Integrating primary medical care with addiction treatment: a randomized controlled trial.
TL;DR: Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective.
Abstract: ContextThe prevalence of medical disorders is high among substance abuse patients,
yet medical services are seldom provided in coordination with substance abuse
treatmentObjectiveTo examine differences in treatment outcomes and costs between integrated
and independent models of medical and substance abuse care as well as the
effect of integrated care in a subgroup of patients with substance abuse–related
medical conditions (SAMCs)DesignRandomized controlled trial conducted between April 1997 and December
1998Setting and PatientsAdult men and women (n = 592) who were admitted to a large health maintenance
organization chemical dependency program in Sacramento, CalifInterventionsPatients were randomly assigned to receive treatment through an integrated
model, in which primary health care was included within the addiction treatment
program (n = 285), or an independent treatment-as-usual model, in which primary
care and substance abuse treatment were provided separately (n = 307) Both
programs were group based and lasted 8 weeks, with 10 months of aftercare
availableMain Outcome MeasuresAbstinence outcomes, treatment utilization, and costs 6 months after
randomizationResultsBoth groups showed improvement on all drug and alcohol measures Overall,
there were no differences in total abstinence rates between the integrated
care and independent care groups (68% vs 63%, P =
18) For patients without SAMCs, there were also no differences in abstinence
rates (integrated care, 66% vs independent care, 73%; P = 23) and there was a slight but nonsignificant trend of higher costs
for the integrated care group ($36796 vs $32409, P
= 19) However, patients with SAMCs (n = 341) were more likely to be abstinent
in the integrated care group than the independent care group (69% vs 55%, P = 006; odds ratio [OR], 190; 95% confidence interval
[CI], 122-297) This was true for both those with medical (OR, 338; 95%
CI, 168-680) and psychiatric (OR, 210; 95% CI, 104-425) SAMCs Patients
with SAMCs had a slight but nonsignificant trend of higher costs in the integrated
care group ($47081 vs $42795, P = 14) The incremental
cost-effectiveness ratio per additional abstinent patient with an SAMC in
the integrated care group was $1581ConclusionsIndividuals with SAMCs benefit from integrated medical and substance
abuse treatment, and such an approach can be cost-effective These findings
are relevant given the high prevalence and cost of medical conditions among
substance abuse patients, new developments in medications for addiction, and
recent legislation on parity of substance abuse with other medical benefits
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TL;DR: In this paper , the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure.
Abstract: Alcohol and other drug (AoD) use is an important health and community issue and may be positively affected by collaborative care programs between specialist AoD services and general practice. This paper describes the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure. There were 367 referrals to the collaborative care program. GPs referred 210 patients, whereas the AoD service referred 157 patients. Most GP referrals (91.9%) were for AoD problems, whereas nearly half the AoD service referrals were for other issues. The primary drugs of concern in the GP group were either opioids or non-opioids (mostly alcohol). The AoD service-referred patients were primarily using opioids. An ATOP was completed for 152 patients. At the time of referral, those in the GP-referred non-opioid group were significantly less likely to be abstinent, used their primary drug of concern more days and were more likely to be employed (all P < 0.001). A second ATOP was completed for 93 patients. These data showed a significant improvement in the number of days the primary drug of concern was used (P = 0.026) and trends towards abstinence, improved quality of life and physical and psychological well-being for patients in the program. There are few studies of GP-AoD collaborative care programs and nothing in the Australian context. This study suggests that GP-AoD collaborative care programs in Australia are feasible and improve drug use.
2 citations
29 Jun 2015
TL;DR: Students from various disciplines worked with and learned from people with a mental illness and applied skills learned in theory in an innovative practice setting.
Abstract: Given that people with a mental illness have a range of biopsychosocial needs, care and treatment is complex and is best delivered by a multidisciplinary team In order for future health professionals to learn skills to understand consumers from an individualised and holistic perspective, students from Nursing, Psychology, Exercise Physiology and Dietetics participated in a therapeutic Recovery Camp alongside 30 people with a mental illness The camp aimed to envelope consumers and students within an experience of therapeutic recovery This interdisciplinary capstone course was to achieve learning outcomes via immersion in various indoor and outdoor activities nested within a strengths-based five-day camp held in the Australian bush Students from different disciplines learned from and educated each other They applied skills learned in theory in what can only be described as an innovative practice setting The setting formed a fundamental part of the therapeutic milieu and students learned that a 'clinic', 'unit,' or 'formal setting' isn't the only way care and treatment can be delivered to this marginalised and vulnerable group This paper showcases how students from various disciplines worked with and learned from people with a mental illness
2 citations
TL;DR: Although lack of financial integration may limit the effect of licensing on C OD treatment implementation, the response of leaders to regulation, funding, and human resources issues may encourage COD treatment practices.
Abstract: Using a random sample of 48 outpatient mental health programs in low-income and racial and ethnic minority communities, this study examined directorial leadership, drug treatment licensure, and implementation of evidence-based protocols and practices to address co-occurring mental health and substance abuse disorders (COD). Understanding of findings was enhanced with focus groups at six clinics. Most programs (81 %) offered COD treatment. Directorial leadership was positively associated with COD treatment (β = 0.253, p = 0.047, 95 % CI 0.003, 0.502) and COD supervision and training (β = 0.358, p = 0.002, 95 % CI 0.142, 0.575). Licensure was negatively associated with COD treatment (β = -0.235, p = 0.041, 95 % CI -0.460, -0.010) and COD supervision and training (β = -0.195, p = 0.049, 95 % CI -0.389, -0.001). Although lack of financial integration may limit the effect of licensing on COD treatment implementation, the response of leaders to regulation, funding, and human resources issues may encourage COD treatment practices. Implications for leadership interventions and policy are discussed in the context of health care reform.
