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EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: AN UPDATE TO THE LITERATURE REVIEW
SECTION SIX: SCREENING AND DETECTION
SUMMARY
This section reviews the effectiveness and cost-effectiveness evidence relating to screening for and detection of problem drinking and alcohol abuse. The main findings of the previous review were;
AUDIT is more effective in detecting at risk, hazardous or harmful drinking;
CAGE is superior in detecting alcohol abuse or dependence;
T-ACE and TWEAK are more sensitive and specific for screening pregnant women;
laboratory tests do not perform well as screening instruments;
telemarketing has been shown to be cost-effective in marketing screening and brief intervention packages to GPs in Australia; and
specialist workers were shown to be cost-effective as screeners in a UK general hospital.
In the current review:
one additional review supports the use of AUDIT;
the importance of screening for fetal alcohol exposure is identified; and
one cost-effectiveness study supports a rapid screening in A&E departments.
Evaluating the performance of screening tests is hampered by the lack of an agreed gold standard.
INTRODUCTION
6.1 This section concerns the screening instruments that are available for the detection of problem drinking, alcohol abuse and dependence. No further evidence relating to laboratory tests was identified. The effectiveness of screening instruments is determined by the accuracy of the information that is provided. Very little additional literature was available.
SCREENING QUESTIONNAIRES
Types of intervention
6.2 In addition to the screening instruments reported previously (Ludbrook et al 2002), a shorter version of AUDIT (Alcohol Use Disorders Identification Test), the Fast Alcohol Screening Test (FAST), has been developed for use in situations where there is insufficient time to use the main 10 item test; for example, accident and emergency departments.
Effectiveness
6.3 A recent review of research relating to AUDIT indicates that this works at least as well as and often better than other measures (Reinert and Allen 2002). A single multi-centre study has assessed FAST, using AUDIT as the gold standard comparator, as an alternative to other quick assessments PAT (Paddington Alcohol Test) and CAGE (Cut down Annoyed Guilty Eye-opener) (Hodgson et al 2003). FAST performed well in comparison to AUDIT and the other alternatives. CAGE appears to be better at low levels of prevalence.
Population groups
6.4 AUDIT appears to be less sensitive and more specific for women, using the traditional cut off point of 8 (Reinert and Allen 2002). This lends support to the use of lower cut offs, with 5 or 6 being suggested. Studies with college students and adolescents are also reviewed but in most of these the AUDIT results have not been well validated. AUDIT does not perform well with the elderly but two studies suggest it may be useful in screening mental illness patients.
6.5 Savage et al (2003) have identified the need to measure fetal exposure to alcohol and not just alcohol dependence in pregnant women.
Setting
6.6 No comparisons of settings identified but the FAST study was carried out in A&E departments (Hodgson et al 2003)
Providers
6.7 No comparisons of different persons administering questionnaires were identified.
COST-EFFECTIVENESS
6.8 The study by Hodgson et al (2003) included information relating to the costs of administering FAST and other screening tests. These were collected in one A&E department and are based on a grade E nurse administering the test. FAST had the lowest cost (£1,669 for an annual population of 50,000 patients). This was not significantly less than the other quick assessment methods but was significantly less than AUDIT (£10,400).
QUALITY AND RELEVANCE OF EVIDENCE
6.9 The cost-effectiveness study is relatively small and detailed costing was only carried in one centre. The assessment of the screening instruments is still limited by the lack of an agreed diagnostic standard against which to confirm the screening results.
FURTHER RESEARCH
The research requirements identified in the previous report remain. These were:
the need to develop an agreed diagnostic gold standard;
research on the performance and role of laboratory tests as they are developed; and
comparisons of screening settings and providers.
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