Date post: | 17-Jan-2016 |
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Early results from SIPS: Screening for brief intervention
Professor Simon Coulton
Overview of screening in SIPS
Three study settings
- Criminal Justice, Primary Care, Emergency Departments
Three screening tools
- Modified SASQ, FAST, Paddington Alcohol Test
Two screening approaches
- Universal screen vs Targeting by presentation
One gold standard
- AUDIT score
The screening tools
Modified SASQ
Measures heavy episodic drinking, 6 for women or 8 for men standard drinks on a single occasion.
Monthly or less is a screen positive
M-SASQ PositiveNegative
The screening tools
Fast Alcohol Screening Test
Measures M-SASQ. If negative probes using questions derived from AUDIT
M-SASQ PositiveNegative
AUDIT QuestionsNegative Positive
The screening tools
Paddington Alcohol Test.
Targeted at specific presenting conditions, asks if attendance is alcohol related, if negative asks M-SASQ.
M-SASQ PositiveNegative
Alcohol related
attendanceNegative Positive
MSASQ is embedded in each screening tool…
The criminal Justice SettingUniversal screening only M-SASQ versus FAST
• Very high prevalence of AUD in this population
• M-SASQ results in far more false positives than FAST
• M-SASQ is far less efficient at identifying high risk alcohol users
The criminal Justice SettingSensitivity, the efficiency in identifying true cases
M-SASQ FAST
M-SASQ has a sensitivity of 81.3% and FAST 92.1%. FAST is significantly more efficient at identifying true positives.
The criminal Justice SettingOdds ratio favouring fast for different outcomes
AUDIT +ve
The odds of being a true positive after scoring positive on FAST is 2.6 times that after scoring positive on M-SASQ, the odds of being categorised as increasing risk is similar for both instruments, but M-SASQ significantly under-estimates high risk individuals (OR 1.58).
Increasing Risk
High Risk
The Emergency Department SettingUniversal M-SASQ and FAST. Targeted PAT
• Higher prevalence than population norm but not as high as CJS
• High risk consumers are more likely to be active consumers of alcohol than in CJS
• M-SASQ is the most efficient screening method in all respects
The Emergency Department SettingSensitivity and odds ratios
• Sensitivity is similar across all screens but the screen conversion rate, screen positives from those that approached was significantly better for M-SASQ.
• M-SASQ and FAST are significantly better at identifying AUDIT positive than PAT.
• M-SASQ is significantly better at identifying increasing risk than PAT
The Primary Care SettingComparing M-SASQ with FAST….
• Lowest prevalence of all the study settings.
• M-SASQ is significantly less sensitive than FAST.
• Other studies report that about 8-10% of primary care population are heavy episodic alcohol users but do not have an alcohol use disorder.
The Primary Care SettingSensitivity and odds ratios
• Sensitivity of FAST is significantly better than M-SASQ
• FAST is significantly better at identifying AUDIT positives but not significantly better than M-SASQ in terms of increasing or high risk differentiation.
The Primary Care SettingComparing targeted versus universal screening
• There are no interactions between screening method and screening approach
• Targeting results in significantly more screen positives
• Targeting is no more sensitive than universal screening
The Primary Care SettingSensitivity and odds ratios
• Sensitivity of targeted screening is similar to universal screening
• Targeted screening has higher odds ratios for AUDIT positive, increasing risk and high risk than universal screening but these are not significantly better.
What does it all mean?First the caveats…
• The data presented needs further detailed analysis
• The data needs modeling to take account of the clustered data
• A concurrent economic analysis will evaluate the cost-efficiency
What does it all mean?The populations….
• There are interesting differences between the population demographics in each study.
• CJS is younger (31 years), male (85%) and less stable. PHC is older (50 years), Female (52%) and the most stable. ED has the most variation in age and stability.
• CJS has the highest prevalence of AUD (c.65%+) and particular high risk AUD. ED has the next highest prevalence (c.45%) and PHC the lowest (c.28%)
• But ED has the highest prevalence of heavy episodic drinking.
• Each study appears to have elements of a distinct population.
What does it all mean?The screening tools….
• FAST is the most efficient screening tool in both PHC and CJS settings, in both settings M-SASQ is associated with more false positives and fewer true positives for high risk drinking.
• M-SASQ is the most efficient screening tool in ED settings in terms of the number of positives identified for the numbers approached.
• In ED settings M-SASQ is as efficient as FAST and both FAST and M-SASQ are more efficient than PAT in terms of diagnostic accuracy.
What does it all mean?Targeting versus universal….
• PAT is the least efficient screening tool in ED.
• In PHC targeting has a significantly better screen conversion rate than universal screening.
• In PHC targeting is no more efficient than universal screening in terms of diagnostic accuracy.
• Almost 50% of PHC presentations in the universal arm do not meet the targeted criteria.
• The most common targeted condition is hypertension and the second new registrations.
Thank you