Screening tool links alcohol use to mortality

New findings enhance clinical value of AUDIT-C screening for addressing unhealthy alcohol use in primary care

AUDIT-C — a 3-question alcohol screening tool — provides valuable insight into the health risks related to patients’ alcohol consumption, with new research finding an association between patient-reported alcohol use and mortality.

“These findings confirm earlier research linking alcohol use and mortality, but this is the first study to do so using routinely collected alcohol screening scores in a large, generalizable primary care population,” said lead author Tessa Matson, PhD, MPH, a collaborative scientist at Kaiser Permanente Washington Health Research Institute (KPWHRI). “This reinforces the value of AUDIT-C as a practical tool that enables primary care clinicians to recognize high-risk alcohol use and engage patients in timely, supportive conversations about reducing their risk.”

What do we know already?

Research over the last decade has expanded our understanding of the harmful effects of drinking alcohol, finding that it increases the risk of many illnesses — including cancer, liver disease, heart disease, and depression — and contributes to nearly 2.5 million deaths worldwide each year.

With such an oversized impact on health and well-being, alcohol consumption is an important modifiable risk factor to address in primary care. Health care organizations are increasingly adopting screening tools to detect unhealthy alcohol use among patients, so clinicians can offer brief interventions (such as information and counseling) or treatment. One common tool is AUDIT-C (short for Alcohol Use Disorder Identification Test, Consumption). It combines questions on drinking frequency, alcohol quantity, and occurrence of episodes of heavy drinking over the prior year to calculate an AUDIT-C score. The score indicates no alcohol use, low-risk use, moderate-risk use, high-risk use, or very high-risk use.

Earlier studies have shown that AUDIT-C is a reliable tool for assessing patients’ alcohol use in primary care settings —  and that higher AUDIT-C scores are associated with subsequent hospitalization. However, it has been less clear whether these scores can also predict mortality. Such information could aid clinicians’ conversations with patients by showing to what degree a person's alcohol use is associated with adverse health outcomes, including death.

What did the new study find?

The study was conducted at Kaiser Permanente Washington, which implemented annual AUDIT-C screening for all adult patients in 2015. The researchers analyzed AUDIT-C scores from more than 530,000 primary care patients between March 1, 2015, and Dec. 31, 2021, and reviewed death data from the Washington Department of Health through 2023.

Taking into account patients’ age, sex, smoking history, and other factors that can affect health and mortality, the researchers found that people reporting very high-risk alcohol use had a 58% higher risk of dying from any cause over the 8-year study period than patients reporting low-risk use. This association was more pronounced for younger adults (ages 18 to 29), for whom very high-risk drinking was linked to an approximately 3-fold higher risk of death than low-risk use.

Similar to earlier research, the study found a “U-shaped” association between alcohol use and mortality — meaning the risk of death was elevated at both the lowest and highest levels of alcohol use, while the lowest risk of death was among those reporting moderate use. Although on face value this suggests moderate drinking has a protective effect, it likely reflects the complex and dynamic relationship between alcohol use and health, according to the authors. For example, people who drink low to moderate levels of alcohol tend to be healthier than those who do not drink in part because non-drinkers may have health issues that restrict their alcohol consumption.

The researchers noted that future studies will need to explore how changes in drinking patterns are associated with mortality, as their findings are based on one snapshot in time when the patient first completed the AUDIT-C tool during the study period.

“AUDIT-C has already proven to be a valuable screening tool in primary care, prompting clinicians to initiate conversations with patients about unhealthy alcohol use,” Matson said. “Linking AUDIT-C scores to mortality risk adds an important dimension to these conversations, which may help patients re-evaluate their drinking habits.”

The study was funded by the National Institute on Alcohol Abuse and Alcoholism. It was published in Alcohol, Clinical and Experimental Research.

Matson’s KPWHRI coauthors on the study include Jennifer Bobb, PhD; Malia Oliver, BA; Katharine Bradley, MD, MPH; and affiliate investigator Kevin Hallgren, PhD.

By Sophie Ramsey