Publications (54)168.26 Total impact
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Article: Extent and Reporting of Patient Nonenrollment in Influential Randomized Clinical Trials, 2002 to 2010.
JAMA internal medicine. 04/2013; -
Article: Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?
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ABSTRACT: AIMS: Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects. METHODS: A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone. RESULTS: Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo. CONCLUSIONS: In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively.Addiction 10/2012; · 4.31 Impact Factor -
Article: Religion, Spirituality, and the Troublesome Use of Substances.
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ABSTRACT: This chapter presents an overview of scientific information on the role of religion and spirituality in the troublesome use of substances. After defining the key terms and providing background information about religion, spirituality, and substance use, the authors discuss the role of religion in the prevention of troublesome use of substances. The authors then turn to how religion and faith-based treatments affect addicted individuals. Next, the authors discuss the effectiveness of spiritual self-help organizations as initiators and supporters of recovery from addiction. The authors close by abstracting principles from the research base that might inform efforts to alleviate troublesome use of substances. (PsycINFO Database Record (c) 2012 APA, all rights reserved)10/2012; -
Article: Religie, spiritualiteit en het problematisch gebruik van alcohol en drugs
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ABSTRACT: Religie en spiritualiteit hebben grote invloed op alcohol- en drugsgebruik. Invloed op preventie, behandeling en vooral op de zelfhulpbeweging. De invloed van spiritualiteit en religie wordt in dit artikel nader onderzocht, aan de hand van de literatuur waarvan een overzicht wordt gegeven. Zowel effecten als factoren van invloed worden besproken. De auteurs geven tevens werkbare definities en analyseren hoe in zelfhulpbewegingen spiritualiteit een belangrijke rol speelt en waarom die onvoldoende onderkend wordt door wetenschappers.04/2012; 3(3):89-95. -
Article: Cross-level bias and variations in care.
JAMA The Journal of the American Medical Association 11/2011; 306(19):2096-7; author reply 2097. · 30.03 Impact Factor -
Article: Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy.
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ABSTRACT: Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.American Journal of Public Health 09/2011; 101(9):1635-42. · 3.93 Impact Factor -
Article: A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients.
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ABSTRACT: To inform policy makers on available options for improving the effectiveness of treatments for substance use disorders and to stimulate debate about treatment improvement strategies among public officials, clinical providers, care managers, service users, families and researchers. We draw on the scientific literature and our public policy experiences in two countries (the United Kingdom and the United States) to give an overview of policies which may improve care for individuals with substance use disorders. We divide such policies into 'process-focused quality improvement strategies' that attempt to change some aspect of treatment (e.g. increased retention, greater use of evidence-based practices) and 'patient-focused strategies' that attempt to reward outcomes directly (e.g. contingency management for patients, payment by results for providers). Many policies of both types are poorly developed, have shown poor results, or both. The evidence is clear that process-focused quality improvement strategies can change what providers do and how treatment programs work, but such changes have thus far demonstrated only minimal impact on patient outcomes. Patient-focused strategies face challenges including treatment providers avoiding hard-to-treat patients or spending inordinate time relocating patients after treatment to assess outcome. However, policies that reward in-treatment outcomes and policies that allow the patient to purchase desired recovery support services show more promise. As policy makers go forward in this endeavor, they can do an enormous service to their countries and the field by embedding careful evaluation studies alongside new treatment outcome improvement initiatives.Addiction 06/2011; 106(12):2058-66. · 4.31 Impact Factor -
Article: Our map should correspond with the territory.
Addiction 12/2010; 105(12):2054-6; discussion 2056. · 4.31 Impact Factor -
Article: Brief intervention, treatment, and recovery support services for Americans who have substance use disorders: An overview of policy in the Obama administration.
