, it is estimated that , among 
         the adult population , 14% have a lifetime prevalence of alcohol dependence.1 a brazilian multicentric study reveals that 
         the prevalence of alcoholism ranges from 7.6 to 9.2% of the population.2 abusive alcohol consumption is the main cause of disability 
         among adult males in developed countries and is the fourth most prevalent cause in 
         developing countries.3 in a study performed 
         in canada , abusive alcohol consumption accounted for 3.1% of all deaths and 2.7% of all 
         hospitalizations in 1995.4 it also has a 
         major economic impact . the total annual cost estimated for alcohol consumption in the united 
         states is 185 billion dollars , which has a great impact on not only direct health costs but 
         also on overall productivity and other societal impacts.5 the prevalence of alcoholism is still greater among hospitalized patients.68 several national and international studies have found a 
         prevalence ranging from 7.4 to 48.0% of hospitalized patients.813 this large variation in the prevalence of alcoholism is largely attributed to the 
         different methodologies used to define alcohol abuse or dependence and population 
         heterogeneity . despite this high prevalence and the associated morbidity and mortality , diagnosing 
         alcoholism as part of the medical history is often neglected by the medical team and , as a 
         result , is often under - recorded in hospital records . a few studies have shown that 
         identification of alcoholism by the medical team ranges from 7 to 89% , depending on the 
         department where the patient is hospitalized and the methodology used for diagnosis.811,1416 there is 
         evidence that suggests that use of questionnaires to screen patients would help identify 
         alcoholic individuals and that brief interventions during the hospitalization would be 
         effective in reducing alcohol consumption.10,1619 hospitalization is , therefore , an excellent 
         opportunity to identify alcohol related disorders and initiate subsequent intervention . the purpose of this study is to investigate the prevalence of alcoholism among hospital 
         patients , to identify social and demographic factors associated with this prevalence , and to 
         determine the rate of recognition of this problem by the medical team . this is a cross - sectional study carried out at hospital so lucas , porto 
         alegre , brazil . this hospital , which currently has 539 beds , receives patients from the 
         public and private systems of several cities . the study population consists of all patients who were admitted to the emergency room and 
         subsequently remained in the hospital for at least 24 hours between july and september of 
         2005 . the following patients were excluded from the study : patients below the age of 15 years , 
         patients who could not answer the interview ( for instance , those on mechanical ventilation 
         or mentally confused ) , and patients who refused to participate in the study . written 
         informed consent the data were collected in two steps : an interview with the patient and a review of the 
         medical records . the interviews were performed in the emergency department during the first 
         48 hours after the patient was admitted by previously trained medical students . the 
         questionnaire consisted of questions concerning social and demographic data , smoking habits 
         and audit ( alcohol use disorders identification test).20 audit was developed by the world health organization and 
         validated for use in the portuguese language by mendez et al.21 it consists of 10 questions concerning alcohol consumption 
         in the last 12 months . the final score of this test ranges from 0 to 40 , with scores greater 
         than or equal to 8 ( the cutoff point generally used in research ) indicating that the patient 
         most likely has an alcohol - related disorder ; this test has a sensitivity between 61 and 96% 
         and a specificity between 84 and 96%.2225 audit was 
         considered the gold standard for the diagnosis of alcoholism in this study . after the patient was discharged from the hospital , two researchers who were not involved 
         in the interviews reviewed the patients medical records . the purpose of this 
         review was to examine the cases of alcoholism recorded by the medical team and the 
         department in which the patient was hospitalized . a case was considered not recorded when 
         the patient obtained a score above or equal to 8 in audit and the record did not show a 
         history of abusive alcohol consumption or similar terms ( alcoholism , alcohol related 
         disorders ) . there was no contact between the researchers and the medical team , which , in turn , was 
         blinded to the data collected in the interviews . the terms  positive audit ,  alcoholic and 
          abusive alcohol consumption are interchangeable for the purposes 
         of this study . for statistical analyses , chi - squared and mantel - haensel tests were used for qualitative 
         variables ; the mann - whitney u test was used when the distribution of central tendency 
         measures was not gaussian in distribution . logistic 
         regression was used to identify social and demographic variables that were independently 
         associated with abusive alcohol consumption . p<0.05 was considered a 
         statistically significant number ; all p - values were two - tailed . of the 284 eligible patients who were hospitalized during the study period , 248 ( 87.3% ) 
         were interviewed . eight ( 2.8% ) patients refused to participate in the study , 11 ( 3.9% ) were 
         physically unable to answer the questionnaire , and 17 ( 6.0% ) were excluded due to an altered 
