Efficacy of a short-term residential smoking cessation therapy versus standard outpatient group therapy ('START-Study'): study protocol of a randomized controlled trial.

BACKGROUND: In Germany, evidence-based outpatient smoking cessation therapies are widely available. Long-term abstinence rates, however, are limited. Studies suggest that short-term residential therapy enables a higher level of environmental control, more intense contact and greater support among patients and from therapists, which could result in higher abstinence rates. The aim of the current START-study is to investigate the long-term efficacy of a short-term residential therapy exclusively for smoking cessation, conducted by a mobile team of expert therapists. METHODS: A randomized controlled trial (RCT) is conducted to examine the efficacy of residential behavior therapeutic smoking cessation therapy compared to standard outpatient behavior therapeutic smoking cessation group therapy. Adult smokers consuming 10 or more cigarettes per day, who are willing to stop smoking, are randomized in a ratio of 1:1 between therapy groups. The primary endpoint is sustained abstinence for 6-month and 12-month periods. Secondary endpoints include smoking status after therapy, 7-day point abstinence after the 6-month and 12-month follow-ups, level of physical dependence, cost-effectiveness, use of nicotine replacement products, health-related quality of life, self-efficacy expectation for tobacco abstinence, motivational and volitional determinants of behavior change, self-reported depressive symptom severity, adverse events and possible side effects. Assessments will take place at baseline, post-therapy, and at 6-month and 12-month intervals after smoking cessation. DISCUSSION: There is a high demand for long-term effective smoking cessation therapies. This study represents the first prospective RCT to examine the long-term efficacy of a residential smoking cessation therapy program compared to standard outpatient group therapy as an active control condition. The residential therapeutic concept may serve as a new model to substantially enhance future cessation therapies and improve the understanding of therapeutic impact factors on tobacco abstinence. Utilizing a mobile team, the model could be applied efficiently to medical centers that do not have permanent and trained personnel for smoking cessation at their disposal. TRIAL REGISTRATION: German Register for Clinical Trials (Deutsches Register für Klinische Studien), DRKS00013466. Retrospectively registered on 1 April 2019. https://www.drks.de/drks_web/navigate.do?navigationId=start.

Changes in Residential Substance Use Treatment Service Access Resulting From Recent Medicaid Section 1115 Waivers.

Medicaid stands to play a significant role in addressing the needs of individuals with a substance use disorder; however, many state Medicaid programs do not cover a full continuum of care. A growing number of states are taking advantage of Section 1115 demonstration waivers to augment their covered benefits, including experimenting with financing residential treatment services that previously were not eligible for reimbursement. Concerns over potential overuse of these services or increased spending due to this service expansion may be tempered by complementary delivery system transformation focused on reining in costs and improving care quality.

Impact of Agency Receipt of Incentives and Reminders on Engagement and Continuity of Care for Clients With Co-Occurring Disorders.

OBJECTIVE: This study examined whether having co-occurring substance use and mental disorders influenced treatment engagement or continuity of care and whether offering financial incentives, client-specific electronic reminders, or a combination to treatment agencies improved treatment engagement and continuity of care among clients with co-occurring disorders. METHODS: The study used a randomized cluster design to assign agencies (N=196) providing publicly funded substance use disorder treatment in Washington State to a research arm: incentives only, reminders only, incentives and reminders, and a control condition. Data were analyzed for 76,044 outpatient, 32,797 residential, and 39,006 detoxification admissions from Washington's treatment data system. Multilevel logistic regressions were conducted, with clients nested within agencies, to examine the effect of the interventions on treatment engagement and continuity of care. RESULTS: Compared with clients with a substance use disorder only, clients with co-occurring disorders were less likely to engage in outpatient treatment or have continuity of care after discharge from residential treatment, but they were more likely to have continuity of care after discharge from detoxification. The interventions did not influence treatment engagement or continuity of care, except the reminders had a positive impact on continuity of care after residential treatment among clients with co-occurring disorders. CONCLUSIONS: In general, the interventions did not result in improved treatment engagement or continuity of care. The limited number of significant results supporting the influence of incentives and alerts on treatment engagement and continuity of care add to the mixed findings reported by previous research. Multiple interventions may be needed for performance improvement.

Agency-level financial incentives and electronic reminders to improve continuity of care after discharge from residential treatment and detoxification.

BACKGROUND: Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment. METHODS: Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care. RESULTS: During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline. CONCLUSIONS: Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies.

Role of recovery residences in criminal justice reform.

