Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy clinics
Introduction
In 1998, the Health Services Research and Development Service of the United States Veterans Health Administration (USVA) launched a national initiative, the Quality Enhancement Research Initiative (QUERI), to improve patient outcomes and quality of life through implementation of evidence-based clinical practice guidelines. Eight disease groups, one of which was substance use disorders, were chosen based on their frequency, and the severity and cost of the disability they caused (Demakis et al., 2000). The QUERI Substance Use Disorder Module (QSUD) chose opioid agonist therapy (OAT) as the first focus of efforts to translate research into practice. Opioid agonist therapy (OAT) has considerable evidence supporting its effectiveness and its cost effectiveness (Ball and Ross, 1991, Barnett, 1999, Ling et al., 1998, Marsch, 1998, Newman and Whitehill, 1979, Zaric et al., 2000). Evidence has also accumulated concerning the contribution to patient outcomes of specific practices within OAT programs (Caplehorn, 1994, Hartel et al., 1995, McGlothlin and Anglin, 1981, McLellan et al., 1993, Sees et al., 2000, Stitzer et al., 1992). Available evidence suggests that implementation of these practices varies across OAT programs (D’Aunno and Vaughn, 1992, D’Aunno and Pollack, 2002, Hamilton and Humphreys, 1996). This discrepancy between the evidence base and clinical practice along with the relatively small number and contained nature of OAT programs within the USVA made OAT an ideal candidate for QSUD to begin its quality improvement process. The opioid agonist therapy effectiveness (OpiATE) Initiative was launched in the spring of 2001 as a research demonstration project to develop and evaluate methods for translating evidence-based OAT practices.
One key goal of the OpiATE Initiative is to improve outcomes for patients enrolled in USVA OAT programs through implementation of evidence-based OAT practices. Patient retention and percentage of urine screens positive for illicit opioids were selected as outcome measures because they are easy for programs to measure, changes in program practices should directly produce change in these outcome measures, and they are predictive of longer-term outcomes such as increased psychosocial and physical well-being and decreased mortality (Cacciola et al., 1998, del Rio et al., 1997, Morral et al., 1997, Morral et al., 1999). Four specific practices within OAT have a solid evidence base and have been demonstrated to affect these patient outcomes. These four practices are: (1) maintenance orientation, where patients are encouraged to continue receiving OAT as long as it is beneficial rather than being encouraged to discontinue it (Caplehorn et al., 1998, Gossop et al., 2001, Magura and Rosenblum, 2001, Sees et al., 2000), (2) use of adequate opioid agonist doses (Caplehorn et al., 1993a, McGlothlin and Anglin, 1981, Strain et al., 1993, Strain et al., 1999, (3) adequate counseling support (Broome et al., 1999, Hser, 1995, Joe et al., 1999, Magura et al., 1998), and (4) systematic application of contingency management principles (Rowan-Szal et al., 1994, Silverman et al., 1996, Stitzer et al., 1980, Stitzer et al., 1992). In this paper, we describe the baseline profiles of nine USVA OAT clinics with respect to these four practices.
Section snippets
Recruitment of clinics
Out of a total of 34 USVA OAT clinics existing at that time, eight sites were eliminated because they were participating in another study and one site was eliminated because it was at the principal investigator’s institution. Among the remaining 25 sites, 11 were chosen based on existing data from a periodic survey of USVA OAT clinics regarding clinic size, geographic location, and average opioid agonist dose (Hamilton and Humphreys, 1996). An attempt was made to achieve a sample that
Clinic demographics
Nine USVA OAT clinics participated in the OpiATE Initiative. The clinics represent various geographic locations including east coast, mid-west, and west coast. As with the majority of OAT clinics, all are located in metropolitan areas. The clinics serve from 44 to 211 patients, with a mean patient population of 131 (S.D.=65). USVA OAT clinics in general have a mean patient population of 140 (S.D.=103,min=8,max=405), indicating that our sample includes clinics with a restricted size range
Discussion
Wide variability in policies and practices exists within nine USVA opioid agonist therapy clinics. These results indicate that the surveyed clinics generally met or exceeded recommendations for counseling frequency. Most clinics had a mix of staff that supported a maintenance orientation and staff that supported an abstinence orientation indicating room for improvement within USVA OAT clinics which could perhaps best be addressed by increased education and training on the benefits of methadone
Acknowledgments
This work was supported by grant number SUT01-035-1 from the Health Services Research Division of the US Veterans Administration. The opinions expressed here are those of the authors, and do not represent those of the Veterans Administration. The authors would like to extend their thanks to the following OAT clinic staff members for the time and effort that they contributed to participation in the OpiATE Initiative: Fatmatta Alhusain, Frank Aviles, Elizabeth Caliboso, Donald Calsyn, Paul
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