22-0.65)
$5 67 75 2.74 (2.00-3.74) 0.43 (0.29-0.65)
$6 62 85 4.05 (2.72-6.04) 0.45 (0.32-0.64)
$7 58 91 6.12 (3.72-10.07) 0.47 (0.34-0.64)
$8 46 92 5.88 (3.33-10.37) 0.58 (0.45-0.75)
AUDIT Question 3 Alone
$Ever 81 69 2.61 (2.04-3.36) 0.28 (0.16-0.49)
$Monthly 62 85 4.05 (2.72-6.04) 0.45 (0.32-0.64)
$Weekly 48 91 5.40 (3.17-9.22) 0.57 (0.44-0.74)
Daily or almost 25 96 6.82 (2.87-16.22) 0.78 (0.66-0.91)
Heavy Drinking and/or Active Alcohol Abuse or Dependence
AUDIT Questions 1-10
$4 90 69 2.86 (2.23-3.67) 0.15 (0.08-0.27)
$5 81 84 5.04 (3.42-7.41) 0.23 (0.15-0.34)
$6 69 91 7.59 (4.45-12.96) 0.34 (0.25-0.46)
$7 62 94 9.85 (5.14-18.89) 0.41 (0.31-0.52)
$8 58 95 11.85 (5.64-24.87) 0.44 (0.35-0.56)
$9 53 97 18.95 (7.09-50.67) 0.48 (0.39-0.60)
AUDIT-C
$3 95 60 2.38 (1.94-2.93) 0.08 (0.04-0.20)
$4 86 72 3.07 (2.34-4.05) 0.19 (0.12-0.32)
$5 68 90 6.95 (4.15-11.63) 0.35 (0.27-0.47)
$6 53 94 9.47 (4.71-19.04) 0.50 (0.40-0.62)
$7 45 98 21.45 (6.86-67.10) 0.56 (0.47-0.67)
$8 37 99 26.46 (6.53-107.26) 0.64 (0.55-0.74)
AUDIT Question 3 Alone
$Ever 77 83 4.59 (3.14-6.71) 0.28 (0.19-0.40)
$Monthly 54 95 11.0 (5.24-23.23) 0.48 (0.39-0.60)
$Weekly 38 97 13.59 (5.01-36.86) 0.64 (0.55-0.75)
Daily or almost 19 99 27.17 (3.70-199.68) 0.82 (0.74-0.90)
*LR indicates likelihood ratio; plus sign, positive; minus sign, negative; CIs, confidence intervals; and AUDIT, Alcohol Use Disorders Identification Test.
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lumbian Way, Seattle, WA 98108.
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