Case-finding of lifestyle and mental health problems in primary care: validation of the 'CHAT' tool NAPCRG Vancouver 2007 Felicity Goodyear-Smith, Bruce Arroll, Nicole Coupe, C Raina Elley, Sean Sullivan Department of General Practice & Primary Health Care University of Auckland

Background In order to prevent disease, first you have to detect risk factors Few validated tools for lifestyle & mental health risk factors in primary care Need for brief case-finding tools

CHAT: Case-finding & ‘Help’ Assessment Tool Lifestyle & mental health screening assessment tool for use in primary care Smoking Alcohol misuse Other drug misuse Problem gambling Depression Anxiety Abuse Anger Physical inactivity Issues around eating

 No  Yes but not today  Yes The ‘HELP’ question For each question or pair of questions: If yes to either or both of these 2 questions, do you want help with this?  No  Yes but not today  Yes

Evaluation of CHAT tool Initial study assessed acceptability of tool Participants: >2,500 consecutive patients from 20 randomly selected urban & 11 rural family physicians & 20 urban & rural practice nurses (50/practitioner)

Evaluation of CHAT Results: Patients wanting help today (0.5 to 13.5%) not overwhelming Well accepted by patients, objections to specific questions <1% Drs & nurses would use tool once available Goodyear-Smith et al (2004) New Zealand Medical Journal 117 (1205)

Value of ‘HELP’ Question Depression study: Adding question inquiring if help is needed to 2 questions on depression increases specificity (reduces false positives) Arroll, Goodyear-Smith et al (2005). BMJ, 25 Sep doi:1136/bmj.38607.464537.7C

To assess validity of CHAT against composite gold standard Aim of current study To assess validity of CHAT against composite gold standard

Method Conducted according to STARD statement for diagnostic tests Setting: Primary care practices in Auckland Participants: 1000 consecutive adult patients completed CHAT & composite gold standard Analysis: Sensitivities, specificities & likelihood ratios

Case prevalence Sensitivity % Specificity LR + test Nicotine dependency 9.8% 89 97 10.6 Problem drinking 14.5% 79 99 12 Drug misuse 2.0% 58 16 Problem gambling 1.8% 78 30 Major depression 5.3% 96 95 10 Anxiety 10.9% 88 9

Case prevalence Sensitivity Specificity LR+ Verbal abuse 2.6% 62 99 12 Physical abuse 0.6% 80 94 13 Anger 2% 77 98 16 Inactivity 55% 31 18 Eating disorder 25% 73 89 3

Inactivity Reason for low sensitivity: Format of question was reversed: confusing & led to inverted response Eating disorder Reason for high prevalence: Gold standard was not precise enough - probably identifying concerns about being overweight & eating patterns rather than formal eating disorder

Addition of ‘HELP’ question Specificity Nicotine dependency: 89%  97% Problem drinking: 88%  99% Other drug use: 97%  99% Gambling: 97%  99% Depression: 69%  95% Anxiety: 74%  99% Verbal abuse: 98%  99% Verbal aggression: 92%  99%

LR of ‘Help’ question: example Nicotine dependency LR +ve Help today 11.5 Help either today or later 10.6 Help but not today 10.4 No help 0.57

Discussion Limitations: Inactivity question inverted – confusion Eating gold standard imprecise Small numbers for some conditions (wide CI) Pragmatic gold standard instruments

Discussion Strengths: Good generalisability: Very low decline rate Consecutive patients Most conditions had tight confidence intervals Patients completed gold std for all conditions

CHAT Quick to use Acceptable Valid Summary CHAT Quick to use Acceptable Valid

Further developments… Integrate CHAT into electronic medical record Self-administration by handheld or touch screen in waiting room Add automatic diagnostic tool if CHAT item +ve Conduct RCT to assess effect of CHAT on clinical outcomes

Thank you Any questions?