The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis
Introduction
Alcohol abuse and dependence affect 6 to 15% of a primary care population [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11] and even a larger percentage, about 15 to 61% [12], of a specialist clinic or hospitalized patient population. However, the problem for clinicians has been one of recognition. Only one-third of patients with alcohol problems is detected by their physician [8], [13], [14]. No single laboratory test or combination of tests has been shown to be appropriate for screening [14], [15], [16]. Although physicians do not easily use them during a routine consultation, questionnaires have better test results in screening for alcohol abuse and dependence [17].
The CAGE questionnaire is one of the most widely studied self-report instruments for alcohol problems [18], [19]. It has demonstrated its superiority over laboratory markers [20], [21], [22]. Sensitivity and specificity of the CAGE are thought to be somewhat lower than other questionnaires (MAST, SAAST, and AUDIT). However, used as a first step before deciding to do a more complex workup, his brevity (four questions) and simplicity (answer yes or no) still makes it a useful screening and case-finding tool, particularly for the busy primary care physician [19].
Studies show that implementation of the CAGE may improve the identification of alcohol problems in different settings [22], [23], [24], [25], [26]; however, application of the CAGE varies widely among physicians (from 38 to 100%) [27]. Data of Jorge and Masur in Brazil demonstrated how an attempt to improve detection of alcohol-dependent patients through the introduction of the CAGE was unsuccessful. Because clinical staff did not agree with the wish to reinforce the search for alcohol problems, this results in a lack of motivation in several physicians [28]. On the other hand, Lawner et al. conducted a successful educational intervention in a primary care practice to improve physicians' use of CAGE questions to screen for alcoholism [29]. The use of the CAGE increased from 6 to 77%. The CAGE can also be used as an oral questionnaire embedded in history taking [30].
Nevertheless, there is no consensus about the diagnostic value of the CAGE. Inconsistent reports for the CAGE and other questionnaires reflect, in part, different study populations, varying reference standards for defining problem drinking and the presence of confounding variables in published validation studies [18], [31]. A recent systematic review performed by Fiellin and his colleagues pointed that the CAGE questions proved superior for detecting alcohol abuse and dependence in primary care [32].
Therefore, we performed a diagnostic meta-analysis, based on guidelines for conducting systematic reviews of studies evaluating the accuracy of diagnostic tests [33], of all published studies to evaluate the diagnostic value of the CAGE in general clinical inpatients, ambulatory medical patients, and primary care patients. To avoid bias resulting from different definitions between studies we restricted ourselves to studies using DSM criteria as the reference standard for alcohol abuse and dependence. By analyzing three different subpopulations and pooling them separately, we also want to avoid clinical heterogeneity. Finally, we tested a new method for pooling ROC curves [34].
Section snippets
Instruments
The CAGE questionnaire was developed from a clinical study undertaken in 1968 at North Carolina Memorial Hospital by Ewing [35] to screen for alcohol abuse and alcohol dependence. It was initially validated by Mayfield and colleagues in a psychiatric service in 1970 [36], and later in different countries and populations [37], [38], [39]. The CAGE is an acronym for each of four questions (Table 1). The questionnaire can be administered in less than 60 sec, and is generally used with a threshold
Results
We identified 35 articles using the DSM criteria as a gold standard to test the screening characteristics of the CAGE in a clinical population. Only 10 studies complied with our inclusion and exclusion criteria [14], [20], [49], [50], [51], [52], [53], [54], [55], [56], [57].
Discussion
The CAGE questionnaire is a widely used diagnostic tool. It is mentioned in more than 200 publications related to alcohol problems. Despite a systematic review of screening for alcohol problems in primary care [32], the most surprising result of this study is the absence of a diagnostic meta-analysis and the finding that only a few studies evaluated the CAGE's diagnostic accuracy in relation to DSM criteria. The questionnaire's diagnostic value also was studied in many articles with other
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