Over the past decade there has been a clear consensus among drug policy researchers that the practice of incarcerating persons for drug offenses has been counterproductive. As a result, U.S. criminal justice policy is increasingly emphasizing alternative dispositions to incarceration for drug related arrests. In addition, large numbers of persons currently incarcerated for drug related offenses are being released into communities. However, there are serious questions about where these individuals are going to live once released and how they will access needed services. Residential recovery homes in the community are good options for those who wish to pursue abstinence from drugs. They provide a drug- and alcohol-free living environment along with social support for abstinence and successful functioning in the community. This paper reviews recent changes in drug policy the U.S. and describes the variety of recovery home options that are available to persons diverted or released from incarceration.

Residential Substance Abuse Treatment for Urban American Indians and Alaska Natives, Part II: Costs.

The present study examined costs of two residential substance abuse treatment programs designed for urban American Indians and Alaska Natives (AI/ANs). Costs for one agency were well within national norms, while costs at the other program were less than expected from nationwide data. Economies of scale accounted for much of the difference between observed and expected costs. Culturally specific residential substance abuse treatment services can be provided to urban AI/ANs within budgets typically found at mainstream programs.

An analysis of the federal funding for mental health care in Brazil.

This article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health's databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

Examining the pathways for young people with drug and alcohol dependence: a mixed-method design to examine the role of a treatment programme.

INTRODUCTION: Young people with drug and alcohol problems are likely to have poorer health and other psychosocial outcomes than other young people. Residential treatment programmes have been shown to lead to improved health and related outcomes for young people in the short term. There is very little robust research showing longer term outcomes or benefits of such programmes. This paper describes an innovative protocol to examine the longer term outcomes and experiences of young people referred to a residential life management and treatment programme in Australia designed to address alcohol and drug issues in a holistic manner. METHODS AND ANALYSIS: This is a mixed-methods study that will retrospectively and prospectively examine young people's pathways into and out of a residential life management programme. The study involves 3 components: (1) retrospective data linkage of programme data to health and criminal justice administrative data sets, (2) prospective cohort (using existing programme baseline data and a follow-up survey) and (3) qualitative in-depth interviews with a subsample of the prospective cohort. The study will compare findings among young people who are referred and (a) stay 30 days or more in the programme (including those who go on to continuing care and those who do not); (b) start, but stay fewer than 30 days in the programme; (c) are assessed, but do not start the programme. ETHICS AND DISSEMINATION: Ethics approval has been sought from several ethics committees including a university ethics committee, state health departments and an Aboriginal-specific ethics committee. The results of the study will be published in peer-reviewed journals, presented at research conferences, disseminated via a report for the general public and through Facebook communications. The study will inform the field more broadly about the value of different methods in evaluating programmes and examining the pathways and trajectories of vulnerable young people.

Marketing Residential Treatment Programs for Eating Disorders: A Call for Transparency.

Residential behavioral treatment is a growing sector of the health care industry and is used by a large proportion of adolescent and adult patients with eating disorders. These programs and the organizations that own them have developed extensive marketing strategies that target clinicians and include promotional gifts, meals, travel reimbursement, and continuing education credit. Legislation and policy changes have limited these types of activities when conducted by the pharmaceutical industry, and awareness of conflicts of interest associated with clinician-targeted advertising of drugs and devices has increased. However, similar practices by the behavioral health care industry have evolved without oversight. The authors urge clinicians to consider how marketing strategies by treatment facilities may influence their referral behaviors and call for improved transparency regarding gifts and payments from treatment facilities.

Continuous quality improvement (CQI) in addiction treatment settings: design and intervention protocol of a group randomized pilot study.

BACKGROUND: Few studies have designed and tested the use of continuous quality improvement approaches in community based substance use treatment settings. Little is known about the feasibility, costs, efficacy, and sustainment of such approaches in these settings. METHODS/DESIGN: A group-randomized trial using a modified stepped wedge design is being used. In the first phase of the study, eight programs, stratified by modality (residential, outpatient) are being randomly assigned to the intervention or control condition. In the second phase, the initially assigned control programs are receiving the intervention to gain additional information about feasibility while sustainment is being studied among the programs initially assigned to the intervention. DISCUSSION: By using this design in a pilot study, we help inform the field about the feasibility, costs, efficacy and sustainment of the intervention. Determining information at the pilot stage about costs and sustainment provides value for designing future studies and implementation strategies with the goal to reduce the time between intervention development and translation to real world practice settings.

The cost-effectiveness of depression treatment for co-occurring disorders: a clinical trial.