         sensory status . the mean age of the population was 55.2  17.4 years , 119 ( 48.0% ) were males , 
         and 129 ( 52.0% ) were females . most of the patients were white ( n = 196 ; 79.0% ) , married ( n = 
         135 ; 54.4% ) , had not completed elementary schooling ( n = 109 ; 44.0% ) and had a family income 
         between one and five - times that of minimum wage ( n = 150 ; 60.5% ) . with regard to the study population s smoking habits , 45 ( 18.1% ) patients were 
         smokers . among the non - smokers , 111 ( 54.7% ) were former smokers , and 92 ( 37.1% ) of the 
         patients had never smoked . twenty - eight ( 11.3% ) patients were identified as alcoholics . among these patients with a 
         positive audit , 26 ( 92.9% ) had a score between 8 and 20 , which corresponds to mild to 
         moderate dependency . only 2 ( 7.1% ) had a score higher than 20 ( severe dependency ) . the mean 
         score was significantly different between the patients with a positive audit ( mean 13.3 ; sd 
         4.8 ) and a negative audit ( mean 0.9 ; sd 1.6 ) ( p<0.001 ) . the social and demographic characteristics of the patients with a positive audit and a 
         negative audit are shown in table 1 . the 
         alcoholic patients were slightly , but not significantly younger ( mean 49.5  
         17.6 years vs 55.8  17.3 years ) ( p = 0.1 ) than the non - alcoholic patients . the 
         characteristics of the patients who were identified as alcoholics by the medical team are 
         shown in table 2 . using a logistic regression analysis , a few variables proved to be independently associated 
         with abusive alcohol consumption . compared to patients with a negative audit , those with a 
         positive audit were more likely to be male , illiterate and smokers ( table 3 ) . among the 248 patients interviewed , the medical records of 217 ( 87.5% ) patients were 
         reviewed . the medical team identified 17 ( 7.8% ) cases of alcoholism , and , when compared with the 
         audit outcomes , 12 ( 70.6% ) of them did not have a positive audit . only 5 ( 20.0% ) of the 25 patients with a positive audit whose medical records were reviewed 
         were identified as alcoholics by the medical team . there was no difference in the incidence 
         of identification that was dependent on the department in which the patient was 
         hospitalized . gastroenterology and internal medicine were the two departments where most of 
         the alcoholic patients were hospitalized , and the medical staff of these departments 
         identified only 25.0% and 14.3% of the patients with a positive audit , respectively . table 4 shows the association between the 
         social and demographic characteristics and the identification of abusive alcohol consumption 
         ( independent of the diagnosis being correct or not ) by the medical team . the mean audit score among the patients identified as alcoholics ( mean 5.9  
         8.7 ) was significantly higher than that of the patients who had not been identified 
         ( identified as non - alcoholics or no mention of alcohol consumption in the medical records ) 
         ( mean 2.1  3.8 ) ( p = 0.05 ) . the diagnosis made by the medical team , compared to 
         audit , shows a 20% sensitivity , 93% specificity and positive and negative predictive values 
         of 29% and 90% , respectively . the prevalence of alcoholism among the hospitalized patients in this study is at the lower 
         limit of the variation of prevalence described in the international literature,8,1013 but it 
         approaches the prevalence of 13% that was found at another porto alegre hospital in a 1998 
           study.9 it only took an average of 6 minutes to apply the questionnaire , and 87.3% of the eligible 
         patients agreed to participate in the study . together , these figures confirm that it is 
         possible to quickly investigate if the patients who come to emergency room have alcoholic 
         tendencies , since it does not require much time and the patients are generally cooperative 
         when asked . these findings had already been verified by horn et al.12 most of the alcoholic patients ( 92.9% ) in our study population were found to be mildly to 
         moderately dependent ( audit between 8 and 20 ) . there is evidence showing that interventions 
         to reduce alcohol consumption have a greater impact on this patient subgroup.2628 for example , moore et al . found that hospital patients who 
         were identified as alcoholics in screening performed by the medical team responded favorably 
         to brief interventions ( for instance , informing them of the diagnosis , advising them to stop 
         drinking and making an appointment with an alcoholism specialist).10 additionally , gentilello et al . reported positive results 
         for brief interventions at a trauma center , concerning the reduction of alcohol consumption 
         and the reduction of risk of being readmitted for trauma.19 for these reasons , it seems logical that using an 
         instrument with a greater capacity to identify at risk individuals within the emergency room 
         patient population , as opposed to the traditional medical approach that has a low 
         sensitivity , would allow for the initiation of early intervention that may provide more 
         positive outcomes for individuals with mild to moderate dependency on alcohol . there were significant social and demographic differences among the patients with a 
         positive audit and a negative audit . chen et al . found a higher 
         prevalence of alcoholism among males , smokers , people who were younger and had a lower level 
         of education.11 another study reported a 
         2.7-fold higher probability of alcoholism among males and a 2.4-fold higher probability of 
         alcoholism among smokers.12 the 
         patient s race may also influence the probability of alcoholism . . 