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ABSTRACT: The Obama Administration plans to reinvigorate the U.S. system of care for substance use disorders through new health insurance parity regulations, the historic health care reform law (formally known as “The Affordable Care Act of 2010”), and the President's National Drug Control Strategy. Parity regulations and health care reform will significantly expand the availability of health insurance, and the proportion of health insurance plans that provide adequate benefits for substance use disorder care. The President's National Drug Control Strategy and Fiscal Year 2011 budget request make investments that will build on this foundation, including broad dissemination of screening, brief intervention and referral to treatment (SBIRT) techniques, integration of care for substance use disorders into Federally Qualified Health Centers and the Indian Health Service, augmentation of reentry programs and drug courts, creation of a pay for performance treatment quality initiative, and expansion of the Access to Recovery voucher program. Collectively, these policies will improve the quantity and quality of substance use disorder care and thereby promote public health and public safety. (PsycINFO Database Record (c) 2012 APA, all rights reserved)Psychological Services 10/2010; 7(4):275-284. · 1.08 Impact Factor -
Article: The cost of concordance with opiate substitution treatment guidelines.
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ABSTRACT: The Multisite Opiate Substitution Treatment study compared four opioid substitution programs that were highly concordant with clinical practice guidelines to four programs that were less concordant. Program staff were surveyed, and consenting new patients from highly concordant (n = 164) and less-concordant programs (n = 91) were assessed. After 12 months, treatment of new clients of highly staffed, guideline concordant sites cost $10,252, which is significantly more than the $6,476 cost at less-concordant programs (p < .01). Clients at highly concordant sites received significantly more group visits (M = 37.0 vs. 13.1, p < .01) but fewer dosing visits. There were no significant differences in medical care costs. Opioid substitution therapy was effective at reducing heroin use, especially at sites that were highly concordant with treatment guidelines. Annual mortality was 3.0% and did not differ by type of care. Preference-based quality of life significantly improved only at highly concordant sites.Journal of substance abuse treatment 09/2010; 39(2):141-9. · 2.90 Impact Factor -
Article: RESEARCH ON ALCOHOLICS ANONYMOUS AND SPIRITUALITY IN ADDICTION RECOVERY. (RECENT DEVELOPMENTS IN ALCOHOLISM VOL 18).
Addiction 01/2010; 105(1):179-180. · 4.31 Impact Factor -
Article: How Internet technology can improve the quality of care for substance use disorders.
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ABSTRACT: By allowing for the efficient delivery of instructional content and the secure collection of self-report data regarding substance use and related problems, the Internet has tremendous potential to improve the effectiveness and accessibility of addiction treatment services. This article discusses some of the ways in which Internet technology can facilitate, complement and support the process of traditional clinician-delivered treatment for individuals with substance use disorders. Internet applications are being used to support a range of activities including (a) the assessment and feedback process that constitutes a central feature of brief motivational interventions, (b) the concurrent monitoring of individual level outcomes among patients who are currently enrolled in addiction treatment programs, (c) the continuing care and ongoing recovery of patients who have completed treatment, and (d) the delivery of clinical training in evidence based practices for addiction treatment providers. This emerging body of literature suggests that addiction counselors and program administrators can enhance the quality of clinician-delivered treatment by incorporating internet applications into existing processes of care. Internet applications provide an unparalleled opportunity to engage patients in the treatment process, incorporate real-time data into treatment planning, prevent relapse, and promote evidence-based treatment approaches.Current Drug Abuse Reviews 09/2009; 2(3):256-62. -
Article: Developing and validating process measures of health care quality: an application to alcohol use disorder treatment.
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ABSTRACT: Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example. An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities. Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11). These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.Medical care 09/2009; 47(12):1244-50. · 3.24 Impact Factor -
Article: HEDIS initiation and engagement quality measures of substance use disorder care: impact of setting and health care specialty.
