The Study of Patient Pathways in Alcohol and Other Drug Treatment

1、XVIII A STUDY OF PATIENT PATHWAYS IN ALCOHOL AND OTHER DRUG TREATMENTPatient Pathways National ProjectLubman, D., Manning, V., Best, D., Berends, L., Mugavin, J., Lloyd, B., Lam, T., Garfield, J., Buykx, P., Matthews, S., Larner, A., Gao, C., Allsop, S., Room, R.FINAL REPORTJune 2014 2014 Commonweal

2、th of Australia Reproduced with permission of the Commonwealth of Australia. Unauthorised reproduction and other uses comprised in the copyright are prohibited without permission.Copyright enquiries can be made to the lead author, at Turning Point, 54-62 Gertrude Street, Fitzroy, Victoria 3065, Aust

3、ralia.Published by Turning Point, which is a part of Eastern Health. This project was funded by the Commonwealth of Australia. The responsibility for all statements made in this document lies with the authors. The views of the authors do not necessarily reflect the views and position of the Commonwe

4、alth of Australia.The correct citation for this report is: Lubman, D., Manning, V., Best, D., Berends, L., Mugavin, J., Lloyd, B., Lam, T., Garfield, J., Buykx, P., Matthews, S., Larner, A.,Gao, C., Allsop, S., Room, R. (2014). A study of patient pathways in alcohol and other drug treatment. Turning

5、 Point, Fitzroy. AcknowledgementsWe thank the participants who were involved across the different phases of the project for the substantial amount of time they have given to help us understand their treatment journeys and experiences. We would also like to thank all of the treatment service staff th

6、at supported the project in both Victoria and West Australia, and members of Alcohol and other Drugs Council of Australia (ADCA) for their support and expertise. The authors also thank Mee Lee Easton and Ying Chen from the Victorian Data Linkages Unit, and Rob Knight and Mark Gill for providing acce

7、ss to the data. This work could not have been completed without the support of the Commonwealth Department of Health. Finally, we would like to thank others members of the research team who assisted with the project: Seraina Agramunt, Julia Butt, Sue Carruthers, Dina Eleftheriadis, Sarah Flynn, Jodi

8、e Grigg, Cherie Helibronn, Barbara Hunter, Klaudia Jones, Shraddha Kashyap, Jessica Killian, Melaine McAleer, Terence McCann, Vijay Rawat and Terry Slomp. Table of contentsAcknowledgementsIIITable of contentsIVList of tablesVList of figuresVIIIList of acronymsIXExecutive summaryX1.Introduction and o

9、verview11.1 Study rationale82.System description132.1 Method132.2 System values and principles152.3 Summary203.Client survey data: baseline and follow-up223.1 Methods223.2 Baseline results303.3 Follow-up403.4 Qualitative findings623.5 Entry into PIT and the experience of treatment63Continuity of car

10、e69Treatment barriers74Areas for improvement774.Patient Pathways Priority 2a: Data linkage804.1 Introduction804.2 Method804.3 Results845.Discussion and recommendations- 115 -5.1 Recommendations- 121 -6.References124List of tablesTable 1.1 Summary of the major international AOD treatment system outco

11、me studies to date11Table 2.1 Proportion of treatment episodes by treatment type and jurisdiction16Table 2.2 AOD treatment service setting by jurisdiction18Table 2.3 Summary of performance and accountability approaches by jurisdiction, as reported in 201219Table 3.1 Items included in structured inte

12、rview with clients new to AOD treatment25Table 3.2 Participant characteristics at baseline31Table 3.3 Drugs of concern by index treatment type at baseline33Table 3.4 Age comparison of Pathways sample and Victorian new-to-treatment population34Table 3.5 Level of quality of life by index treatment typ

13、e at baseline36Table 3.6 Level of service use in past 12 months by index treatment type at baseline38Table 3.7 Contact with the justice system by index treatment type at baseline39Table 3.8 Changes in personal circumstances at baseline and follow-up (post-PIT) (ns =549-554)42Table 3.9 Use in the yea