         found that the rate of alcoholism is higher among black patients ( 13.1% ) than among the 
         others ( 6.6%).13 being unmarried is 
         another previously described risk factor.12,13 the association between alcohol consumption and tobacco use has also been described in the 
           literature.29,30 it was suggested that the greater the nicotine dependence 
         is , the higher the alcohol consumption.31,32 in some studies , smoking 
         has been defined as the main risk factor for alcoholism among hospitalized patients.1113 the results of the present study confirm these conclusions . acknowledging these social and demographic variables associated with abusive alcohol 
         consumption allows us to establish a risk profile . certainly , these variables must not be 
         used instead of the questionnaires developed for diagnosis . on the other hand , thorough 
         investigation of all of patients who come to the emergency room may not be possible or even 
         necessary . recognizing this risk profile may alert the medical staff to patients at high 
         risk for alcoholism , make using the diagnostic instrument more effective , and consequently , 
         increase the predictive value of the applied test , although this risk factor - based approach 
         would have to be tested and validated in future studies . the under - recording of cases of alcoholism at hospital admission is a problem that has been 
         described previously.811,1416 in this study , 
         only 20% of the actual cases , as identified by audit , were identified by the medical team 
         during emergency room treatment . although males were most frequently identified as being 
         alcoholics , which might indicate that the medical staff looks more actively at this subgroup 
         for alcohol abuse , the overall frequency of identification was low , even among these higher 
         risk patients . furthermore , most ( 70.6% ) of the cases diagnosed by the medical team did not 
         meet the alcoholism criteria established in our study and in others that relied on audit . many factors have been associated with the low identification indexes for alcoholic 
         patients by medical staff . lack of knowledge and communication problems involving alcohol 
         consumption are barriers that make it more difficult for medical personnel to arrive at a 
         correct diagnosis.33 rowland et al . 
         concluded that physicians did not consider it a priority to ask patients about their alcohol 
         consumption habits.34 lack of discussion 
         in medical school concerning patients potential psychoactive substance 
         consumption is also a major cause of problems in diagnosing alcoholism.8 one of the consequences of this high rate of underdiagnosis is that the indication for 
         intervention occurs only when alcohol consumption leads to somatic diseases , social problems 
         or severe withdrawal symptoms.35 under 
         these circumstances , interventions are less successful . screening for alcoholism , especially 
         using standardized instruments , not only identifies a much larger number of patients but it 
         also identifies them at an earlier stage . first , it was developed at a single hospital , which might 
         make it difficult to extend the results to other hospitals and/or regions . all of 
         the presented data are consistent with previously published reports in the literature , and 
         it is likely that these results are not specific characteristics of the population at this 
         hospital . second , we can not exclude an interobserver variability during the interview in the 
         emergency department . third , we consider audit the gold standard for the diagnosis of 
         alcoholism , and , therefore , its limitations should be taken into account when interpreting 
         the results . finally , the evaluation of identification by the medical team was based only on 
         information in the medical record . . showed that , when identification of 
         alcoholics by the physicians is performed only from the medical records , it is less 
         effective than when evaluated by a direct interview.16 on the other hand , another study found that the failure to 
         detect patients with possible alcohol - related problems largely occurs as a result of a lack 
         of investigation and diagnosis , and not because of incomplete records.9 it is concluded that alcoholism has not been adequately investigated and diagnosed on 
         hospital admission , and that this opportunity for possible intervention is often lost . a few 
         social and demographic factors could provide the physicians with warning signs and , used 
         together with a standardized diagnostic instrument , could significantly improve the 
         identification of alcoholic patients . this is the first step to reduce alcohol consumption 
         and offer appropriate treatment to these patients . an aspect that is beyond the scope of 
         this study is the need to better educate medical students , residents and other hospital 
         professionals on the risk factors and signs of alcoholism to correct this flaw in accurately 
         diagnosing alcoholism . moreover , the implementation of programs designed to reduce 
         patients alcohol consumption at early stages may reduce the costs and social 
         and personal consequences associated with alcohol abuse .
objectives : 
 the purpose of this study was to investigate the prevalence of alcoholism among 
             inpatients , to identify social and demographic factors associated with this prevalence 
             and to determine its rate of recognition by the medical team . 
 methods : 
 the study population consisted of all patients admitted to the emergency room at 
             hospital so lucas , porto alegre , brazil , between july and september of 
             2005 . 
 the data were collected in two steps : an interview with the patient and a review 
             of the medical records to investigate the cases of alcoholism recorded by the medical 
             team . 
 the questionnaire consisted of questions concerning social and demographic data , 
             smoking habits and alcohol use disorders identification test . 
 results : 
 we interviewed 248 patients . 
 twenty - eight ( 11.3% ) were identified as alcoholics . 
 compared to the patients with a negative alcohol use disorders identification test value 
             ( less than 8) , those with a positive alcohol use disorders identification test were more 
             likely to be male , illiterate and smokers . 
 the medical records of 217 ( 87.5% ) patients 
             were reviewed . only 5 ( 20.0% ) of the 25 patients with a positive alcohol use disorders 
             identification test whose medical records were reviewed were identified as alcoholics by 
             the medical team . 
 the diagnosis made by the medical team , compared to alcohol use 
             disorders identification test , shows only a 20% sensitivity , 93% specificity and 
             positive and negative predictive values of 29% and 90% , respectively . 
 conclusion : 
 alcoholism has been underrecognized in patients who are hospitalized , and , as such , 
             this opportunity for possible early intervention is often lost . 
 key social and 
             demographic factors could provide physicians with risk factors and , when used together 
             with a standardized diagnostic instrument , could significantly improve the rate of 
             identification of alcoholic patients .