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ABSTRACT: Many health care systems track the HEDIS measures of initiation and engagement in substance use disorder (SUD) care. However, the impact of setting of care (inpatient vs. outpatient) and health care specialty (SUD, psychiatric, other) on the likelihood of patients meeting the initiation and engagement criteria are unknown. If the vast majority of initiation and engagement occurs within SUD specialty clinics, then these quality measures could be used to discriminate among and incentivize SUD clinic managers. However, if these criteria are satisfied in different settings and specialties, then they should be considered characteristics of the entire facility, rather than just specialty SUD units. Using a Markov model, the probabilities of advancing to treatment initiation and engagement given initial setting and specialty of care were estimated for 320,238 SUD-diagnosed Veterans Health Affairs (VA) patients. Patients in SUD specialty units progressed more often (diagnosis to initiation, initiation to engagement) than patients in other specialties. Progression through the criteria differed for inpatients vs. outpatients. Approximately 25% of initiation and over 40% of engagement occurred outside of SUD specialty care. VA patients who have contact with SUD specialty treatment have higher rates of advancing to initiation, and from initiation to engagement, compared to SUD-diagnosed patients in psychiatric or other medical locations. Even so, a substantial portion of initiation and engagement occurs outside of SUD specialty units. Therefore, these quality measures should be considered measures of facility performance rather than measures of the quality of SUD specialty care. The usual combining of inpatient and outpatient performance on these measures into overall facility scores clouds measurement and interpretation.Population Health Management 09/2009; 12(4):191-6. · 1.02 Impact Factor -
Article: Inquirers, triers, and buyers of an alcohol harm reduction self-help organization
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ABSTRACT: Moderation Management (MM) is the only self-help organization designed to help problem drinkers who wish to moderate their alcohol consumption rather than abstain. Experienced MM members tend to be highly educated and employed and have minimal signs of physical dependence on alcohol or co-occurring drug use. As a result, MM is sometimes dismissed as an organization that attracts only “the worried well”, or, is initially accessed by a wide range of problem drinkers but ultimately retains only “easy cases” as enduring members (e.g., alcoholic individuals are tempted to join MM but relapse and drop out immediately). Both of these possibilities were evaluated by comparing 445 nonmembers who were called MM's helpline (“inquirers” or “callers”), 41 early stage MM members (“triers”), and 124 experienced MM members (“buyers”). In general, experienced MM members reported the most severe drinking histories, followed by early stage members and then by callers, whose reported problems were quite modest. Measures of social stability and resources did not tend to differentiate the groups. Thus, it appears that contrary to what some have speculated, even though MM does attract a relatively privileged population in demographic terms, those with more serious alcohol problems are the most likely, rather than the least likely to become long-term MM members.07/2009; 14(5):527-535. -
Article: Performance monitoring of substance use disorder interventions in the Veterans Health Administration.
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ABSTRACT: Measuring and improving the quality of treatment for patients with substance use disorders are enduring challenges. This article describes how the Veterans Affairs health care system is using incentivized performance measures to promote more effective delivery of interventions for nicotine, illegal drug, and alcohol disorders. The monitoring and incentive system has increased the delivery of evidence-based services, including screening for alcohol use disorders. Further work remains to be done to strengthen the connection between process-based measures and longer-term patient outcomes.The American Journal of Drug and Alcohol Abuse 02/2009; 35(3):123-7. · 1.55 Impact Factor -
Article: Measuring the quality of substance use disorder treatment: evaluating the validity of the Department of Veterans Affairs continuity of care performance measure.
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ABSTRACT: This study examined the patient- and facility-level associations between the continuity of care performance measure adopted by the Department of Veterans Affairs (VA) and improvements in self-administered Addiction Severity Index (ASI) composites and other indicators of problematic substance use. Up to 50 patients from each of a nationally representative sample of 109 VA substance use disorder (SUD) treatment programs at 73 VA facilities were assessed at intake and posttreatment. The continuity of care performance measure specifies that patients should receive at least two SUD outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. In analyses adjusting for baseline characteristics, meeting the continuity of care performance measure was not associated with patient-level improvements in the ASI alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Facility-level rates of continuity of care were negatively associated with improvements in ASI alcohol and drug composites. The continuity of care performance measure derived from prior patient-level evidence did not discriminate facility-level performance as predicted. Translating research into process-of-care quality measures requires postconstruction validation.Journal of substance abuse treatment 11/2008; 36(3):294-305. · 2.90 Impact Factor -
Article: Does meeting the HEDIS substance abuse treatment engagement criterion predict patient outcomes?