14、rs before and after PIT of AOD specialist, community and acute medical service43Table 3.10 Use in the years before and after PIT of AOD specialist, community and acute medical service among outpatient participants44Table 3.11 Use in the years before and after PIT of AOD specialist, community and acu

15、te medical service among acute withdrawal participants45Table 3.12 Use in the years before and after PIT of AOD specialist, community and acute medical service among residential rehabilitation participants46Table 3.13 Post PIT AOD specialist, community and acute medical service use by PDOC46Table 3.

16、14 Abstinence rates by service use post-PIT49Table 3.15 Changes in severity of dependence on PDOC by PIT type50Table 3.16 Changes in median score on each WHOQOL domain between baseline and follow-up for each PIT type51Table 3.17 Proportion of treatment episodes by treatment type and jurisdiction58Ta

17、ble 3.18 Abstinence and Success rates by PIT using weighted and unweighted data59Table 3.19 Abstinence and Success rates by PDOC using weighted and unweighted data59Table 3.20 Key outcome by PIT using weighted data60Table 3.21 Key outcome by PDOC using weighted data60Table 4.1 Definition of disease

18、categories for emergency department and hospital diagnoses83Table 4.2 Sociodemographic characteristics by ED presentations, 2009/10 to 2011/12, among those who were AOD clients in 2010/1185Table 4.3 Sociodemographic characteristics by ED presentations in 2009/10, 2010/11 and 2011/1287Table 4.4 Treat

19、ment type and treatment characteristics by ED presentation, 2009/10 to 2011/1289Table 4.5 Treatment type and treatment characteristics by ED presentations in 2009/10, 2010/11 and 2011/1290Table 4.6 Drug use characteristics by ED presentations, 2009/10 to 2011/1292Table 4.7 Drug use characteristics b

20、y ED presentations in 2009/10, 2010/11 and 2011/1293Table 4.8 Median number of ED presentations and median hours of ED stay for 2010/11 AOD clients, 2009/10 to 2011/1293Table 4.9 ED presentations for alcohol-related acute conditions by AOD treatment type, primary drug of concern and treatment termin

21、ation status, 2009/10, 2010/11 and 2011/1294Table 4.10 ED presentations for other drug-related acute conditions by AOD treatment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/1295Table 4.11 ED presentations for alcohol-related chronic conditions by AOD tre

22、atment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/1296Table 4.12 ED presentations for injuries by AOD treatment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/1297Table 4.13 ED presentations for non-AOD-related

23、 conditions by AOD treatment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/1298Table 4.14 Sociodemographic characteristics by hospital admission, 2009/10 to 2011/12100Table 4.15 Sociodemographic characteristics by hospital admission in 2009/10, 2010/11 and

24、 2011/12102Table 4.16 Treatment type and treatment characteristics by admissions, 2009/10 to 2011/12104Table 4.17 Treatment type and treatment characteristics by admissions in 2009/10, 2010/11 and 2011/12105Table 4.18 Drug use characteristics by hospital admission, 2009/10 to 2011/12107Table 4.19 Dr

25、ug use characteristics by hospital admission, 2009/10, 2010/11 and 2011/12- 108 -Table 4.20 Median number of hospital admissions and length of stay- 108 -Table 4.21 Admissions for alcohol-related acute conditions by AOD treatment type, primary drug of concern and treatment termination status, 2009/1

26、0, 2010/11 and 2011/12- 109 -Table 4.22 Admissions for other drug-related acute conditions by AOD treatment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/12- 110 -Table 4.23 Admissions for alcohol-related chronic conditions by AOD treatment type, primary d

27、rug of concern and treatment termination status, 2009/10, 2010/11 and 2011/12- 111 -Table 4.24 Admissions for injuries by AOD treatment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/12- 112 -Table 4.25 Admissions for non-AOD-related conditions by AOD treat

