Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Nurse referral for counseling of patients who screen positive for alcohol abuse increased the referral rate

ACP J Club. 1992 Mar-April;116:62. doi:10.7326/ACPJC-1992-116-2-062

Source Citation

Goldberg HI, Mullen M, Ries RK, Psaty BM, Ruch BP. Alcohol counseling in a general medicine clinic. A randomized controlled trial of strategies to improve referral and show rates. Med Care. 1991 Jul;29:JS49-56.



To determine whether nurse referral for counseling of patients who screen positive for alcohol abuse increases the referral rate, and to determine whether introduction to the counselor at the time of referral improves attendance at the first scheduled appointment.


Eligible patients had been randomized on an ongoing basis to 1 of 3 equivalent ambulatory practices. Practices were assigned randomly to the control and 2 intervention conditions.


An academic adult ambulatory general medicine clinic.


During the 4-month study period, 1328 eligible patients were seen in the 3 practices. 428 patients who screened positive for alcohol abuse were available for comparisons related to the 2 objectives.


Of 3 practices, 2 were randomized to nurse referral for counseling of patients who answered yes to either of the following: Have you ever had a drinking problem? Have you had a drink in the last 24 hours? For the third practice, referral for counseling was solely at the initiative of physicians who were not informed of screening results. The 2 nurse-referral practices were assigned randomly to have patients either introduced, or not introduced, to the alcohol counselor at the time of referral.

Main outcome measures

The proportion of patients accepting an appointment for counseling among those who screened positive, and, of those referred for counseling, the proportion attending the first scheduled appointment.

Main results

133 patients in the control practice and 295 in the 2 nurse-referral practices screened positive for alcohol abuse. Referral rates were 2.3% for controls and 10.8% for nurse referrals ({absolute difference 8.5%, 95% CI 4.2% to 12.9%}* P = 0.003). Among 14 nurse-referred patients randomized to counselor introduction, 7 (50%) attended the first appointment compared with 11 of 18 patients (61%) without introduction (P > 0.2).


A screening program for alcohol abuse with nurse referral to counseling increased referral rates almost 5-fold compared with referral by physicians unaware of screening results. Too few patients were referred for conclusions to be drawn about the effect on appointment keeping of an introduction to a counselor at the time of referral.

Sources of funding: In part, Pew Charitable Trusts; Rockefeller Foundation; National Institute of Drug Abuse.

Address for article reprint: Dr. H.I. Goldberg, Harborview Medical Center, ZA-60, 325 Ninth Avenue, Seattle, WA 98104, USA.

*Numbers calculated from data in article.


This study adds to the literature documenting that alcohol problems are common in academic general medicine practices and demonstrates the feasibility of incorporating simple alcohol screening into routine nursing activities. The screening was effective in that patients in the intervention arms were more likely to schedule a referral with an alcohol counselor than were control patients. Although the relative increase in the referral rate was impressive (almost 5-fold), the absolute effect was modest, as only 11% of identified patients accepted referral and only 6% actually met with the counselor. The reason that the overall effect was so small is an important issue. The screening test might have been inaccurate. In the initial study of the 2-question drinking test, the sensitivity and specificity were about 90%. However, a subsequent study in a population of elderly veterans found a sensitivity of only 52% and a specificity of 76% (1). Many individuals with a history of problem drinking were not actively drinking and thus did not need counseling. The intervention (nurse referral), although relatively easy to implement, might not have been effective. Denial, which is characteristic of problem drinking, was not specifically addressed.

Based on this study, routine screening and intervention in similar settings are appropriate. However, important questions remain. These include whether the 2-question test is the best screening method and what the most appropriate intervention is once screening has identified problem drinkers. For example, counseling by primary physicians may be as effective as more intensive efforts (2).

John B. Schorling, MD, MPH
University of VirginiaCharlottesville, Virginia, USA


1. Moran MB, Naughton BJ, Hughes SL. Screening elderly veterans for alcoholism. J Gen Intern Med. 1990;5:361-4.

2. Drummond DC, Thom B, Brown C, Edwards G, Mullan MJ. Specialist versus general practitioner treatment of problem drinkers. Lancet.1990;336:915-8.