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ABSTRACT: This study examines the patient-level associations between the Health Plan Employer Data and Information Set (HEDIS) substance use disorder (SUD) treatment engagement quality indicator and improvements in clinical outcomes. Administrative and survey data from 2,789 US Department of Veterans Affairs SUD patients were used to estimate the effects of meeting the HEDIS engagement criterion on improvements in Addiction Severity Index Alcohol, Drug, and Legal composite scores. Patients meeting the engagement indicator improved significantly more in all domains than patients who did not engage, and the relationship was stronger for alcohol and legal outcomes for patients seen in outpatient settings. The benefit accrued by those who engaged was statistically significant but clinically modest. These results add to the literature documenting the clinical benefits of treatment entry and engagement. Although these findings only indirectly support the use of the HEDIS engagement measure for its intended purpose-discriminating quality at the facility or system level-they confirm that the processes of care captured by the measure are associated with important patient outcomes.The Journal of Behavioral Health Services & Research 10/2008; 37(1):25-39. · 1.32 Impact Factor -
Article: Subject eligibility criteria can substantially influence the results of alcohol-treatment outcome research.
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ABSTRACT: Most alcohol-treatment studies exclude some patients from participation based on particular criteria (e.g., comorbid illegal drug abuse, homelessness). The current study evaluated whether such eligibility criteria can change the outcome results a study obtains. Five widely used treatment research eligibility criteria--(1) psychiatric problems, (2) medical problems, (3) social-residential instability, (4) low motivation/noncompliance, and (5) drug problems--were applied to two samples of real-world alcohol patients whose outcomes were known. Comparing outcomes of the samples with and without the application of eligibility criteria produced estimates of bias in outcome results, as well as an assessment of change in statistical power. Medical and psychiatric eligibility criteria produced a moderate bias in outcome estimates (e.g., a 10% or less change in outcome results). In contrast, social-residential instability, low motivation/noncompliance, and drug use produced a large (e.g., up to an 18% change) to a very large (e.g., up to a 51% change) bias in outcome estimates. Sensitivity analyses showed that these biases are even larger if eligibility criteria are operationalized in a broad rather than a narrow fashion. Contrary to expectation, eligibility criteria did not produce their theoretically expected benefit of increased statistical power. Researchers who use eligibility criteria should do so judiciously and interpret outcome results in light of potential bias introduced by the ineligibility of some patients for study enrollment. Efforts to integrate findings across treatment outcome studies should also consider how conclusions might be affected by the eligibility criteria used in different research areas.Journal of studies on alcohol and drugs 10/2008; 69(5):757-64. · 2.25 Impact Factor -
Article: A randomized trial of a mental health consumer-managed alternative to civil commitment for acute psychiatric crisis.
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ABSTRACT: This experiment compared the effectiveness of an unlocked, mental health consumer-managed, crisis residential program (CRP) to a locked, inpatient psychiatric facility (LIPF) for adults civilly committed for severe psychiatric problems. Following screening and informed consent, participants (n = 393) were randomized to the CRP or the LIPF and interviewed at baseline and at 30-day, 6-month, and 1-year post admission. Outcomes were costs, level of functioning, psychiatric symptoms, self-esteem, enrichment, and service satisfaction. Treatment outcomes were compared using hierarchical linear models. Participants in the CRP experienced significantly greater improvement on interviewer-rated and self-reported psychopathology than did participants in the LIPF condition; service satisfaction was dramatically higher in the CRP condition. CRP-style facilities are a viable alternative to psychiatric hospitalization for many individuals facing civil commitment.American Journal of Community Psychology 08/2008; 42(1-2):135-44. · 1.74 Impact Factor
Top co-authors
Top Journals
Institutions
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2004–2012
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VA Palo Alto Health Care System
Palo Alto, CA, USA
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2002–2011
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Stanford University
- Division of Veterans Affairs
Stanford, CA, USA -
Alcohol Research Group
Emeryville, CA, USA
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2006–2009
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U.S. Department of Veterans Affairs
- Center for Health Care Evaluation
Washington, D. C., DC, USA
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