CAGE, RAPS4, RAPS4-QF and AUDIT screening tests for men and women admitted for acute alcohol intoxication to an emergency department: are standard thresholds appropriate?

Abstract

Aims: A number of screening instruments are routinely used in Emergency Department (ED) situations to identify alcohol-use disorders (AUD). We wished to study the psychometric features, particularly concerning optimal thresholds scores (TSs), of four assessment scales frequently used to screen for abuse and/or dependence, the cut-down annoyed guilty eye-opener (CAGE), Rapid Alcohol Problem Screen 4 (RAPS4), RAPS4-quantity-frequency and AUD Identification Test (AUDIT) questionnaires, particularly in the sub-group of people admitted for acute alcohol intoxication (AAI).

Methods: All included patients [AAI admitted to ED (blood alcohol level ≥0.8 g/l)] were assessed by the four scales, and with a gold standard (alcohol dependence/abuse section of the Mini International Neuropsychiatric Interview), to determine AUD status. To investigate the TSs of the scales, we used Youden's index, efficiency, receiver operating characteristic (ROC) curve techniques and quality ROC curve technique for optimized TS (indices of quality).

Results: A total of 164 persons (122 males, 42 females) were included in the study. Nineteen (11.60%) were identified as alcohol abusers alone and 128 (78.1%) as alcohol dependents (DSM-IV). Results suggest a statistically significant difference between men and women (P < 0.05) in performance of the screening tests RAPS4 (≥1) and CAGE (≥2) for detecting abuse. Also, in this population, we show an increase in TSs of RAPS4 (≥2) and CAGE (≥3) for detecting dependence compared with those typically accepted in non-intoxicated individuals. The AUDIT test demonstrates good performance for detecting alcohol abuse and/or alcohol-dependent patients (≥7 for women and ≥12 for men) and for distinguishing alcohol dependence (≥11 for women and ≥14 for men) from other conditions.

Conclusion: Our study underscores for the first time the need to adapt, taking into account gender, the thresholds of tests typically used for detection of abuse and dependence in this population.

Fig. 1.

ROC curves of RAPS4, RAPSQF1, CAGE and AUDIT for men and women admitted for drunkenness. *Optimal threshold scores (by calculating the indices of quality [number total of subjects × k(1,0) × k(0,0)]. for detecting alcohol abuse/harmful drinking and/or alcohol dependence. **Optimal threshold scores (by calculating the indices of quality) for detecting alcohol dependence. Alcohol misuse diagnostic was measured by the MINI (Lecrubier et al., 1997). According to the MINI, alcohol dependence was established from a positive response in three or more of the seven domains on DSM-IV diagnostic criteria of dependence, while harmful drinking/abuse was established from a positive response on one or more of the four consequence items related to harmful drinking on DSM-IV for individuals who did not meet the criteria for dependence. (a) ROC curve of RAPS4 (men) for detecting alcohol abuse/harmful drinking and/or alcohol dependence, (b) ROC curve of RAPSQF1 (men) for detecting alcohol abuse/harmful drinking and/or alcohol dependence, (c) ROC curve of CAGE (women) for detecting alcohol abuse/harmful drinking and/or alcohol dependence, (d) ROC curve of AUDIT (men) for detecting alcohol abuse/harmful drinking and/or alcohol dependence, (e) ROC curve of AUDIT (women) for detecting alcohol abuse/harmful drinking and/or alcohol dependence, (f) ROC curve of RAPS4 (men) for detecting alcohol dependence, (g) ROC curve of RAPSQF1 (men) for detecting alcohol dependence, (h) ROC curve of CAGE (women) for detecting alcohol dependence, (i) ROC curve of AUDIT (men) for detecting alcohol dependence and (j) ROC curve of AUDIT (women) for detecting alcohol dependence.