Routine CAGE Screening for Alcohol Use Disorders 

Among Veteran Outpatients May Not Be Cost-Effective 

 

In the United States, alcohol misuse is responsible for about 100,000 deaths and $185 billion in costs 

annually. Research evidence shows that brief interventions can reduce alcohol consumption and 

improve health outcomes, thus many groups recommend screening adults in primary care settings. 

There is ongoing debate about how best to translate these recommendations to real-world settings.

 

The VA requires annual alcohol screening and monitors screening as a quality measure and thus 

provides an ideal laboratory for studying the impact of implementing evidence-based interventions. 

This study sought to determine the extent to which VA patients are screened and diagnosed with alcohol 

use disorders, as well as the numbers who receive follow-up evaluations. Using data from several VA 

databases, this study focused on 15,580 veterans seen in 2002 across139 VA medical centers. During 

this time period, the CAGE questionnaire was the screening instrument for most clinic settings. 

Investigators examined information about patient demographics, medical and mental health diagnoses, 

and service utilization for the six months before and after patient alcohol screening.

 

Results show that 74.2% of eligible veterans had been screened for alcohol use disorders. Of those, 

4.2% screened positive, but less than half of them were diagnosed with an alcohol disorder, representing 

only 1.7% of the original cohort of 15,580. This relatively low yield from the CAGE raises questions 

about the value of large-scale, routine screening, as well as the frequency of screening with this 

instrument. Study findings also show that the likelihood of being screened for alcohol problems was 

lower at academically affiliated medical centers, and follow-up evaluation for positive screen was less 

likely at the largest facilities. Veterans with a service-connected disability and those with a psychiatric 

disorder were less likely to be screened, but were more likely to be followed up if screening was 

positive.

*Important Note: The majority of the veterans in 2002 were screened using the CAGE questionnaire 

which focuses on detecting clinical alcohol abuse/dependence rather than risky drinking. VA currently 

mandates the Alcohol Use Disorders Identification Test (AUDIT-C), which has been shown to be more 

sensitive in detecting less severe alcohol problems that may be more amenable to brief counseling 

interventions during the office visit. Future investigations are needed to evaluate the impact of current 

policy, but the higher yield of the AUDIT-C, as well as the use of non-MD clinicians to administer the 

instrument, are expected to improve overall cost-effectiveness. 

Desai MM, Rosenheck RA, Craig TJ. Screening for alcohol use disorders among medical outpatients: The influence of 

individual and facility characteristics. American Journal of Psychiatry 2005 Aug;162(8):1521-26. 

Dr. Desai is supported by an HSR&D Career Development Award and is part of the VA Northeast Program Evaluation 

Center. Dr. Rosenheck is Director of the VA Northeast Program Evaluation Center, and Dr. Craig is part of VA’s Office of 

Quality and Performance. 

 
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. If you have any 

questions or comments about this e-Brief, please email CIDER at Cider.Boston@med.va.gov.

 

The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged 

with disseminating important HSR&D findings and information to VA policy makers, managers, clinicians, and researchers 

working to improve the health and care of veterans.