A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: Past issues and future directions.

BACKGROUND: The US Preventive Services Task Force recommends that clinicians screen all adults for alcohol misuse and provide brief counseling to those engaged in risky or hazardous drinking. The World Health Organization's (WHO's) Alcohol Use Disorders Identification Test (AUDIT) is the most widely tested instrument for screening in primary health care. OBJECTIVES: This paper describes the structural and functional features of the AUDIT and methodological problems with the validation of the alcohol consumption questions (AUDIT-C). The content, scoring, and rationale for a new version of the AUDIT (called the USAUDIT), adapted to US standard drink size and hazardous drinking guidelines, is presented. METHOD: Narrative review focusing on the consumption elements of the AUDIT. Four studies of the AUDIT-C are reviewed and evaluated. RESULTS: The AUDIT has been used extensively in many countries without making the changes in the first three consumption questions recommended in the AUDIT User's Manual. As a consequence, the original WHO version is not compatible with US guidelines and AUDIT scores are not comparable with those obtained in countries that have different drink sizes, consumption units, and safe drinking limits. Clinical and Scientific Significance. The USAUDIT has adapted the WHO AUDIT to a 14 g standard drink, and US low-risk drinking guidelines. These changes provide greater accuracy in measuring alcohol consumption than the AUDIT-C.

Screening for Excessive Alcohol Use and Brief Counseling of Adults - 17 States and the District of Columbia, 2014.

Excessive and/or risky alcohol use* resulted in $249 billion in economic costs in 2010 (1) and >88,000 deaths in the United States every year from 2006 to 2010 (2). It is associated with birth defects and disabilities (e.g., fetal alcohol spectrum disorders [FASDs]), increases in chronic diseases (e.g., heart disease and breast cancer), and injuries and violence (e.g., motor vehicle crashes, suicide, and homicide).† Since 2004, the U.S. Preventive Services Task Force (USPSTF) has recommended alcohol misuse screening and brief counseling (also known as alcohol screening and brief intervention or ASBI) for adults aged ≥18 years (3).§ Among adults, ASBI reduces episodes of binge-level consumption, reduces weekly alcohol consumption, and increases compliance with recommended drinking limits in those who have an intervention in comparison to those who do not (3). A recent study suggested that health care providers rarely talk with patients about alcohol use (4). To estimate the prevalence of U.S. adults who reported receiving elements of ASBI, CDC analyzed 2014 Behavioral Risk Factor Surveillance System (BRFSS) data from 17 states¶ and the District of Columbia (DC). Weighted crude and age-standardized overall and state-level prevalence estimates were calculated by selected drinking patterns and demographic characteristics. Overall, 77.7% of adults (age-standardized estimate) reported being asked about alcohol use by a health professional in person or on a form during a checkup, but only 32.9% reported being asked about binge-level alcohol consumption (3). Among binge drinkers, only 37.2% reported being asked about alcohol use and advised about the harms of drinking too much, and only 18.1% reported being asked about alcohol use and advised to reduce or quit drinking. Widespread implementation of ASBI and other evidence-based interventions could help reduce excessive alcohol use in adults and related harms.

Stigmatization of alcohol and other drug users by primary care providers in Southeast Brazil.

This study reports on the views of Primary Health Care (PHC) providers in Southeast Brazil on the use of alcohol and other drugs which reflect stigma, moralization, or negative judgment. Six hundred nine PHC professionals from the Brazilian states of São Paulo and Minas Gerais took part in the study. The majority (86.5%) of these professionals were female. Attitudes toward the use of alcohol and other drugs were evaluated in comparison to Hansen's disease, obesity, depression, schizophrenia, HIV/AIDS, and tobacco use. The use of tobacco, marijuana/cocaine, and alcohol were the most negatively judged behaviors (p < 0.05). Nursing assistants and community health care workers demonstrated the severest judgment of alcohol use. In addition, marijuana/cocaine addicts and alcoholics suffered the highest rate of rejection by professionals. The hypothesis that the use of alcohol and other drugs is a behavior stigmatized by health professionals being confirmed, it is important to develop strategies for changing provider attitudes in order to provide a higher quality of service to these patients. This study is important as a first study among PHC professionals about social stigma of alcohol and other drugs users.

The effect of screening and brief intervention for risky drinking on health care utilization in managed care organizations.

