Indicadores de Tratamiento y su evidencia científica

Slide 1: Tre at me nt I ndicat ors Some Additional Considerations

Slide 2: Moving On  More than 3 decades of research show that drug misuse treatments can be effective • In reducing drug use • Improving personal health & social functioning • Reducing public health & safety risks  Time for policy makers, providers & researchers to have a more ambitious agenda: • How can treatment be improved? • How can treatment be tailored to meet the needs of clients?

Slide 3: Improving patient outcomes & treatment  Treatment is more than just specific procedures  Treatment is a complex process.  Need to understand: • Nature & severity of client problems • The process which occur during treatment • The role of staff competence & skills • The organization & provision of service  Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely  Involvement of providers in understanding & improving process of treatment is essential.

Slide 4: Treatment Outcomes  4 major national drug treatment outcome studies: • NTORS (National Treatment Outcome Research Study , UK) • DARP (Drug Abuse Reporting Program, US) • TOPS (Treatment Outcome Prospective Study, US) • DATOS (Drug Abuse Treatment Outcome Study, US)

Slide 5: Findings  Substantial reductions in illegal drug misuse & other outcomes after treatment  Improved outcomes for injecting risk behaviour  Most drug dependent clients were multiple substance misusers, often with multiple dependencies • Focus on single substance disorders likely outdated & misleading  Reductions in crime levels provide substantial & immediate cost savings for society

Slide 6: Findings (& considerations)  Most drug dependent clients received more than 1 episode of treatment • Not a failure of treatment, a reality to understand • Drug dependence for many is a chronic, relapsing condition – Need to understand • cumulative effects of multiple treatments • how episodes interact or interfere with each other • characteristics of clients most likely to require multiple treatments so we can incorporate this into treatment processes  Drinking outcomes often poor • Many clients continuing to drink heavily • May reflect focus on illegal drugs in treatment & insufficient attention to alcohol

Slide 7: Findings (& considerations)  Time in treatment & treatment completion associated with better treatment outcomes • Staying in treatment & completing treatment more likely to achieve best outcomes regardless of outcome measure • Treatment duration effects reported from studies of range of treatment interventions (drug-free, drug maintenance, residential, outpatient) • Need an adequate exposure to treatment to achieve positive outcomes – Beyond 90 days for most drug problems – Beyond a year for those treated with methadone – Outcomes tend to improve as retention increases from 3 months to 12 or more

Slide 8: Retention in Treatment  Treatment effectiveness, outcomes improve with retention in treatment • In UK, National Treatment Agency developed Public Service Agreement target to “ increase year on year the proportion of users successfully sustaining or completing treatment programmes”  Study of 2,616 client in community-based services, north west England • 49 specialist drug treatment services & 100 general practitioners (physicians)

Slide 9: Study findings  Factors NOT associated with retention or completion: • Ethnicity of client • Type of drug misuser (heroin, crack cocaine or both) • Whether client injected drugs • Whether client using methadone at time of presentation for treatment

Slide 10: Study findings  Factors associated with retention or completion • Younger clients more likely to drop out within 6 months • Males 1.5 times more likely to drop out early than females • Those with no previous treatment experience 1.7 times more likely to drop out early than those with previous treatment • Clients referred from criminal justice system 2.7 times more likely to drop out early • Clients attending the worst performing services 7.1 times more likely to drop out early than clients attending the best  Strongest predictor of retention or completion of treatment NOT a characteristic of client but related to agency

Slide 11: Improving patient outcomes & treatment  Treatment is more than just specific procedures  Treatment is a complex process.  Need to understand: • Nature & severity of client problems • The process which occur during treatment • The role of staff competence & skills • The organization & provision of service  Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely  Involvement of providers in understanding & improving process of treatment is essential.

Slide 12: Outcome domains  Increasing agreement on domains - area of life function or status that is expected to be positively influenced by treatment (patient level) • Substance use • Employment / self support • Crime • Stability in housing • Social connectedness • Perception of care (or services) • Access • Retention  SAMHSA - 2004

Slide 13: Indicadores de Resultados (SAMHSA, 2003)  Funcionamiento social • Soporte • Vínculos  Accesibilidad de servicios • Cobertura  Retención en tratamiento  Percepción sobre la atención  Costo efectividad  Uso de prácticas basadas en la evidencia 01/18/08

Slide 14: Indicadores de Resultados (SAMHSA, 2003)  Reducción de Morbilidad • Abstinencia • Reducción de sintomas  Laboral / Académico • Permanencia • Recuperación  Delito / P. legales • Disminución  Residencia • Incremento de estabilidad de vivienda 01/18/08

Slide 15: Outcome Measures  Specific items, measures or tests of an individual’s functional status within a domain • For example domain of Employment – Number of days worked – Dollars earned – Days of unexcused absence – Tax return for a year  Functional domains have many facets - multiple measures, tests or items often needed for each domain

Slide 16: Performance or quality indicators  System level  Traditional methods to measure outcomes & effectiveness: costly, time-consuming, dependent on scarce research skills  Performance or quality indicators • measures to estimate & monitor extent a program or provider conforms to best or evidence-based practices or other standards of quality • Often derived from administrative information systems – Financial and/or client

Slide 17: No single measure or indicator  At this point, available measures and indicators have benefits & limitations  No single measure or indicator = quality of treatment or sufficient for accountability  Needs & goals of treatment system should determine the set of measures & indicators that will most efficiently provide the amount & detail of information to improve quality of care at a given time.

Slide 18: Opening the door together  Must ‘ open the door’ for scientific understanding of treatment  Look at ourselves, our services and help others understand  Dynamic process - based in monitoring & tailored to meet changing objective & goals.  Success depends upon collaboration of service providers, policy makers & researchers

Slide 19: Treatment process improvement & data- driven decisions  Supporting providers to make process improvement & data-driven decisions to improve client access to and retention in care  Success factors • Provider leadership valued data & provided resources • Staff received training on data collection & use • Sharing of change results • Success making data-driven decisions

Slide 20: Gracias por su atención  Cuando es cuestión del tratamiento de las adicciones, nada justifica la falta de transparencia por parte de proveedores, centros, o autoridades publicas...Pacientes, contribuyentes, y legisladores deben exigir a los que proporcionan tratamiento a personas con adicciones pruebas razonables de intentos de control y mejora tanto de estos tratamientos como de los resultados conseguidos. -A.Thomas McLellan, Mady Chalk, John Bartlett Journal of Substance Abuse Treatment 32 (2007)

Slide 21: Gracias por su atención