28、ment type, primary drug of concern and treatment termination status, 2009/10, 2010/11 and 2011/12- 113 -List of figuresFigure 1.1 Conceptual model of AOD treatment system and its connections with other sectors examined as part of the patient pathway in the current study (adapted from Babor et al., 2

29、008)10Figure 3.1 Primary drug of concern32Figure 3.2 Proportion of participants who nominated alcohol as a drug of concern endorsing each alcohol-related treatment goal35Figure 3.3 Proportion of participants who nominated any substance other than alcohol or tobacco as a drug of concern endorsing eac

30、h drug-related treatment goal35Figure 3.4 Overview of cohort recruitment, participation and outcome rates41Figure 3.5 Differences in rates of abstinence for PDOC and all DOCs when the PDOC is the indicated substance47Figure 3.6 Abstinence rates from PDOC and all DOCs by PIT type48Figure 3.7 Proporti

31、on of participants (total sample) achieving different degrees of treatment success (frequency of use)49Figure 3.8 Direction of change in each WHO-QOL domain between baseline and follow-up51Figure 3.9 Proportion of participants receiving the various levels of optimal care pathways56List of acronymsAD

32、ISAlcohol and Drug Information SystemAODAlcohol and Other DrugAODTS-NMDSAlcohol and Other Drug Treatment Services National Minimum Data SetAUDITAlcohol Use Disorders Identification TestBTIBarriers to Treatment InventoryCAICommunity Assessment InventoryDHDepartment of Health (Victoria)DISC-12Discrimi

33、nation and Stigma ScaleDOCDrug of concernEDEmergency DepartmentGPGeneral PractitionerGOGovernment Organisation IQRInter quartile range PDOCPrimary drug of concern PITPrimary index treatmentMSPSSMultidimensional Scale of Perceived Social SupportNDRINational Drug Research InstituteNGONon-Government Or

34、ganisationSDSSeverity of Dependence ScaleTCU- CEST-IntakeTexas Christian University-Client Evaluation of Self and Treatment Intake-VersionVAEDVictorian Admitted Episodes DatasetVDLVictorian Data Linkages UnitVEMDVictorian Emergency Minimum DatasetWHOQOL-BREFWorld Health Organization Quality of Life

35、(Brief version) SLKStatistical linkage keySUDSubstance use disorderExecutive summary1. Background:There is now a substantial evidence base indicating that once in addiction treatment, many individuals with alcohol and drug dependence improve. However, questions remain around what combination of serv

36、ice use is associated with these improvements and how systems can be configured to optimise and maintain positive treatment outcomes. The literature on treatment effectiveness to date is limited in that outcome studies typically describe the response to an isolated episode of care within a particula

37、r treatment modality (e.g., inpatient detoxification), which represents only a fraction of the overall treatment episode. In addition, while Australian outcome studies typically involve participants using major illicit drugs (heroin, amphetamines), there has been no cohort study of alcohol and canna

38、bis users in Australia, despite these being the most commonly abused substances and the two most frequent primary drugs of concern among the 659 publicly funded alcohol and other drug (AOD) treatment services across Australia (AIHW, 2013), accounting for 70% of treatment episodes in 2009-10 (48% alc

39、ohol and 23% cannabis) (AIHW, 2011). Whilst there is increasing recognition that specialist AOD services are merely one component of a larger interconnected system which includes health and welfare services, the extent of inter- and intra-sectorial linkage and the resulting pathways of care for clie

40、nts accessing AOD specialist services remain poorly understood. Nevertheless, Babor et al. (2008; 2010) suggest that the cumulative impact of engaging with AOD services and non-specialist AOD services in the community should translate into population health benefits, such as reduced mortality, morbi

41、dity, disability, suicide, crime, unemployment and healthcare costs. 2. Study RationaleThere have been a number of international outcome studies in the addictions field although only two in Australia each focused on a particular class of substances. While all of the major outcome studies have shown

