Recurrent use of inpatient withdrawal management services: Characteristics, service use, and cost among Medicaid clients

Clinical management of the alcohol withdrawal syndrome

Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.

Effects of Medicaid Health Homes among people with substance use disorder and another chronic condition on health care utilization and spending: Lessons from New York State

INTRODUCTION

New York State implemented a Health Homes (HH) care management program to facilitate access to health services for Medicaid enrollees with multiple chronic conditions. This study assessed the impact of HH on health care utilization outcomes among enrollees who have substance use disorder (SUD).

METHODS

Using HH enrollment data and Medicaid claims data 1 year before and after enrollment, this study compared HH enrollees who enrolled between 2012 and 2014 to a statistically matched comparison group created with propensity score methods. Analyses used generalized gamma models, logistic regression models, and difference-in-differences analyses to assess the impact of HH on general (all-cause) health care and SUD-related outpatient, emergency department (ED), hospitalization, and detoxification utilization as well as total Medicaid cost.

RESULTS

The sample consisted of 41,229 HH enrollees and a comparison group of 39,471 matched patients. HH-enrolled patients who had SUD utilized less SUD-related ED services (average marginal effect (AME) = -1.85; 95% CI = -2.45, -1.24), SUD-related hospitalizations (AME = -1.28; 95% CI: -1.64, -0.93), and detoxification services (AME = -1.30; 95% CI = -1.64, -0.96), relative to the comparison group during the 1 year post-HH enrollment. SUD-related outpatient visits did not change significantly (AME = -0.28; 95% CI = -0.76, 0.19) for enrollees, but general health care outpatient visits increased (AME = 1.63; 95% CI = 1.33, 1.93).

CONCLUSION

These findings provide preliminary evidence that care management programs can decrease ED visits and hospitalizations among people with SUD.

National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness

OBJECTIVE

People experiencing homelessness (PEH) have high rates of substance use, and homelessness may be an important driver of health disparities in the opioid overdose epidemic. However, few studies focus on homelessness among the opioid use disorder (OUD) treatment population. We examine national-level trends in substance use treatment admissions among PEH with OUD.

METHODS

This study used data from first-time treatment admissions in the United States from the Treatment Episode Data Set: Admissions (TEDS-A) to examine characteristics and trends of adults experiencing homelessness who entered state-licensed substance use treatment programs for OUD from 2013 to 2017. We used chi-squared analyses to examine changes in characteristics of this population over time and logistic regression to assess characteristics associated with receipt of medications for opioid use disorder (MOUD) among PEH.

RESULTS

Among all adults with OUD entering specialty treatment from 2013 to 2017, 12.5% reported experiencing homelessness. Compared to individuals not experiencing homelessness, PEH were more likely to be male, inject opioids, use cocaine or methamphetamine, and enter into residential detoxification treatment. PEH were less likely to enter outpatient treatment or receive MOUD. From 2013 to 2017, significant increases occurred in the proportion of PEH who had co-occurring psychiatric problems and used methamphetamines. Over time, treatment type shifted significantly from residential detoxification to outpatient treatment. Receipt of MOUD increased among PEH over time (13.7% to 25.2%), but lagged behind increases among individuals not experiencing homelessness. Among PEH, being older was associated with receiving MOUD, while concurrent methamphetamine use [adjusted odds ratio (AOR) 0.63; 95% CI 0.58, 0.69] and living in the southern United States (AOR 0.27; 95% CI 0.25, 0.30) were associated with not receiving MOUD.

DISCUSSION

The proportion of PEH with OUD who receive medications as part of treatment increased over time, but three quarters of PEH entering treatment still do not receive this highest standard in evidence-based care. The sharp increase observed in concomitant methamphetamine use in this population is concerning and has implications for treatment.

A facilitation model for implementing quality improvement practices to enhance outpatient substance use disorder treatment outcomes: a stepped-wedge randomized controlled trial study protocol

BACKGROUND

The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder.

METHODS

A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data.

DISCUSSION

This study will provide the field with a strong test of a multicomponent intervention to improve providers' capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system.

TRIAL REGISTRATION

Trial # NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020.

Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship

AIMS

We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012.

METHODS

Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings.

RESULTS

A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings.

CONCLUSIONS

The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Evaluating the feasibility and impact of case rate payment for recovery support navigator services: a mixed methods study

Background

Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service.

Methods

We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings.

Results

Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model.

Conclusions

Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05861-8.