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The Paddington Alcohol Test (PAT) confers considerable advantage over the CAGE as the accident and emergency (A&E) screen for alcohol misuse.
Hadida et al's commendable study1 identified 28% (out of 413) A&E attendees as having an alcohol related problem. A pilot study using the CAGE, run in our department a decade ago,2 had a very low pick up rate, which was one of the reasons behind the development of the PAT. Our recent study,3 using the PAT, had an overall detection rate of 6.4% rising to 9.8% in the third month after intensive audit and feedback.
Four features could explain the discrepancy:
in the PAT study only 61.1% of patients had presenting complaints mandating the test. The detection rate for this group (in month 3) was 14.3%.
in this group, 62 patients (of 286) were missed—that is, did not have the test applied.
the Hadida et al study identified a number of misusers by “staff assessment”. The basis of this assessment is unclear. Two questions are paramount: (a) Was an alcohol history taken?, (b) Did the patient agree with the doctor/nurse's assessment?
the Hadida et al study effectively had an extra member of staff run the screening protocol—whereas PAT usage simply reflects our own routine practice, with no extra staffing.
Studies suggest the CAGE detects dependent rather than hazardous drinkers,4 a point rightly discussed by Hadida et al, and emphasised elsewhere.5 Compared with dependent drinkers, hazardous drinkers (earlier on in their drinking history) are more likely to respond to brief interventions.5
The PAT is designed specifically for use by A&E practitioners, to detect hazardous as well as dependent drinkers. Detection is not indiscriminate but guided by “The Top Ten” presenting conditions, whereby screening is targeted and most effective. Furthermore, question 3 of the PAT—“do you feel your current attendance in A&E is related to alcohol?”—helps reinforce the idea that their presenting problem may be alcohol related, even if the patient were to refuse help on this occasion.
As the number of A&E departments that work with alcohol health workers increases it is hoped that the worth of the PAT will be further recognised.
We thank Huntley and colleagues for their comments on our paper.1 They make the point that the Paddington Alcohol Test 2 is a better instrument for screening for alcohol problems in the emergency department than the CAGE.3 We would not take issue with this.
The main aim of our study was not to investigate the sensitivity and specificity of different screening tests, but rather to show the feasibility of screening high proportions of patients as a first step towards intervention. We successfully screened 413 of 429 patients (96%), a much higher proportion than other studies.4, 5 As Huntley et al point out, this may reflect the fact that we effectively had an extra member of staff to run the screening. In addition we chose to recruit a representative flow sample of patients rather than consecutive attenders.
A further aim of our study was to ascertain whether different screening instruments identified different groups of patients. Our results suggested that they did, and we suspect that this would have been the case regardless of the precise screening instrument used in the study. The main point is that patients presenting to the emergency department with alcohol problems are a complex and heterogeneous group. Blanket approaches to treatment are unlikely to work and we need to target specific interventions to those patients who might most benefit.
As regards assessment tools, a brief alcohol history was taken by the researcher interviewing the patients. The staff assessment consisted simply of the interviewer asking the member of emergency department staff who had seen the patient whether they thought the attendance was alcohol related. The patient agreed with the staff assessment in just over one third of cases (29 of 76). There was a higher level of agreement between the patient and the CAGE assessment, with agreement in two thirds of cases (49 of 75).
We would strongly support the use of tools such as the PAT and the CAGE to screen for alcohol problems in the emergency department. However, for this to be a useful process all emergency department attenders need to be screened. Screening programmes that miss significant numbers of patients are unlikely to be worthwhile.