Indicadores de Tratamiento y su evidencia científica

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Indicadores de Tratamiento y su evidencia científica.
Presentacion del Seminario “Avances en el desarrollo de indicadores e instrumentos de calidad en la atención de personas con consumo problemático de drogas”
Autor. Larry Corea. Director del Centro de Adicciones y Salud Mental de la Universidad de Toronto, Canadá
Organizador del Seminario: Conace

Published in: Health & Medicine
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  • Indicadores de Tratamiento y su evidencia científica

    1. 1. Treatment Indicators Some Additional Considerations
    2. 2. Moving On <ul><li>More than 3 decades of research show that drug misuse treatments can be effective </li></ul><ul><ul><li>In reducing drug use </li></ul></ul><ul><ul><li>Improving personal health & social functioning </li></ul></ul><ul><ul><li>Reducing public health & safety risks </li></ul></ul><ul><li>Time for policy makers, providers & researchers to have a more ambitious agenda: </li></ul><ul><ul><li>How can treatment be improved? </li></ul></ul><ul><ul><li>How can treatment be tailored to meet the needs of clients? </li></ul></ul>
    3. 3. Improving patient outcomes & treatment <ul><li>Treatment is more than just specific procedures </li></ul><ul><li>Treatment is a complex process. </li></ul><ul><li>Need to understand: </li></ul><ul><ul><li>Nature & severity of client problems </li></ul></ul><ul><ul><li>The process which occur during treatment </li></ul></ul><ul><ul><li>The role of staff competence & skills </li></ul></ul><ul><ul><li>The organization & provision of service </li></ul></ul><ul><li>Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely </li></ul><ul><li>Involvement of providers in understanding & improving process of treatment is essential. </li></ul>
    4. 4. Treatment Outcomes <ul><li>4 major national drug treatment outcome studies: </li></ul><ul><ul><li>NTORS (National Treatment Outcome Research Study , UK) </li></ul></ul><ul><ul><li>DARP (Drug Abuse Reporting Program, US) </li></ul></ul><ul><ul><li>TOPS (Treatment Outcome Prospective Study, US) </li></ul></ul><ul><ul><li>DATOS (Drug Abuse Treatment Outcome Study, US) </li></ul></ul>
    5. 5. Findings <ul><li>Substantial reductions in illegal drug misuse & other outcomes after treatment </li></ul><ul><li>Improved outcomes for injecting risk behaviour </li></ul><ul><li>Most drug dependent clients were multiple substance misusers, often with multiple dependencies </li></ul><ul><ul><li>Focus on single substance disorders likely outdated & misleading </li></ul></ul><ul><li>Reductions in crime levels provide substantial & immediate cost savings for society </li></ul>
    6. 6. Findings (& considerations) <ul><li>Most drug dependent clients received more than 1 episode of treatment </li></ul><ul><ul><li>Not a failure of treatment, a reality to understand </li></ul></ul><ul><ul><li>Drug dependence for many is a chronic, relapsing condition </li></ul></ul><ul><ul><ul><li>Need to understand </li></ul></ul></ul><ul><ul><ul><ul><li>cumulative effects of multiple treatments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>how episodes interact or interfere with each other </li></ul></ul></ul></ul><ul><ul><ul><ul><li>characteristics of clients most likely to require multiple treatments so we can incorporate this into treatment processes </li></ul></ul></ul></ul><ul><li>Drinking outcomes often poor </li></ul><ul><ul><li>Many clients continuing to drink heavily </li></ul></ul><ul><ul><li>May reflect focus on illegal drugs in treatment & insufficient attention to alcohol </li></ul></ul>
    7. 7. Findings (& considerations) <ul><li>Time in treatment & treatment completion associated with better treatment outcomes </li></ul><ul><ul><li>Staying in treatment & completing treatment more likely to achieve best outcomes regardless of outcome measure </li></ul></ul><ul><ul><li>Treatment duration effects reported from studies of range of treatment interventions (drug-free, drug maintenance, residential, outpatient) </li></ul></ul><ul><ul><li>Need an adequate exposure to treatment to achieve positive outcomes </li></ul></ul><ul><ul><ul><li>Beyond 90 days for most drug problems </li></ul></ul></ul><ul><ul><ul><li>Beyond a year for those treated with methadone </li></ul></ul></ul><ul><ul><ul><li>Outcomes tend to improve as retention increases from 3 months to 12 or more </li></ul></ul></ul>
    8. 8. Retention in Treatment <ul><li>Treatment effectiveness, outcomes improve with retention in treatment </li></ul><ul><ul><li>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” </li></ul></ul><ul><li>Study of 2,616 client in community-based services, north west England </li></ul><ul><ul><li>49 specialist drug treatment services & 100 general practitioners (physicians) </li></ul></ul>
    9. 9. Study findings <ul><li>Factors NOT associated with retention or completion: </li></ul><ul><ul><li>Ethnicity of client </li></ul></ul><ul><ul><li>Type of drug misuser (heroin, crack cocaine or both) </li></ul></ul><ul><ul><li>Whether client injected drugs </li></ul></ul><ul><ul><li>Whether client using methadone at time of presentation for treatment </li></ul></ul>
