Developing adaptive interventions for adolescent substance use treatment settings: protocol of an observational, mixed-methods project

Prioritizing Needs and Outcomes for Adolescent Substance Use Treatment Planning: An Online Modified-Delphi Process

Key stakeholders can have differing views about which information is essential to inform placement decisions for all patients. This study examined consensus across stakeholder groups on the most important individual needs and treatment outcomes for informing decisions specifically about the level of care for an adolescent in substance use treatment.

Identifying optimal level-of-care placement decisions for adolescent substance use treatment

BACKGROUND

Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset.

METHODS

We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset.

RESULTS

Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome.

CONCLUSIONS

Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.

Practical factors determining adolescent substance use treatment settings: Results from four online stakeholder panels

Practical factors can significantly influence the setting, or level of care, where an adolescent receives substance use treatment. This study aimed to identify practical factors that stakeholders find most critical to consider when planning adolescent substance use treatment. We conducted online panels with four stakeholder groups: providers, policymakers, researchers, and parents. Stakeholders nominated, rated, and commented on the importance of 10 practical factors that could influence treatment setting decisions. We assessed consensus on the rated importance of practical factors using the RAND/UCLA Appropriateness Method. We thematically analyzed stakeholders comments to explain how they differentiated relative importance. 153 stakeholders (66 providers, 38 policymakers, 27 researchers, and 22 parents) identified continuity of care, coordination of care across service sectors, and quality of care as the practical factors of highest importance. Participants rated higher the practical factors they perceived to (1) trump clinical appropriateness as the reason for placing an adolescent in a given setting, (2) steer adolescents toward specific settings, or (3) steer an adolescent away from specific settings. Conversely, participants rated lower the practical factors they perceived (1) applicable to clinical intervention rather than treatment setting, (2) unrelated to initial recommendations, (3) relevant to any setting, or (4) applicable only to certain contexts and sub-populations. These findings help elucidate why stakeholders view certain practical factors as critical to consider in actual decisions about substance use treatment settings for adolescents. Future research should investigate how to incorporate these practical factors alongside clinical needs and treatment goals in placement criteria and treatment matching.