The authors aimed to determine the economic value of providing on-site group cognitive behavioral therapy (CBT) for depression to clients receiving residential substance use disorder (SUD) treatment. Using a quasi-experimental design and an intention-to-treat analysis, the incremental cost-effectiveness and cost-utility ratio of the intervention were estimated relative to usual care residential treatment. The average cost of a treatment episode was $908, compared to $180 for usual care. The incremental cost effectiveness ratio was $131 for each point improvement of the BDI-II and $49 for each additional depression-free day. The incremental cost-utility ratio ranged from $9,249 to $17,834 for each additional quality adjusted life year. Although the intervention costs substantially more than usual care, the cost effectiveness and cost-utility ratios compare favorably to other depression interventions. Health care reform should promote dissemination of group CBT to individuals with depression in residential SUD treatment.

Families of individuals with intellectual and developmental disabilities: policy, funding, services, and experiences.

Families are critical in the provision of lifelong support to individuals with intellectual and developmental disabilities (IDD). Today, more people with IDD receive long-term services and supports while living with their families. Thus, it is important that researchers, practitioners, and policy makers understand how to best support families who provide at-home support to children and adults with IDD. This article summarizes (a) the status of research regarding the support of families who provide support at home to individuals with IDD, (b) present points of concern regarding supports for these families, and (c) associated future research priorities related to supporting families.

Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings.

OBJECTIVE: The purpose of this study was to assess whether polypharmacy regimens can be safely and effectively reduced for youth placed in a residential treatment center, and to assess the cost savings achieved from medication reductions. METHODS: Data were collected for 131 youth ages 11-18, who were admitted to and discharged from a residential treatment center between 2007 and 2011. Six month postdischarge data were available for 51 youth. Data include demographics, admission and discharge medications, place of discharge, and postdischarge stability level. RESULTS: Upon admission, 30 youth were not on medication, at discharge 48 were not; a 60% increase. Mean number of admission medications was 2.16 (SD=0.97) versus 1.55 (SD=0.70) upon discharge. Upon admission, one youth was on five and nine were on four medications. At end-point, only one youth was on four medications. The number of youth needing two or more medications declined by 55%, and the number of those needing three or more declined by 69%. The largest reduction was seen in the number of antipsychotics and antidepressants. Mood stabilizer and antipsychotic combinations declined by 65%. Youth with medication reduction were more likely to be discharged to a less restrictive setting than were youth without medication reduction (72.6% vs. 53.8%), p=0.03. At 6 months postdischarge, of the 51 out of 131 youth with available follow-up data, 71% were doing well. Cost analysis based on discontinued medication by class showed monthly savings of $21,365, or $256,368 yearly. The largest contributor was the reduction in the use of antipsychotics, accounting for $205,332 of the total savings. CONCLUSIONS: Our study indicates that comprehensive treatment can lead to significant reductions in polypharmacy, and positive short- and longer-term treatment outcomes. Judicial prescribing also resulted in significant cost reduction in an already costly healthcare system.

Clinical and cost-effectiveness of acute and subacute residential mental health services: a systematic review.

OBJECTIVE In recognition of a service gap between hospital inpatient and community-based care, a range of mental health services have been developed to provide treatment and support for people with mental illness outside the inpatient setting. Acute and subacute residential services provide care for individuals experiencing episodes of acute mental illness and provide transitional services to assist people in their reintegration into the community. This article provides a systematic review of studies evaluating the effectiveness of these alternative services. METHODS A systematic review of the literature was conducted by searching MEDLINE, PsycINFO, CINAHL, and Cochrane with no years specified to identify studies that have evaluated the clinical effectiveness, user satisfaction, or cost-effectiveness of acute or subacute residential treatments. Outcome data were extracted from quantitative studies, and themes relevant to service satisfaction were extracted from qualitative studies. RESULTS A total of 26 studies were identified that evaluated the effectiveness of acute or subacute residential services. Most studies of acute residential units demonstrated clinical improvements equal to those of inpatient units and similar readmission rates, as well as cost benefits. User satisfaction was generally higher for clients of acute residential units. Only three studies examined subacute units, a number not sufficient to evaluate the effectiveness of these services. CONCLUSIONS Acute residential mental health services offer treatment outcomes equivalent to those of inpatient units, with users reporting high satisfaction. Acute residential services offer a cost-effective alternative to inpatient services. Further research is needed to determine client groups that will benefit most from these alternative services.

Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users' engagement in activities.

