ITEM BIAS IN THE CAGE SCREENING-TEST FOR ALCOHOL-USE DISORDERS

OBJECTIVE: To explore potential item bias in the CAGE questions (mnemo nic for cut-down, annoyed, guilty, and eye-opener) when used to screen for alcohol use disorders in primary care patients. DESIGN AND SETTIN G: Cross-sectional study, conducted in a university-based, family prac tice clinic, with the presence of an alcohol use disorder determined b y structured diagnostic interview using the Alcohol Use Disorder and A ssociated Disabilities Interview Schedule. PATIENTS: A probability sam ple of 1,333 adult primary care patients, with oversampling of female and minority (African-American and Mexican-American) patients. MAIN RE SULTS: Unadjusted analyses showed marked differences in the sensitivit y and specificity of each CAGE question against a lifetime alcohol use disorder, across patient subgroups. Women, Mexican-American patients, and patients with annual incomes above $40,000 were consistently less likely to endorse each CAGE question ''yes,'' after adjusting for the presence of an alcohol use disorder and pattern of alcohol consumptio n. In results from logistic regression analyses predicting an alcohol use disorder, cut-down was the only question retained in models for ea ch of the subgroups. The guilty question did not contribute to the pre diction of an alcohol use disorder; annoyed and eye-opener were incons istent predictors. CONCLUSIONS: Despite its many advantages, the CAGE questionnaire is an inconsistent indicator of alcohol use disorders wh en used with male and female primary care patients of varying racial a nd ethnic backgrounds. Gender and cultural differences in the conseque nces of drinking and perceptions of problem alcohol use may explain th ese effects. These biases suggest the CAGE is a poor ''rule-out'' scre ening test. Brief and unbiased screens for alcohol use disorders in pr imary care patients are needed.