Comparison of AUDIT-C collected via electronic medical record and self-administered research survey in HIV infected and uninfected patients

Abstract

Background Using electronic medical record (EMR) data for clinical decisions, quality improvement, and research is common. While unhealthy alcohol use is particularly risky among HIV infected individuals (HIV+), the validity of EMR data for identifying unhealthy alcohol use among HIV+ is unclear. Among HIV+ and uninfected, we: 1) assess agreement of EMR and research AUDIT-C at validated cutoffs for unhealthy alcohol use; 2) explore EMR cutoffs that maximize agreement; and 3) assess subpopulation variation in agreement. Methods Using data from the Veterans Aging Cohort Study (VACS), EMR AUDIT-C cutoffs of 2+, 3+, and 4+ for men (2+ and 3+ for women) were compared to research AUDIT-C 4+ for men (3+ for women). Agreement was compared by demographics, HIV, hepatitis C infection, and alcohol related diagnosis. Results Among 1,082 HIV+ and 1,160 uninfected men, 14% and 22% had an EMR and research AUDIT-C 4+, respectively. Among 32 HIV+ and 115 uninfected women, 9% and 14% had an EMR and research AUDIT-C 3+. For men, EMR agreement with the research AUDIT-C 4+ was highest at a cutoff of 3+ (kappa = 0.49). For women, EMR agreement with AUDIT-C 3+ was highest at a cutoff of 2+ (kappa = 0.60). Moderate agreement was consistent across subgroups. Conclusions EMR AUDIT-C underestimates unhealthy alcohol use compared to research AUDIT-C in both HIV+ and uninfected individuals. Methods for improving quality of clinical screening may be in need of investigation. Researchers and clinicians may consider alternative EMR cutoffs that maximize agreement given limitations of clinical screening.

Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare

“…Third, we assessed level of alcohol use using clinically-documented responses to a 3-item alcohol screen and clinically documented AUD, both of which may underestimate alcohol use. Though clinically-documented AUDIT-C scores have acceptable agreement with patient-reported scores among PLWH, 67 clinical screening in the VA may not be conducted in a validated, standardized, or reproducible way 68 and may be subject to social desirability bias. 69 Fourth, use of EHR data limited measurement of some potential biological/behavioral mechanisms underlying associations between alcohol use and HIV care continuum measures.…”

Changes in alcohol use associated with changes in HIV disease severity over time: A national longitudinal study in the Veterans Aging Cohort

“…These findings could also relate to unreliable reports of decreases over time. Known limitations to the quality of clinical alcohol screening in VA, which result in under-detection of drinking (Bradley et al, 2011; McGinnis et al, 2016; Williams et al, 2015), may have resulted in misclassification. Finally, it is possible that we did not have adequate power to understand associations between changes in drinking and changes in HIV disease severity for those with large changes due to increasingly small sample sizes.…”

“…Although analyses used inverse probability weighting to account for biases arising from differential loss to follow-up, results may not be generalizable to PLWH not engaged in healthcare and/or not screened for unhealthy alcohol use. Second, alcohol use measurement may have been influenced by both patient and provider-level factors (Bradley et al, 2011; Lapham et al, 2013; McGinnis et al, 2016; Williams et al, 2015) which may have resulted in inaccurate reflections of changes—particularly decreases—in drinking. Further research should be conducted using gold-standard assessments of alcohol use, (e.g., timeline follow-back methods) and/or biomarkers (Williams et al, 2016a).…”

Differences in Receipt of Alcohol‐Related Care Across Rurality Among VA Patients Living With HIV With Unhealthy Alcohol Use

“…Use of secondary clinical and administrative data may be associated with measurement error. Specifically, identification of eligible patients using clinically documented AUDIT‐C screens may have resulted in under‐identification of PLWH with unhealthy alcohol use due to methods of screening administration, social desirability bias, or limited patient recall . Measurement of brief interventions using text data generated via use of electronic clinical decision support may be limited for capturing brief intervention receipt, and data did not enable assessment of the quality of brief intervention delivered .…”