42、positive benefits for treatment, Patient Pathways is a unique study in that; It includes both alcohol and illicit drug use Its focus is on treatment systems and pathways through specialist and linked services, rather than focusing exclusively on the client AOD treatment journey It includes not only

43、a large cohort follow-up study (with quantitative and qualitative components), but also a linked analysis of acute harms based on data from AOD treatment engagement, emergency departments and hospital admissionsThe rationale for the Patient Pathways study was based on the recognition that clients pr

44、esent with complex life problems as well as their alcohol and/or drug dependence, and are often engaged in a diverse range of professional supports and services. The Pathways study attempted to map and measure the systems within which individuals attempted to navigate their way through such inter-li

45、nking services, their experiences of services and the changes in behaviours and social capital that resulted, as well as the impact of treatment on utilisation of acute health resources. The design was unique in combining a diverse range of research methodologies and approaches to produce a coherent

46、 model of treatment experience and navigation. The findings from each of the components of this work are described individually prior to a description of the integrated emerging themes and the resulting recommendations from this work. 3. Priority One: Findings from the System Description The investi

47、gation of AOD treatment systems in each state and territory involved a documentary analysis supported by key stakeholder interviews with a diverse range of policy makers. These individuals subsequently participated in reviewing the initial analysis of their own jurisdictional findings, providing inv

48、aluable context to the work conducted. The analysis showed important commonalities as well as areas of difference across jurisdictions, with broad principles articulated in most relevant strategic policy documents. In essence, most systems strive to provide accessible, client-centred services that d

49、eliver evidence-based treatment within a harm-reduction framework. There is also a general aspiration that specialist services are one part of a larger interconnected system integrating with other health and welfare services. Assessment, counselling and withdrawal are the central components of the t

50、reatment system in many jurisdictions, although there is considerable variability in treatment utilised across the country. While some client characteristics are relatively homogenous across jurisdictions (e.g. gender, age, country of birth), there is considerable heterogeneity in terms of Indigenou

51、s status, primary drug of concern and referral source, although it is not clear that system variations are a direct response to differences in presenting populations or profiles. The review revealed diversity of models of service provision across Australia, and limitations in capacity for demand mod

52、elling or mapping the effectiveness of aspects of the treatment system.There is apparent commitment in all states and territories to monitoring and accountability, although the mechanisms in place vary by jurisdiction and it is an area for ongoing development. There is clear support for ensuring AOD

53、 service systems that are accessible and responsive to the needs of clients. Further, ensuring adequate care pathways is an objective in many states and territories, although the challenges in achieving this are widely recognised, as are the attempts to integrate effectively with linked services, su

54、ch as primary care, mental health, criminal justice, housing and social services.Given the policy emphasis on accessible and interconnected service systems in most jurisdictions, it is not clear from the evidence gathered through the document review and consultation processes how well integrated exi

55、sting AOD systems currently are, or what mechanisms exist for evaluating this. This links to the perceived omission around formal mechanisms for demand modelling and for mapping addiction and treatment careers. Key findings from this work have already been used by the Drug Policy Modelling Program (

56、DPMP), at the University of New South Wales, to inform a Commonwealth funded review of the AOD treatment service sector. 4. Priority Two Part 1: Treatment cohort outcomes studyIn total, 796 clients were recruited between January 2012 and January 2013 from 20 AOD specialist services in Victoria (VIC)

57、 and Western Australia (WA), of which 29% were in long-term residential treatment, 44% in acute withdrawal services, and 27% in outpatient delivered treatment. The cohort was predominantly male (62%), Australian-born (80%), with English as their first language (95%) and had a median age of 35.9 year

58、s. At baseline, the primary drug of concern (PDOC) was alcohol (47%); cannabis (15%); meth/amphetamine (20%); opioids (15%); and other drugs (3%). Almost all participants (99%) had addiction severity scores in the probable dependence range. In addition to severe AOD problems, the cohort had multiple life complexities. Fewer than 2