2 citations
Cites background from "Integrating primary medical care wi..."
...Evidence has indicated that increasing minority populations’ access to COD treatment can reduce health care costs and achieve positive health outcomes (Butler et al. 2008; Chalk et al. 2010; Grella et al. 2004; Weisner et al. 2001)....
[...]
27 Sep 2007
TL;DR: Focus groups conducted with physicians across the state of Pennsylvania ascertain the barriers to identifying problem alcohol and drug use in patients by practicing physicians and explores the education that could be offered to physicians in order to increase their knowledge in the area of screening and the identification of problem drug or alcohol use.
Abstract: Substance abuse is related to many other health problems, thus making the topic of great public health significance. The scope of this study is the results of focus groups conducted with physicians across the state of Pennsylvania; specifically Harrisburg, Pittsburgh, and Philadelphia. The purpose was to ascertain the barriers to identifying problem alcohol and drug use in patients by practicing physicians. Physicians statewide acknowledged key barriers to screening; time, access to treatment and financial reasons, both patient financial issues or problems and reimbursement from insurers or commercial payers. Additional barriers that were identified as a result of the focus groups included stigmatizing attitude toward substance use, physicians' lack of self-efficacy in managing substance use disorders, and lack of knowledge in this area, among others. The study discusses the results of the focus groups and explores the education that could be offered to physicians in order to increase their knowledge in the area of screening and the identification of problem drug or alcohol use.
2 citations
Cites background from "Integrating primary medical care wi..."
...Patients are more willing to discuss their use with physicians as there is less stigma involved (Weisner et al., 2001)....
[...]
TL;DR: In this article, the NDTC Cervical Screening guidelines were reviewed for documentary evidence indicating that information about the cervical screening programme had been discussed, and one month after the implementation of an awareness-raising educational intervention.
Abstract: Women diagnosed with substance use disorders (SUDs) have higher rates of major medical conditions compared to women without SUDs. Cervical cancer is the second leading cause of cancer death in women aged 20–39 years worldwide and women with SUDs have an increased risk of cervical cancer compared to women without SUD. The National Drug Treatment Centre (NDTC) cervical screening programme, derived from the national CervicalCheck programme, offers free cervical screening to patients attending for treatment of SUDs. This study aimed to audit adherence to the NDTC Cervical Screening guidelines before and after the implementation of an awareness-raising educational intervention. The electronic clinical records of women aged between 25 and 60 years attending the lead consultant’s (M.S.) outpatient clinic were reviewed for documentary evidence indicating that information about the cervical screening programme had been discussed. This was completed before and one month after the implementation of an awareness-raising educational intervention. All women (n = 46, mean age 36.3 (SD = 6.5) years) had an opioid use disorder; 85% had a benzodiazepine use disorder, and 24% had an alcohol use disorder. Of these, 80% had at least one chronic medical condition, 76% had a psychiatric disorder, and 59% were homeless. Adherence to the NDTC cervical screening guideline, as indicated by documentary evidence in clinical records, was 33% (14/43) at baseline, and rose to 88% (36/41) (p < 0.0001) one month after the intervention. This completed audit cycle shows that an awareness-raising educational intervention can significantly improve adherence to a cervical screening programme in women with SUDs.
1 citations
References
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01 Jan 1993TL;DR: This article presents bootstrap methods for estimation, using simple arguments, with Minitab macros for implementing these methods, as well as some examples of how these methods could be used for estimation purposes.
Abstract: This article presents bootstrap methods for estimation, using simple arguments. Minitab macros for implementing these methods are given.
37,183 citations
TL;DR: The clinical and research uses of the ASI over the past 12 years are discussed, emphasizing some special circumstances that affect its administration.
4,045 citations
TL;DR: General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders, with the finding that fewer than half of cases with 12-monthCo-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.
Abstract: General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders. Co-occurrence is highly prevalent in the general population and usually due to the association of a primary mental disorder with a secondary addictive disorder. It is associated with a significantly increased probability of treatment, although the finding that fewer than half of cases with 12-month co-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.
1,424 citations
TL;DR: The Medical Outcomes Study was designed to determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and develop more practical tools for the routine monitoring of patient outcomes in medical practice.
Abstract: The Medical Outcomes Study was designed to (1) determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and (2) develop more practical tools for the routine monitoring of patient outcomes in medical practice. Outcomes included clinical end points; physical, social, and role functioning in everyday living; patients' perceptions of their general health and well-being; and satisfaction with treatment. Populations of clinicians (n = 523) were randomly sampled from different health care settings in Boston, Mass; Chicago, Ill; and Los Angeles, Calif. In the cross-sectional study, adult patients (n = 22 462) evaluated their health status and treatment. A sample of these patients (n = 2349) with diabetes, hypertension, coronary heart disease, and/or depression were selected for the longitudinal study. Their hospitalizations and other treatments were monitored and they periodically reported outcomes of care. At the beginning and end of the longitudinal study, Medical Outcomes Study staff performed physical examinations and laboratory tests. Results will be reported serially, primarily inThe Journal. (JAMA. 1989;262:925-930)
1,139 citations
TL;DR: This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
Abstract: Objective. —Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers. Design. —Randomized controlled clinical trial with 12-month follow-up. Setting. —A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties. Participants. —Of the 17 695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures. Intervention. —The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information. Main Outcome Measures. —Alcohol use measures, emergency department visits, and hospital days. Results. —There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls;t=4.33;P Conclusions. —This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
839 citations