OBJECTIVE: We sought to estimate the effect of screening and brief intervention (SBI) for risky alcohol use on the health care utilization of risky drinkers in 4 managed care organizations. RESEARCH DESIGN: A quasi-experimental group design was implemented in which 12 participating primary care clinics randomly were assigned to 1 of 3 study conditions. In one condition, physicians, physician assistants, and nurse practitioners delivered the brief intervention. In another condition, midlevel professionals (usually nurses) performed the brief intervention. In the third condition, SBI was not performed. Using administrative claims data, we estimated the effect of SBI on individual-level annual days of total and inpatient health care utilization; annual outpatient visits; annual emergency room visits; and annual visits related to alcohol, drug, or mental health conditions. Negative binomial regression models were used to control for other factors that may affect health care utilization. RESULTS: Across all categories of care, the pre- to postintervention change in average health care utilization among risky drinkers in the intervention clinics was not significantly different from that of risky drinkers in the comparison clinics. CONCLUSIONS: Our findings suggest that there is no effect of SBI on the health care utilization of risky drinkers in the year following the intervention. Although SBI does not appear to reduce health care utilization, previous studies find that it significantly reduces the alcohol consumption of risky drinkers. Because these reductions presumably improve patients' overall health and well-being, managed care organizations may still find it beneficial to implement SBI on a broad scale.

Brief interventions for at-risk drinking: patient outcomes and cost-effectiveness in managed care organizations.

AIMS: Evaluate effectiveness and costs of brief interventions for patients screening positive for at-risk drinking in managed health care organizations (MCOs). METHODS: A pre-post, quasi-experimental, multi-site evaluation conducted at 15 clinic sites within five MCO settings. At-risk drinkers (N = 1329) received either: (i) brief intervention delivered by licensed practitioners; or (ii) brief intervention delivered by mid-level professional specialists (nurses); or (iii) usual care (comparison condition). Clinics were randomly assigned to three study conditions. Data were collected on the cost of screening and brief intervention. Follow-up interviews were conducted at 3 and 12 months. RESULTS: Participants in all three study conditions were drinking significantly less at 3-month follow-up, but the decline was significantly greater in the two intervention groups than in the control group. There were no significant differences between the two intervention conditions. Of the patients in the intervention conditions 60% reduced their alcohol consumption by > or =1 drink per week, compared with 53% of those in the control condition. No differences were found on a measure of the quality of life. Differential reductions in weekly alcohol consumption between intervention and control groups were significant at 12-month follow-up. Average incremental costs of the interventions were 4.16 US dollar per patient using licensed practitioners and 2.82 US dollar using mid-level specialists. CONCLUSION: Alcohol screening and brief intervention when implemented in managed care organizations produces modest, statistically significant reductions in at-risk drinking. Interventions delivered to a common protocol by mid-level specialists are as effective as those delivered by licensed practitioners at about two-thirds the cost.

Intervención breve para el consumo de riesgo y perjudicial de alcohol : un manual para la utilización en Atención Primaria

Manual dirigido al personal de Atención Primaria en el manejo de personas cuyo consumo de alcohol ha llegado a ser de riesgo o perjudicial para su salud. Su objetivo es unir la investigación científica con la práctica clínica mediante la descripción de cómo llevar a cabo las intervenciones breves en pacientes con trastornos debidos al consumo de alcohol y en aquellos con riesgo de desarrollarlos. Está diseñado para ser utilizado junto al documento \"Test de Identificación de los Trastornos Debidos al Consumo de Alcohol (AUDIT)\", disponible en LIS España.

AUDIT. Test de identificación de los trastornos debidos al consumo de alcohol : pautas para su utilización en Atención Primaria

Manual que describe cómo utilizar el test para identificar a las personas con un patrón de consumo de riesgo o perjudicial de alcohol. Proporciona un marco de trabajo para la intervención dirigida a los bebedores de riesgo, para que puedan reducir o abandonar el consumo de alcohol y, con ello, evitar las consecuencias perjudiciales de su consumo. Está diseñado para ser utilizado junto al documento \"Intervención breve para el consumo de riesgo y perjudicial de alcohol \", disponible en LIS España.

Alcohol screening and brief intervention in primary care settings: implementation models and predictors.

