A systems approach to care pathways into in-patient alcohol detoxification: outcomes from a retrospective study

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

OBJECTIVES

To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.

DESIGN

Systematic review with meta-analyses.

METHODS

Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs-heterogeneity was assessed using I2 statistics.

RESULTS

Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).

CONCLUSIONS

This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

Patient, Program, and System Barriers and Facilitators to Detoxification Services in the U.S. Veterans Health Administration: A Qualitative Study of Provider Perspectives

BACKGROUND

Because substance use disorder (SUD) treatment is expanding, and detoxification (detox) is often the entry point to SUD treatment, it is critical to provide ready access to detox services.

OBJECTIVES

The purpose of the current study was to examine patient, program, and system barriers or facilitators to detox access within an integrated health care system with variable rates of detox utilization across facilities.

METHODS

Inpatient and outpatient providers from 31 different U.S. Veterans Health Administration detox programs were interviewed.

RESULTS

Qualitative analyses identified six facilitators and 11 barriers to detox access. Facilitators included program staff and program characteristics such as encouragement and immediate access, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including lack of available detox services, program rules or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities.

CONCLUSIONS/IMPORTANCE

To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, educating patients on available detox services and the detox process, and addressing patient centered barriers such as resistance to detox or competing responsibilities. In addition, programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, thus improving outcomes and reducing utilization of high-cost services.

Translation of the diabetes prevention program into a community mental health organization for individuals with severe mental illness: a case study

Individuals with severe mental illness (SMI) have significant health disparities. Wellness services embedded in community mental health organizations could lessen these disparities. This case study illustrates the integration of the Diabetes Prevention Program (DPP) lifestyle intervention into a community mental health organization. The Diffusion of Innovations Theory was used as a model for integration, which included a collaboration between researchers and the organization and qualitative work, culminating in a small pilot of the DPP led by peer specialists to test the feasibility of the DPP in this setting. Fourteen individuals with SMI participated in the 19-week intervention. Three dropped out, but the remaining 11 demonstrated 92% attendance. Weight loss was minimal, but the participants reported benefit and showed continued interest in the intervention. The use of a peer-led DPP in a community mental health organization is feasible and warrants further investigation to demonstrate efficacy.

Possible association between OPRM1 genetic variance at the 118 locus and alcohol dependence in a large treatment sample: relationship to alcohol dependence symptoms

BACKGROUND

Several lines of evidence from previous research indicate that opioid receptors play an important role in ethanol reinforcement and alcohol dependence (AD) risk. Conflicting results were reported on the role of the mu-opioid receptor (OPRM1) polymorphism A118G (Asn40Asp, rs1799971) in the development of alcoholism.

METHODS

We investigated a total number of 1,845 alcohol-dependent subjects recruited from inpatient facilities in Germany and 1,863 controls for the mu-opioid receptor (OPRM1) polymorphism using chi-square statistics.

RESULTS

An association between the OPRM variant and AD was detected (p = 0.022), in recessive (AA vs. GA/GG) and co-dominant (AA vs. GA) models of inheritance. An association between the OPRM variant and the DSM-IV criterion "efforts to cut down or could not" (p = 0.047) was found, but this did not remain significant after the correction for multiple testing.

CONCLUSIONS

The results indicate that this functional OPRM variant is associated with risk of AD and these findings apply to more severe AD, although the association is only nominally significant.

Hitting the Target and Missing the Point

This article examines the policy of using target-setting and measurement to deliver on the United Nations’ (UN) development goals. Using evidence from similar monitoring and management strategies in the United Kingdom (UK), we question the purpose of using process and outcome targets and suggest that this approach can be counter-productive. It can also lead to a situation where maintaining public relations and image is prioritised at the expense of making real impacts on key development issues. While the UN's aims are praiseworthy, we suggest that the somewhat simplistic methodology adopted is damaging to the very people that the UN is seeking to help.