Research project DR/68 (Research action DR)
State of the art:
Current care for patients with alcohol dependence (AD) is not organised from a chronic care perspective; continuity and integration of care provision after discharge from a specialist alcohol service are lacking.
Wagner proposed the Chronic Care Model to optimize the care for patients with a chronic disease. This model relies on the concept of continuous, integrated care and encourages the interaction of informed, activated patients with prepared, proactive practice teams [1].
Although this model has not been implemented in addiction care yet, evidence indicates that it improves health outcomes in many other chronic diseases like diabetes, COPD and depression [2]. But also in addiction care there is an urgent need for a shift from an acute treatment model to an integrated care model, organized from a chronic care perspective [3]. Initial treatment in a specialty care setting should be followed by a phase of maintenance treatment, in order to sustain the positive effects of the initial more intense treatment phase and improve outcomes on the short and long-term [4]. Several evidence based interventions in aftercare for patients with AD have been developed and could be part of an integrated care program (ICP), based upon Wagner’s Chronic Care Model [4;5].
Objectives:
We aim to improve continuing care for patients with AD. Therefore, we intend to develop an integrated care program (ICP) based on the research performed in this project. Our hypothesis is that the implementation of an integrated care program (ICP), offered to patients after initial rehabilitation treatment in a specialty care setting, will improve the quality of aftercare and reduce the risk of relapse. Moreover, the developed ICP could serve as a generic model for wider implementation in addiction care.
Research questions:
We focus on patients with AD in an ambulant setting after the initial more intensive rehabilitation phase. This is called the ‘aftercare’ or ‘continuing care’ phase [4].
1. Which aftercare interventions sustain the principles of integrated care and what is known about their effectiveness?
2. Which indicators can be validated to assess the quality of AD aftercare: outcome indicators (drinking related outcomes) and process indicators (e.g. treatment adherence, experiences of patients/providers, etc.)
3. What is the quality of the current aftercare (based upon the validated indicators)?
4. What are the barriers and facilitating factors to improve the quality of AD aftercare?
5. Based upon the answers to the previous questions: what should an effective and feasible ICP consist of?
Methodology:
To develop such an ICP, we need to follow a systematic approach, which we base on an internationally validated approach [6].
1. Systematic literature review (ongoing research) to identify interventions sustaining the principles of integrated care and evaluate their effectiveness.
2. Selection and validation of quality indicators
To assess the quality of current care, outcome and process indicators will be validated. Quality indicators will be generated systematically, using the RAND-modified Delphi method [7]. A multidisciplinary expert panel will be assembled representing each discipline involved in AD care, patients and two experts in health care implementation science. Indicators will we tested for acceptability, feasibility, reliability, sensitivity to change and validity.
3. Assessment of the quality of current AD aftercare
Using the selected and validated indicators, current AD continuing care will be assessed. This will be done by a retrospective cohort study based upon the Intego database, an ongoing Belgian general practice-based morbidity registry, covering more than 100 general practitioners and including about 2 million patient-years till 2012. Also the WIV database will be used as well as data from the residential centres. Interviews with physicians and patients will be used for those indicators that are not reported in the medical records. Finally, questionnaires will be sent electronically to all health care providers involved.
4. Identifying barriers and facilitating factors to improve the quality of care
In order to identify barriers and facilitating factors to improve the quality of care, focus groups will be conducted with physicians, nurses, patients with AD and their relatives. Data analysis will be guided by a ‘grounded theory’ approach. NVivo 10 will be used.
5. Drafting the ICP
A multidisciplinary expert team will then draft the ICP, based upon previous results (the systematic review revealing the most effective interventions, the evaluation of current care with the validated quality indicators and the barriers and facilitators to optimal care resulting from the focus group analysis). It is not possible to describe the exact content of the ICP now because this must result from the previously described research phases. Components of the program will focus on patient-oriented quality of care and organizational quality. The ICP will make active efforts to bring the treatment to the patient, and will use alternative service deliveries instead of the traditional clinic-based approach of aftercare.
