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Ethnic and Sex Bias in Primary Care Screening Tests for Alcohol Use Disorders

Jeffrey R. Steinbauer, MD; Scott B. Cantor, PhD; Charles E. Holzer III, PhD; and Robert J. Volk, PhD
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From The University of Texas Medical Branch at Galveston, Galveston, Texas; and the University of Texas M.D. Anderson Cancer Center, Houston, Texas. For current author addresses, see end of text. Acknowledgments: The authors thank Kristi O'Dell, PhD, Carol Carlson, and Kristy Smith for assistance in managing this project and Lynn Alperin for editorial expertise. They also thank Cherry Lowman, PhD, and Bridget Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism, for guidance and support. The SAAST is copyrighted by the Mayo Foundation and is used with permission. Grant Support: In part by grants from the National Institute on Alcohol Abuse and Alcoholism (AA09496) and the Bureau of Health Professions, Health Resources and Services Administration (D32-PE16033). Requests for Reprints: Robert J. Volk, PhD, Department of Family Medicine and Community Medicine, Baylor College of Medicine, 5510 Greenbriar, Houston, TX 77005. Current Author Addresses: Dr. Steinbauer: Blackstock Family Health Center, 4614 IH-35, Austin, TX 78751.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(5):353-362. doi:10.7326/0003-4819-129-5-199809010-00002
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Background: The use of self-report screening tests for alcohol use disorders in the primary care setting has been advocated.

Objective: To test for ethnic and sex bias in three self-report screening tests for alcohol use disorders in a primary care population.

Design: Cross-sectional study with patients randomly selected from appointment lists.

Setting: University-based family practice clinic.

Patients: Probability sample of 1333 adult family practice patients stratified by sex and ethnicity.

Measurements: Patients completed 1) a diagnostic interview to determine the presence of a current alcohol use disorder and 2) three screening tests: the CAGE questionnaire, the Self-Administered Alcoholism Screening Test (SAAST), and the Alcohol Use Disorders Identification Test (AUDIT).

Results: The areas under the receiver-operating characteristic (ROC) curves for the CAGE questionnaire and the SAAST ranged from 0.61 to 0.88 and were particularly poor for African-American men and Mexican-American women. For the AUDIT, the area under the ROC curves was greater than 0.90 for each patient subgroup. The sensitivity of the CAGE questionnaire and the SAAST at standard cut-points was lowest for Mexican-American women (0.21 and 0.13, respectively). Positive likelihood ratios for the AUDIT were similar to or higher than those for the other screening tests, whereas negative likelihood ratios were lowest for the AUDIT (<0.33), indicating the superiority of this test in ruling out a disorder.

Conclusions: A marked inconsistency in the accuracy of common self-report screening tests for alcohol use disorders was found when these tests were used in a single clinical site with male and female family practice patients of different ethnic backgrounds. The AUDIT does not seem to be affected by ethnic and sex bias.


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. Self-Administered Alcoholism Screening Test (SAAST). Reprinted by permission of Mayo Foundation from Colligan and colleagues .
Appendix Figure 1[22]
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. Alcohol Use Disorders Identification Test (AUDIT). Reprinted with permission from Babor and colleagues .
Appendix Figure 2[28]
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