title: Decreasing sensitivity of clinical alcohol screening with the AUDIT-C after repeated negative screens in VA clinics.
abstract: BACKGROUND
  Routine screening for unhealthy alcohol use is widely recommended in primary care settings. However, the validity of repeat screening among patients who have previously screened negative remains unknown. This study aims to evaluate the performance of a clinical alcohol screen compared to a confidential comparison alcohol screen among patients with previous negative alcohol screens.
  
  
  METHODS
  This study included four nested samples of Veteran Health Administration (VA) outpatients with at least one (N=18,493) and up to four (N=714) prior negative annual clinical AUDIT-C screens who completed the AUDIT-C the following year, both in a VA clinic (clinical screen) and on a confidential mailed survey (comparison screen). AUDIT-C screens were categorized as either negative (0-3 points men; 0-2 women) or positive (≥4 men; ≥3 women). For each sample, the performance of the clinical screen was compared to the comparison screen, the reference measure for unhealthy alcohol use.
  
  
  RESULTS
  The sensitivity of clinical screens decreased as the number of prior negative screens in a sample increased (40.0-17.4%) for patients with 1-4 negative screens. The positive predictive value also decreased as the number of prior negative screens in a sample increased (67.7-33.3%) while specificity was consistently high for all samples (≥97.8%).
  
  
  CONCLUSIONS
  Repeat clinical alcohol screens became progressively less sensitive for identifying unhealthy alcohol use among patients who repeatedly screened negative over several years. Alternative approaches for assessing unhealthy alcohol use may be needed for these patients.
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States. Electronic address: lapham.g@ghc.org.
authors.forename: Gwen T
authors.initials: GT
authors.lastname: Lapham
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 3801 Miranda Ave, Menlo Park, CA 94304, United States.
authors.forename: Anna D
authors.initials: AD
authors.lastname: Rubinsky
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Department of Health Services, University of Washington, Seattle, WA 98195, United States.
authors.forename: Emily C
authors.initials: EC
authors.lastname: Williams
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Hawkins
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States.
authors.forename: Joel
authors.initials: J
authors.lastname: Grossbard
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Department of Health Services, University of Washington, Seattle, WA 98195, United States.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Chavez
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Kivlahan
authors.affiliation: Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care; VA Puget Sound Health Services Research & Development 1100 Olive Way, Seattle, WA 98101, United States; Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, United States; Department of Medicine, University of Washington, Seattle, WA 98195, United States; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States; Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, United States.
authors.forename: Katharine A
authors.initials: KA
authors.lastname: Bradley
mesh_terms: D000328:Adult; D000368:Aged; D000437:Alcoholism / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D011320:Primary Health Care; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
keywords: AUDIT-C; Alcohol screening; Unhealthy alcohol use; Validation