Expected outcomes and contribution to an integral and integrated drugs policy in Belgium:
We are aware of the challenging nature of this project. Still, we expect an ICP to be effective in improving the quality of AD care because of following reasons:
Firstly, evidence indicates that ICPs based on Wagner’s chronic care model improve the care of other chronic conditions (congestive heart failure, COPD, diabetes…) [2;8]. The principles of these ICPs are generic and could be implemented more widely, including in addiction care.
Besides, in the treatment for patients with AD, several isolated continuing care interventions have been described and proven to be effective [4]. They could be part of the ICP we will develop.
Also, more in general, research indicates that treatment for patients with AD is effective both in terms of reduction of drinking rates as in reducing mortality [9;10]
Finally, pharmacological interventions are insufficient as isolated intervention in the maintenance care for patients with AD [11]. Meta-analyses indicate that treatment effects of acamprosate and naltrexone are only moderate [12;13].
We expect that the developed ICP could serve as a generic model for wider implementation in addiction care. Therefore, the ICP will have to be tested in a pilot study and in a randomized controlled trial. These trials will only take place in a later phase and are no part of this research proposal.
In this research project we focus on the exploratory research needed to develop the ICP.
Reference List:
1 Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness. JAMA 2002;288:1775-1779.
2 Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002;288:1909-1914.
3 McLellan AT, Lewis DC, O'Brien CP, Kleber HD: Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-1695.
4 McKay JR: Continuing care research: what we have learned and where we are going. J Subst Abuse Treat 2009;36:131-145.
5 Lash SJ, Timko C, Curran GM, McKay JR, Burden JL: Implementation of evidence-based substance use disorder continuing care interventions. Psychol Addict Behav 2011;25:238-251.
6 Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003;362:1225-1230.
7 Campbell SM, Braspenning J, Hutchinson A, Marshall MN: Research methods used in developing and applying quality indicators in primary care. BMJ 2003;326:816-819.
8 Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R: Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005;17:141-146.
9 Rehm J, Shield K, Rehm MX, Gmel G, Frick U: Alcohol consumption, alcohol dependence and attributable burden of disease in Europe: Potential gains from effective interventions for alcohol dependence.; Centre for Addiction and Mental Health , 2012.
10 Anderson P, Chisholm D, Fuhr DC: Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009;373:2234-2246.
11 NICE Clinical Guidelines, No. 115.: in Leicester (UK): British Psychological Society, (ed): 2011.
12 Rosner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M: Acamprosate for alcohol dependence. Cochrane Database Syst Rev 2010;CD004332.
13 Rosner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M: Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev 2010;CD001867.
Integrated Care for patients with Alcohol Use disorders( ICArUS) : final report part 1 : Continuing care for patients with alcohol use disorders - a systematic review
Bekkering, Trudy - Lenaerts, Evelien - Matthys, Frieda ... et al Brussels : Belgian Scientific Policy , 2017 (SP2684)
[To download]
Integrated Care for patients with Alcohol Use disorders( ICArUS) : final report, part 2 : Development and validation of quality indicators on aftercare for patients with AUD : a Delphi study
Bekkering, Trudy - Lenaerts, Evelien - Matthys, Frieda ... et al Brussels : Belgian Scientific Policy , 2017 (SP2685)
[To download]
Integrated Care for patients with Alcohol Use disorders( ICArUS) : final report, part 3 : Identifying barriers and facilitating factors to improve the quality of AUD aftercare : a focus group study
Bekkering, Trudy - Lenaerts, Evelien - Matthys, Frieda ... et al Brussels : Belgian Scientific Policy , 2017 (SP2686)
[To download]
Integrated Care for patients with Alcohol Use disorders( ICArUS) : résumé
Bekkering, Trudy - Lenaerts, Evelien - Matthys, Frieda ... et al Brussels : Belgian Scientific Policy , 2017 (SP2687)
[To download]
Integrated Care for patients with Alcohol Use disorders( ICArUS) : samenvatting
Bekkering, Trudy - Lenaerts, Evelien - Matthys, Frieda ... et al Brussel : Federaal Wetenschapsbeleid, 2017 (SP2688)
[To download]
