CORK Bibliography: TWEAK (Screening Test)

8 citations. January 2003 to present

Prepared: June 2011

Burns E; Gray R; Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: A systematic review. (review). Addiction 105(4): 601-614, 2010. (80 refs.)

Aims: Although prenatal screening for problem drinking during pregnancy has been recommended, guidance on screening instruments is lacking. We investigated the sensitivity, specificity and predictive value of brief alcohol screening questionnaires to identify problem drinking in pregnant women. Methods: Electronic databases from their inception to June 2008 were searched, as well as reference lists of eligible papers and related review papers. We sought cohort or cross-sectional studies that compared one or more brief alcohol screening questionnaire(s) with reference criteria obtained using structured interviews to detect 'at-risk' drinking, alcohol abuse or dependency in pregnant women receiving prenatal care. Results: Five studies (6724 participants) were included. In total, seven instruments were evaluated: TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Kut down), T-ACE [Take (number of drinks), Annoyed, Cut down, Eye-opener], CAGE (Cut down, Annoyed, Guilt, Eye-opener], NET (Normal drinker, Eye-opener, Tolerance), AUDIT (Alcohol Use Disorder Identification Test), AUDIT-C (AUDIT-consumption) and SMAST (Short Michigan Alcohol Screening Test). Study quality was generally good, but lack of blinding was a common weakness. For risk drinking sensitivity was highest for T-ACE (69-88%), TWEAK (71-91%) and AUDIT-C (95%), with high specificity (71-89%, 73-83% and 85%, respectively). CAGE and SMAST performed poorly. Sensitivity of AUDIT-C at score >= 3 was high for past year alcohol dependence (100%) or alcohol use disorder (96%) with moderate specificity (71% each). For life-time alcohol dependency the AUDIT at score >= 8 performed poorly. Conclusion: T-ACE, TWEAK and AUDIT-C show promise for screening for risk drinking, and AUDIT-C may also be useful for identifying alcohol dependency or abuse. However, their performance as stand-alone tools is uncertain, and further evaluation of questionnaires for prenatal alcohol use is warranted.

Bush KR; Kivlahan DR; Davis TM; Dobie DJ; Sporleder JL; Epler AJ et al. The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients. Alcoholism: Clinical and Experimental Research 27(12): 1971-1978, 2003. (57 refs.)

Background: The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. Methods: Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person inter-views with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. Results: Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point (1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74).Conclusions: The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.

Cremonte M; Cherpitel CJ. Performance of screening instruments for alcohol use disorders in emergency department patients in Argentina. Substance Use & Misuse 43(1): 125-138, 2008. (32 refs.)

The performance of the Alcohol Use Disorders Identification Test (AUDIT), CAGE, Brief Michigan Alcohol Screening Test (Brief MAST), Rapid Alcohol Problems Screen ( RAPS), Rapid Alcohol Problems Screen-Quantity and Frequency (RAPS4-QF), and TWEAK was evaluated against a diagnosis of alcohol dependence and harmful drinking or alcohol abuse from ICD-10 and DSM-IV criteria. Data were collected from a probability sample of 779 patients admitted to the emergency department of a public general hospital in Mar del Plata, Argentina, during the year 2001. The majority of the patients sampled were male. The age range was 18 to 89 years, with a mean value of 36 years and a median of 31 years. Almost half of the sample had an elementary school education or less. All instruments were more sensitive for alcohol dependence than for harmful drinking or abuse and more sensitive for men than for women. Findings suggest the RAPS4 and RAPS4-QF may be preferred when screening for alcohol use disorders in the emergency department in Argentina. The study's limitations are noted.

Cremonte M; Ledesma RD; Cherpitel CJ; Borges G. Psychometric properties of alcohol screening tests in the emergency department in Argentina, Mexico and the United States. Addictive Behaviors 35(9): 818-825, 2010. (45 refs.)

The objective of this article is to report psychometric characteristics of the AUDIT, CAGE, RAPS4, and TWEAK and to compare them across three countries: Argentina, Mexico, and the United States which used a similar protocol and methodology. Probability samples of patients 18 years and older were drawn from emergency departments in Mar del Plata, Argentina (n = 780), Pachuca, Mexico (n=1624) and Santa Clara, U.S. (n=1220). Concurrent validity was assessed by comparing their performance against a diagnosis of alcohol dependence (DSM-IV) obtained through the Composite International Diagnostic Interview, and for the briefer measures, also by their correlation with the AUDIT. The internal consistency of the CAGE, RAPS4, and TWEAK scores was estimated by the KR-20 formula and by Cronbach's Alpha for the AUDIT. Corrected item-total correlation and D-values were used as item discrimination measures. In Argentina and Mexico the AUDIT and the RAPS4 showed the highest validity. Reliability of all instruments was higher in the US than in Argentina or Mexico. In all three countries, reliability of the TWEAK was lowest, while the AUDIT was highest. With a few exceptions, all items showed good discrimination powers.

Gareri J; Chan D; Klein J; Koren G. Screening for fetal alcohol spectrum disorder. Canadian Family Physician 51: 33-34, 2005. (6 refs.)