    10. 10. Study findings <ul><li>Factors associated with retention or completion </li></ul><ul><ul><li>Younger clients more likely to drop out within 6 months </li></ul></ul><ul><ul><li>Males 1.5 times more likely to drop out early than females </li></ul></ul><ul><ul><li>Those with no previous treatment experience 1.7 times more likely to drop out early than those with previous treatment </li></ul></ul><ul><ul><li>Clients referred from criminal justice system 2.7 times more likely to drop out early </li></ul></ul><ul><ul><li>Clients attending the worst performing services 7.1 times more likely to drop out early than clients attending the best </li></ul></ul><ul><li>Strongest predictor of retention or completion of treatment NOT a characteristic of client but related to agency </li></ul>
    11. 11. Improving patient outcomes & treatment <ul><li>Treatment is more than just specific procedures </li></ul><ul><li>Treatment is a complex process. </li></ul><ul><li>Need to understand: </li></ul><ul><ul><li>Nature & severity of client problems </li></ul></ul><ul><ul><li>The process which occur during treatment </li></ul></ul><ul><ul><li>The role of staff competence & skills </li></ul></ul><ul><ul><li>The organization & provision of service </li></ul></ul><ul><li>Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely </li></ul><ul><li>Involvement of providers in understanding & improving process of treatment is essential. </li></ul>
    12. 12. Outcome domains <ul><li>Increasing agreement on domains - area of life function or status that is expected to be positively influenced by treatment (patient level) </li></ul><ul><ul><li>Substance use </li></ul></ul><ul><ul><li>Employment / self support </li></ul></ul><ul><ul><li>Crime </li></ul></ul><ul><ul><li>Stability in housing </li></ul></ul><ul><ul><li>Social connectedness </li></ul></ul><ul><ul><li>Perception of care (or services) </li></ul></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Retention </li></ul></ul><ul><li>SAMHSA - 2004 </li></ul>
    13. 13. Indicadores de Resultados (SAMHSA, 2003) <ul><li>Funcionamiento social </li></ul><ul><ul><li>Soporte </li></ul></ul><ul><ul><li>Vínculos </li></ul></ul><ul><li>Accesibilidad de servicios </li></ul><ul><ul><li>Cobertura </li></ul></ul><ul><li>Retención en tratamiento </li></ul><ul><li>Percepción sobre la atención </li></ul><ul><li>Costo efectividad </li></ul><ul><li>Uso de prácticas basadas en la evidencia </li></ul>
    14. 14. Indicadores de Resultados (SAMHSA, 2003) <ul><li>Reducción de Morbilidad </li></ul><ul><ul><li>Abstinencia </li></ul></ul><ul><ul><li>Reducción de sintomas </li></ul></ul><ul><li>Laboral / Académico </li></ul><ul><ul><li>Permanencia </li></ul></ul><ul><ul><li>Recuperación </li></ul></ul><ul><li>Delito / P. legales </li></ul><ul><ul><li>Disminución </li></ul></ul><ul><li>Residencia </li></ul><ul><ul><li>Incremento de estabilidad de vivienda </li></ul></ul>
    15. 15. Outcome Measures <ul><li>Specific items, measures or tests of an individual’s functional status within a domain </li></ul><ul><ul><li>For example domain of Employment </li></ul></ul><ul><ul><ul><li>Number of days worked </li></ul></ul></ul><ul><ul><ul><li>Dollars earned </li></ul></ul></ul><ul><ul><ul><li>Days of unexcused absence </li></ul></ul></ul><ul><ul><ul><li>Tax return for a year </li></ul></ul></ul><ul><li>Functional domains have many facets - multiple measures, tests or items often needed for each domain </li></ul>
    16. 16. Performance or quality indicators <ul><li>System level </li></ul><ul><li>Traditional methods to measure outcomes & effectiveness: costly, time-consuming, dependent on scarce research skills </li></ul><ul><li>Performance or quality indicators </li></ul><ul><ul><li>measures to estimate & monitor extent a program or provider conforms to best or evidence-based practices or other standards of quality </li></ul></ul><ul><ul><li>Often derived from administrative information systems </li></ul></ul><ul><ul><ul><li>Financial and/or client </li></ul></ul></ul>
    17. 17. No single measure or indicator <ul><li>At this point, available measures and indicators have benefits & limitations </li></ul><ul><li>No single measure or indicator = quality of treatment or sufficient for accountability </li></ul><ul><li>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. </li></ul>
    18. 18. Opening the door together <ul><li>Must ‘ open the door’ for scientific understanding of treatment </li></ul><ul><li>Look at ourselves, our services and help others understand </li></ul><ul><li>Dynamic process - based in monitoring & tailored to meet changing objective & goals. </li></ul><ul><li>Success depends upon collaboration of service providers, policy makers & researchers </li></ul>
    19. 19. Treatment process improvement & data-driven decisions <ul><li>Supporting providers to make process improvement & data-driven decisions to improve client access to and retention in care </li></ul><ul><li>Success factors </li></ul><ul><ul><li>Provider leadership valued data & provided resources </li></ul></ul><ul><ul><li>Staff received training on data collection & use </li></ul></ul><ul><ul><li>Sharing of change results </li></ul></ul><ul><ul><li>Success making data-driven decisions </li></ul></ul>
    20. 20. Gracias por su atención <ul><li>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. </li></ul><ul><li>-A. Thomas McLellan, Mady Chalk, John Bartlett </li></ul><ul><li> Journal of Substance Abuse Treatment 32 (2007) </li></ul>
    21. 21. Gracias por su atención

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