Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
NIDAMED released 20 April 2009! www.drugabuse.gov Our Strategy Involves BLENDING RESEARCH and PRACTICE Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice Community Bedside Bench Interagency Collaborations are indispensable NIDA-SAMHSA Blending Teams Buprenorphine Training for Addiction Professionals Motivational Interviewing Supervisory Tools Promoting Awareness of Motivational Incentives (PAMI) Short-Term Opioid Withdrawal Using Buprenorphine Treatment Planning Using the Addiction Severity Index (ASI) Promoting Awareness of Motivational Incentives (PAMI) NIDA - SBIRT Initiatives: Cooperation with AMA Mainstreaming addictions is a focus of AMA’s Department of Healthy Lifestyles and Primary Prevention, including the joint NIDA/AMA -• Primary Care Physician Outreach Project and Centers of Excellence Grants to 5 Universities to embed addiction/SBIRT in medical student and resident education NIDA - SBIRT Initiatives: Cooperative actions with WHO • NIDA participates in the international WHO ASSIST project (WHO Lead: Vladimir Pozniak; Program Director: Robert Ali), part of a key policy for the WHO Department of Mental Health and Substance Dependence -To integrate mental health and substance dependence care into general health care NIDA - SBIRT Initiatives: Cooperative actions with other public health agencies • Workshop on SBIRT for prescription drug abuse, 2008 (with ONDCP and Health Canada) • Support Meeting and Workshops for American Medical Education and Research on Substance Abuse (AMERSA - with SAMHSA and NIAAA) • Conference on SBIRT, 2007 (with SAMHSA, ONDCP) NIDA - SBIRT Initiatives: Cooperative actions with other Public Health Agencies • Substance Use Disorders: CPT Codes Approved 2008, with reimbursement now in 13 state Medicare and Medicaid programs, and 71 commercial carriers (and counting) Braiding Funding Streams • Assessment and Brief Interventions in Primary Care (FY2004 with SAMHSA) • NIDA Funding Research on CSAP’s National SPF-SIG Program (FY2004) • Service to Science Grants for State Substance Abuse Authorities (FY2005 with SAMHSA) • Screening, Brief Interventions and Referral to Treatment (SBIRT) in General Medical Settings (FY2008 with SAMHSA) 9 Community Bedside Bench Working in “Real-World Settings” is key. National Drug Abuse Treatment Clinical Trials Network (CTN) Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) Research Centers Coordinating Center NIDA - SBIRT Initiatives: Grants in 2008 in SAMHSA SBIRT Sites • Roy-Byrne, Peter P Brief Intervention in Primary Care for Problem Drug Use and Abuse (SAMHSA Site/Team-Seattle) • Saitz, Richard Screening and Brief Intervention Models to Address Unhealthy Drug Use (SAMHSA Site/Team-Boston) Improving Health Through Implementation Science Wilson M. Compton, M.D., M.P.E., Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse May 2, 2009 American Society of Addiction Medicine Outcomes can be improved by: Developing interventions that are highly effective as delivered Type 1 Translational Research Bench Bedside Outcomes can be improved by: Developing interventions that are highly effective as delivered, or Implementing an effective intervention more widely. Type 2 Translational Research Bedside Practice Methadone Maintenance Dosing Improved, but standards often not met Low-dose programs characterized by: – More AfricanAmerican & Latino patients – More managed care (pre-authorization requirements) – Staff endorsement of abstinence orientation, and rejection of HIV prevention activities (syringe exchange) Pollack & D’Aunno (2008) Health Services Research, 43:2143-2163 Slow adoption of pharmacotherapies • Specialty care addiction treatment settings have been slow to adopt and implement pharmacotherapies • Private sector programs should have fewer barriers to medication adoption – More physicians – More patients with insurance coverage – More hospital affiliations / medicalization • Yet data from a sample of 300 programs in 2008 showed continued slow adoption, and limited prescribing to patients for whom medications were appropriate Personal Communication: Paul Roman et al., (manuscript in development) Developing an intervention is only one part of translating research into practice. Access and Engagement Organization Structure and Climate Intervention Provider knowledge and behavior External Environment (stigma, financing) Type 2 Translation Requires a Different Science than Type 1 (with feedback linkages) Type 1 Type 2 Key Concepts for Type 2 Translation • Information Dissemination • Adoption as a Process (Diffusion Theory) Implementation Science Information Dissemination 24 Information Dissemination • Essential first step in Type 2 translation research – BUT • Generally produces only a vague awareness that new science exists • Does not address the conditions and circumstances of the numerous providers, clients and contexts involved. Adoption is a Process Early Majority=34% Late Majority=34% Early Adopters=13.5% Laggards=16% Innovators=2.5% x-2sd x-sd x x+sd Rogers (2005) “…the best candidate for rapid adoption would be an evidencebased treatment that was simple, was similar with previous practice, had clear advantage, could be tried out temporarily, and was readily observable.” -Henggeler, Lee, & Burns (2002) Clinical Psychology-Science and Practice Successful Implementation of EBPs Effective Intervention Practices + Effective Implementation Strategies Adoption of EBPs Enhanced Patient Outcomes Fixsen, Naoom, Blase, Friedman, & Wallace, 2005 A Comprehensive Approach for Evidence-Based Practice Implementation Systemic Factors Financial Legal/Regulatory Org Structure & Culture Program Components Engage & Sustain Health Care Infrastructure Initial Services Clinical Practices Therapeutic Interventions Patient Engagement Staffing Assessment Info & Clinical Care Systems Research & Knowledge Transfer Education & Training National Quality Forum (2005) Measurement Domains Organizational attributes Contextual factors Change process attributes Intervention attributes Client attributes Networking - cross-agency linkages and collaborations Implementation Science Implementation science is not intended to test interventions, per se, but to study how to get evidence-based interventions adopted, adapted, and sustained. Outpatient Drug Treatment Programs Increasingly Engaged in HIV Services • HIV testing significantly increased at every interval – More likely among programs holding more licenses, having more referral sources, and under public ownership (public funding) • Outreach significantly more common in 2000 vs 1988 – More likely among programs with more referral sources, and with directors who used more ways of staying current with the field Pollack et al (2006) Journal of Substance Abuse Treatment Everybody Wants Innovative Organizations, But…. • Barriers to improved performance are typically numerous, complex, and not always evident. • Change resources are always limited. • Complexity Theory says you only have to improve a few things to improve a lot of things….. – This is because everything is dynamically connected to everything else in an organization (at least a little). – To introduce a single innovation usually requires changing other practices that affect it or enable it. •R D Stacey (1996) Complexity and Creativity in Organizations, Berrett-Koehler, San Fransisco. SAMHSA RWJF Plan, Do, Study, Act (PDSA) Change Cycle “Turning a Change Idea Into Action” NIATx Outcomes Replicable and Sustainable • Two cohorts of treatment programs, each using NIATx for 18 months; cohorts occurred 2 years apart. • Both cohorts showed significant reductions in wait times and increases in retention at 4th tx session • Results for Cohort 1 were sustained for an additional 20 months Hoffman et al., (2008). Drug & Alcohol Dependence, 98:63-69 NIATx 200: A randomized trial of process improvement • NIATx targets 4 primary outcomes: – Reduced waiting time, reduced no-show rates, increased admissions, increased continuation (from 1st to 4th tx session) – Focus is on improving organizational processes (e.g., intake, paperwork, scheduling) NIATx 200: RCT Self-directed “change teams” of program leaders + Web-based process improvement resources vs. Self-directed “change teams” of program leaders + Web-based process improvement resources + Intensive coaching by process improvement experts Conclusions Areas for Future Research: • Provider Training and Support • Intervention Access and Engagement • Delivery Methods and Features • Financing and Cost/Economic Policies • Sustainability • Collaborative Research Conclusions: Implementation Science • Type 2 translation (aka implementation science) requires a different set of hypotheses and methods: – Organization and management sciences – Economics – Social behaviors, etc. • BOTH Types 1 and 2 translation research are essential to improving public health National Institute on Drug Abuse Division of Epidemiology, Services and Prevention Research Promoting Extraordinary Public Health Research to Eradicate Drug Abuse