QUESTION I have several patients whom I suspect are drinking during pregnancy. How can I find out for sure if they are? ANSWER You can use one of the validated tools to screen for problem drinking. Motherisk uses the TWEAK test, but others are just as good. Following birth, you can test infants' meconium for metabolites of ethanol to detect whether they were exposed in utero to excessive drinking.

Mengel MB; Searight HR; Cook K. Preventing alcohol-exposed pregnancies. (review). Journal of the American Board of Family Medicine 19(5): 494-505, 2006. (103 refs.)

Fetal alcohol exposure affects approximately 1% to 3% of live births in the United States. Family physicians are in a unique position to reduce the incidence of alcohol-exposed pregnancy. Fetal alcohol exposure can be minimized through 2 general approaches: reducing alcohol consumption or increasing effective contraception among childbearing-aged women who engage in "at-risk" drinking and encouraging pregnant women to abstain from alcohol. Although no safe level of alcohol consumption during pregnancy is established, women who binge drink are more likely to deliver infants with physical and cognitive-developmental anomalies. Screening tools, such as quantity/frequency questions, the TWEAK and the T-ACE, developed specifically for prenatal care, are more useful with women than the CAGE and Michigan Alcohol Screening Test (MAST). Screening alone seems to reduce alcohol use among pregnant women. Brief interventions, including education about alcohol's effects on the developing fetus, are effective among women not responding to screening. Unfortunately, many barriers exist to effective implementation of alcohol-exposed pregnancy (AEP) prevention in the clinical setting. Designing effective office base systems so the entire burden of implementing AEP prevention activities doesn't fall solely on the family physician is critical.

Moraes CL; Viellas EF; Reichenheim ME. Assessing alcohol misuse during pregnancy: Evaluating psychometric properties of the CAGE, T-ACE and TWEAK in a Brazilian setting. Journal of Studies on Alcohol 66(2): 165-173, 2005. (73 refs.)

Objective: The present article evaluates the psychometric properties of the Portuguese-language versions of the CAGE, TWEAK and T-ACE questionnaires when used to identify alcohol misuse during pregnancy and compares these to historical data from the English-language versions. Also, construct validity of the Portuguese versions of those instruments was assessed. Method: Data were collected from March to September 2000 in three large public maternity wards in Rio de Janeiro, Brazil. Sample size varied according to the analysis. An intra-observer reliability evaluation involved 95 replications carried out within a 24-48 hour period. Kappa was used as an estimator. Cronbach's alpha coefficient, whether or not each item from the analysis was excluded, and the item-rest point-biserial correlations addressed internal consistency (N = 786). For the appraisal of construct validity (n = 528), the relationship between alcohol misuse (evaluated by each instrument according to different cutoff points) and several putative underlying theoretically related dimensions (schooling, age, smoking, marital status, social support, illicit drug use, domestic violence and per capita household income) were evaluated. Results: All kappas were above 0.70. The alpha coefficients for the Portuguese versions ranged from 0.48 to 0.68, a finding consistent with studies assessing the original instruments in English. Yet, irrespective of the instrument concerned, a systematic increase was observed whenever the item on morning alcohol use ("Eye-opener") was removed from the analysis. Regarding construct validity, most tested hypotheses were corroborated, except for the CAGE using the cut-off point of 2. Conclusions: This study confirms other authors' findings that all but the aforementioned CAGE may be recommended to identify heavy alcohol use during pregnancy in general as well as in Portuguese-speaking populations in particular.

O'Connor MJ; Whaley SE. Alcohol use in pregnant low-income women. Journal of Studies on Alcohol 64(6): 773-783, 2003. (46 refs.)

Objective: The present study had two aims: (1) to examine the prevalence rates of prenatal alcohol consumption in a group of women participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Southern California, with special emphasis on Hispanic women, and (2) to identify variables associated with postconception drinking in low-income minority women. Method: The study employed a cross-sectional survey that assessed alcohol use rates, demographic variables, and alcohol risk status. Participants were 826 pregnant women enrolled in the Public Health Foundation Enterprises (PHFE) WIC Program in Los Angeles and Orange counties, California. Pregnant women who enrolled self-administered a specially designed alcohol screener. Results: Findings were that 24% of sample women were consuming alcohol post conception. Of that percentage, approximately two thirds drank prior to pregnancy recognition, and one third continued to drink after pregnancy was confirmed. Approximately 30% of white non-Hispanic, black non-Hispanic and English-speaking Hispanic women were found to drink post conception compared with 15.8% of Spanish-speaking Hispanic women. This finding supported recent research that suggests more acculturated Hispanic women tend to incorporate the drinking patterns of the larger U.S. population to a greater extent than less acculturated Hispanic women. Although a number of demographic variables differentiated women who were abstinent from those who were postconception drinkers, the best predictor of postconception alcohol consumption was the woman's high-risk drinking score as measured by the TWEAK (sensitivity = 70.1%, specificity = 88.5%). Conclusions: Results suggest the importance of screening low-income minority pregnant women in a community setting so that interventions can be initiated to prevent fetal alcohol syndrome and related conditions.