OBJECTIVE: This study compared two different implementation strategies for Cutting Back, a primary care alcohol screening and brief intervention (SBI) program for hazardous and harmful drinkers. It also identified organizational factors contributing to the success or failure of SBI implementation. METHOD: Cutting Back was implemented in 10 primary care practices associated with managed care organizations (MCOs) in five states, through a system of planning, training, technical assistance and clinic feedback. Clinics were randomly assigned to one of two brief intervention systems: In the P Model, medical providers were responsible for delivering interventions, whereas in the S Model mid-level professionals (usually nurses) acted as the clinic specialists to provide that service. Data were collected to measure the performance of screening and delivery of interventions in each clinic. RESULTS: The S Model screened a higher percentage of patients than did the P Model during the best month of program operation (50% vs 44%) and over all months of operation (24% vs 19%). Of those patients who screened positive, more patients in the S condition received an intervention than in the P condition (73.1% vs 57.1%), but there was a considerable range of performance among the five sites within each condition. Results at the clinic level were mixed, with some MCOs performing alcohol SBI significantly better with the S model and others doing better with the P model. The ability of clinics to conduct SBI was significantly correlated with both provider characteristics and organizational factors (e.g., prior SBI experience, MCO stability, number of clinicians trained and the quality of the MCO coordinator's work). Lack of provider time, staff turnover and competing priorities correlated negatively with SBI performance. CONCLUSIONS: The extent to which a given delivery model is likely to work best within an MCO depends on complex provider and organizational characteristics.

Training medical providers to conduct alcohol screening and brief interventions.

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Alcohol drinking patterns and health care utilization in a managed care organization.

OBJECTIVE: To estimate the relationship between current drinking patterns and health care utilization over the previous two years in a managed care organization (MCO) among individuals who were screened for their alcohol use. STUDY DESIGN: Three primary care clinics at a large western MCO administered a short health and lifestyle questionnaire to all adult patients on their first visit to the clinic from March 1998 through December 1998. Patients who exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for moderate drinking were given a more comprehensive alcohol screening using a modified version of the Alcohol Use Disorders Identification Test (AUDIT). Health care encounter data for two years preceding the screening visit were linked to the remaining individuals who responded to one or both instruments. Using both quantity-frequency and AUDIT-based drinking pattern variables, we estimated negative binomial models of the relationship between drinking patterns and days of health care use, controlling for demographic characteristics and other variables. PRINCIPAL FINDINGS: For both the quantity-frequency and AUDIT-based drinking pattern variables, current alcohol use is generally associated with less health care utilization relative to abstainers. This relationship holds even for heavier drinkers, although the differences are not always statistically significant. With some exceptions, the overall trend is that more extensive drinking patterns are associated with lower health care use. CONCLUSIONS: Based on our sample, we find little evidence that alcohol use is associated with increased health care utilization. On the contrary, we find that alcohol use is generally associated with decreased health care utilization regardless of drinking pattern.

The costs of screening and brief intervention for risky alcohol use.

OBJECTIVE: The purpose of this study was to estimate provider-incurred costs of alcohol screening and brief intervention (SBI) for risky drinking as implemented in four managed care organizations (MCOs) participating in the Cutting Back project implemented by the University of Connecticut Health Center. METHOD: Each MCO provided two comparable primary care clinics in which two different SBI models were implemented: the "Practitioner" (P) model and the "Specialist" (S) model. Risky drinkers were identified based on responses to a health appraisal form. They were administered the AUDIT to determine an appropriate intervention. Using data collected from these sites, we separately estimated start-up and ongoing implementation costs of the intervention. RESULTS: SBI start-up costs per MCO ranged from approximately dollars 86,000 to dollars 115,000 across the four study MCOs. Across all four study MCOs, the estimated median ongoing implementation cost of administering the health appraisal was dollars 0.25 per patient appraised, and the estimated median cost of screenings was dollars 0.42 per patient screened. The estimated median cost of performing the brief intervention across the study MCOs was dollars 2.59 per patient receiving the intervention in the S clinics and dollars 3.43 per patient receiving the intervention in the P clinics. Labor costs dominated start-up and ongoing implementation. Technical assistance costs accounted for a significant proportion of start-up costs. Implementation in the S model is less costly than in the P model, largely because of the S model's use of less expensive nonphysician labor. CONCLUSIONS: Our analysis suggests that the cost of SBI is modest, and MCOs may want to consider adopting SBI as an alcohol use prevention tool. Although our results suggest that the S model is less costly than the P model, clinic-level implementation factors may affect the relative costs of the S versus P models.