BACKGROUND: This study focuses on people with complex and severe mental health problems who require inpatient rehabilitation. The majority have a diagnosis of schizophrenia whose recovery has been delayed due to non-response to first-line treatments, cognitive impairment, negative symptoms and co-existing problems such as substance misuse. These problems contribute to major impairments in social and everyday functioning necessitating lengthy admissions and high support needs on discharge to the community. Engagement in structured activities reduces negative symptoms of psychosis and may lead to improvement in function, but no trials have been conducted to test the efficacy of interventions that aim to achieve this. METHODS/DESIGN: This study aims to investigate the clinical and cost-effectiveness of a staff training intervention to increase service users' engagement in activities. This is a single-blind, two-arm cluster randomised controlled trial involving 40 inpatient mental health rehabilitation units across England. Units are randomised on an equal basis to receive either standard care or a "hands-on", manualised staff training programme comprising three distinct phases (predisposing, enabling and reinforcing) delivered by a small team of psychiatrists, occupational therapists, service users and activity workers. The primary outcome is service user engagement in activities 12 months after randomisation, assessed using a standardised measure. Secondary outcomes include social functioning and costs and cost-effectiveness of care. DISCUSSION: The study will provide much needed evidence for a practical staff training intervention that has potential to improve service user functioning, reducing the need for hospital treatment and supporting successful community discharge. The trial is registered with Current Controlled Trials (Ref ISRCTN25898179).

Residential addiction treatment for injection drug users requiring intravenous antibiotics: a cost-reduction strategy.

OBJECTIVES: Injection drug users (IDUs) are prone to developing infections and complications requiring prolonged intravenous (IV) antibiotic treatment. Our institution's unique multidisciplinary approach provides special consideration and successful management of IDUs in a residential addiction treatment facility with nurse-administered IV antibiotics. Our hypothesis is that hospital costs can be reduced by providing both IV antibiotics and addiction treatment in a community residential treatment setting outside the hospital. METHODS: A retrospective chart review was performed for inpatients requiring prolonged antibiotic treatment who were admitted to the university teaching hospital between January 2006 and December 2011 and were treated at the residential addiction treatment facility. Data were gathered to characterize this population of patients and estimate cost savings. RESULTS: A total of 205 patients were sent to the residential addiction treatment facility from 2006 to 2011. The majority were African American, men, and in their early forties. Heroin was the most popular injected substance, but most patients were polysubstance users, including alcohol and tobacco. The most common infections were osteomyelitis and septic arthritis. There was a 73% completion rate of antibiotic treatment in this program. The relapse rate for return to illicit drug use was at least 32%. This program has resulted in a significant cost savings of $2.43 million in a 6-year period. CONCLUSIONS: The program saved $2.43 million over 6 years for the health care system by reducing hospital length of stay with safe and appropriate discharge planning for IDUs with infections requiring long-term IV antibiotics.

The use and costs of health and social services in patients with longstanding substance abuse.

BACKGROUND: Persons with longstanding substance abuse might become increasingly dependent on help by the public, eventually requiring permanent care. In 2006 the municipality of Stavanger established a so-called addiction ward for these clients, comprising 17 beds at the largest municipal nursing home. We assumed that the residents of this ward were high consumers of health care and social services during the last months preceding their admission. The aim of the study was to register the type and extent of services that were claimed by this client group during the last six months prior to admission, and to calculate the costs that were caused. Further, we estimated the incremental costs for nursing home placement. METHODS: In 15 residents from the addiction ward the use of all welfare services during the six months prior to admission were registered. Costs were calculated by unit costs from a municipal, national and societal perspective. RESULTS: Mean total costs during this period were €32 474. Approximately half of these costs were borne by state-funded institutions, and half were borne by the municipality. The clients used a great variety of services aimed at subsistence, health care and support in independent living, while services aimed at drug withdrawal were not claimed. There was no correlation between costs and the level of functioning. The incremental costs for nursing home admission were borne by the municipalities. CONCLUSION: Persons with longstanding substance abuse represent a group with a high use of welfare resources and hence cause high costs. However, our findings do not indicate any correlation between the amount of services rendered and the level of functioning. Further research should focus on the identification of the clients' need for support in order to facilitate targeted interventions that might prevent further deterioration and, finally, the need for permanent care.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment.

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

The employment of nurses in publicly funded substance abuse treatment programs.

Little is known about the organizational and environmental factors associated with the employment of nurses in substance abuse treatment programs. Using data collected from the administrators of 250 publicly funded substance abuse treatment programs, this study examined the organizational and environmental correlates of nurse employment in these settings. Negative binomial regression models indicated that the number of nurses employed by treatment programs was positively associated with government ownership, location within a healthcare setting, and the availability of detoxification services. Outpatient-only programs employed fewer nurses than programs with inpatient/residential services. Two environmental factors were associated with nurse employment. Programs that more strongly endorsed a scale of financial barriers employed significantly fewer nurses, whereas programs indicating that funding from state contracts could be used to pay for healthcare providers employed significantly more nurses. These findings suggest that organizational decisions about employing nurses may reflect both the characteristics of the program and the funding environment. Future research should continue to examine the employment of nurses in substance abuse treatment settings, particularly given the shifting environment due to the implementation of healthcare reform.