Early results from SIPS: Screening for brief intervention

1. Early results from SIPS: Screening for brief intervention Professor Simon Coulton

2. Overview of screening in SIPS Three study settings - Criminal Justice, Primary Care, Emergency DepartmentsThree screening tools- Modified SASQ, FAST, Paddington Alcohol TestTwo screening approaches- Universal screen vs Targeting by presentationOne gold standard- AUDIT score

3. 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 Negative Positive

4. The screening tools Fast Alcohol Screening TestMeasures M-SASQ. If negative probes using questions derived from AUDIT Negative M-SASQ Positive AUDIT Questions Negative Positive

5. The screening tools Paddington Alcohol Test.Targeted at specific presenting conditions, asks if attendance is alcohol related, if negative asks M-SASQ. Alcohol related attendance Negative Positive Negative M-SASQ Positive MSASQ is embedded in each screening tool…

6. The criminal Justice Setting Universal 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

7. The criminal Justice Setting Sensitivity, 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.

8. The criminal Justice Setting Odds ratio favouring fast for different outcomes AUDIT +ve Increasing Risk High Risk 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).

9. The Emergency Department Setting Universal 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

10. The Emergency Department Setting Sensitivity 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

11. The Primary Care Setting Comparing 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.

12. The Primary Care Setting Sensitivity 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.

13. The Primary Care Setting Comparing 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

14. The Primary Care Setting Sensitivity 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.

15. 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

16. 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.

17. 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.

18. 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.

19. Thank you