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.