医师常忽略饮酒问题


  【24drs.com】根据刊载于1/2月版家庭医学志的研究,与标准筛检仪器相比,单靠临床直觉会忽略了大多数的酗酒问题患者。
  
  哥伦比亚密苏里大学家庭与社区医学系Daniel Vinson医师写道,我们的研究证实这方面需要有制度,或许透过团队照护,以验证过的问题或系列问题而系统性地筛检饮酒问题,使用实证方法探讨此健康威胁。
  
  研究者设计了横断面研究来评估临床判断对于辨识酗酒问题患者的效果。
  
  研究团队纳入40处开业机构的94名主治医师,要求这些医师和符合资格的病患在就诊后完成简短的调查,病患调查包括了引用自饮酒异常监别问卷或精神疾病诊断与统计手册第四版的5题饮酒相关问题,医师调查则是问医师是否认为某特定患者有饮酒问题。
  
  作者们接著比较了病患问卷和医师问卷的结果,控制变项包括病患性别、年纪、教育程度、种族、医师类别。
  
  完成「出口调查」的这1,699名病患中,171人(10.1%)筛检为危险性饮酒阳性,64人(3.8%)筛检为伤害性饮酒阳性;「危险性饮酒」和「伤害性饮酒」的差异根据为病患在各种问卷中的评分。
  
  当医师认为病患有饮酒问题时,理论上有机会是判断正确的,医师们认为81名病患有饮酒问题,医师的正确预测值为62%。
  
  不过,医师们更可能准确辨识没有饮酒问题的患者(不论是风险性或伤害性,医师怀疑的专一性达98%),优于准确辨识有饮酒问题的病患(风险性或伤害性饮酒的医师怀疑敏感性为27%)。
  
  根据作者指出,医师通常无法在例行诊视中辨识饮酒问题;不过,当医师发现且提出饮酒问题时,可帮助病患减少饮酒量。
  
  这篇研究结果支持例行性使用筛检来帮助医师判断。
  
  根据作者表示,虽然将例行筛检整合到一般照护并不容易,还是有一些方法可以让它更简单。与结构式、研究者访谈相比,为了增加实务上饮酒问题筛检的可能性,可以用验证过的单一筛检问题。例如,「你最近一次一天中喝超过X杯是什么时候?(女性的X值为4、男性为5)」,如果答案是过去3个月内,则测出饮酒问题的敏感性为86%,专一性为86%。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6977&x_classno=0&x_chkdelpoint=Y
  

Physicians Frequently Miss Alcohol Problems

By Joanna Broder
Medscape Medical News

Clinical intuition alone misses most patients with alcohol problems compared with a standard screening instrument, according to a study published in the January/February issue of the Annals of Family Medicine.

"Our study affirms that systems need to be in place, possibly through team-based care, to screen systematically for alcohol problems with a validated question or series of questions and to address this health threat using evidence-based approaches," write Daniel Vinson, MD, MSPH, from the Department of Family and Community Medicine, University of Missouri, Columbia, and colleagues.

The researchers designed the cross-sectional study to evaluate the effectiveness of clinical judgment in the identification of patients with alcohol problems.

The team recruited 94 primary care physicians in 40 practices. They asked both physicians and their eligible patients to complete short surveys after the appointment. The patient survey included 5 alcohol-related questions drawn from the Alcohol Use Disorders Identification Test-Consumption or adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The physician surveys asked whether the clinician thought a particular patient had problems with alcohol.

The authors then compared results from the patient questionnaires with those from physicians' questionnaires, controlling for patient sex, age, educational attainment, race/ethnicity, and clustering by clinician.

Of the 1699 patients who filled out exit questionnaires, 171 (10.1%) screened positive for hazardous drinking and 64 (3.8%) screened positive for harmful drinking. The difference between "hazardous" and "harmful" drinking is based on how the patient scored on various questionnaires.

When physicians thought a patient had an alcohol problem, they had a reasonable chance of being right. Physicians sensed that 81 patients had problems with alcohol; the positive predictive value of clinician suspicion was 62%.

Physicians, however, were much more likely to accurately identify patients who did not have alcohol problems (the specificity of clinician suspicion of either hazardous or harmful drinking was 98%) than to accurately identify patients with alcohol problems (the sensitivity of clinician suspicion of either hazardous or harmful drinking was 27%).

According to the authors, physicians often do not identify alcohol problems during a routine office visit. However, "[w]hen alcohol problems are detected and addressed by clinicians, patients can be helped to reduce consumption."

Results from this study support the routine use of screening to supplement clinician judgment, according to the authors.

Although incorporating routine screening into primary care is not easy, there are ways to make it simpler, according to the authors. "To increase the feasibility of screening for alcohol problems in practice, a validated single screening question can be used. For example, for the question, 'When was the last time you had more than X drinks in one day?' where X is 4 for women and 5 for men, an answer of any time in the past 3 months was 86% sensitive and 86% specific in detecting alcohol problems compared with a structured, researcher-administered interview."

This study was supported by the Robert Wood Johnson Foundation. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2013;11:53-59.

    
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