Examining the Relationship Between the Lean Management System and Quality Improvement Care Management Processes

BACKGROUND AND OBJECTIVES

The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean Management System based on the Shingo principles originally developed by Toyota in Japan. Our objective was to examine the association between hospital use of the Lean Management System and evidence-based or recommended quality improvement care management processes.

METHODS

A cross-sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals was conducted.

RESULTS

Controlling for hospital organizational and market characteristics, the number of years using Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the P < .05 level. The degree of education and training in Lean methods and processes was also positively associated ( P < .05) with greater support for care transitions. The number of years using Lean was marginally associated with screening for clinical conditions at the P < .10 level. There was an unexpected negative association between education and training scores and screening for clinical conditions.

CONCLUSIONS

Greater experience in using the Lean Management System is positively associated with several evidence-based and/or recommended quality improvement care management processes.

Validation of the Lean Healthcare Implementation Self-Assessment Instrument (LHISI) in the finnish healthcare context

BACKGROUND

Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare.

METHODS

The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA).

RESULTS

A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR).

CONCLUSIONS

The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.

Lean Management and Breakthrough Performance Improvement in Health Care

BACKGROUND AND OBJECTIVES

Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health care organizations to substantially improve quality of care and patient outcomes while containing costs in the relatively short term, many health care leaders are looking for ways to achieve large breakthrough improvements in their organization's performance. The objective of this research is to understand whether and how Lean management can be used to achieve breakthrough improvements in performance.

METHODS

This study used grounded theory and content analysis of in-depth, semistructured interviews with 10 nationally recognized experts in the use of Lean management in health care organizations. The 10 participants constitute a purposive sample of experts with in-depth understanding of the strengths and limitations of Lean management in health care organizations.

RESULTS

Two out of 10 participants defined breakthrough improvement as a major change in a performance metric; 2 participants defined it as a fundamental redesign in a process or service; the remaining 6 participants defined breakthrough improvement as having both these characteristics. The extent to which participants believed Lean was an effective means for achieving breakthrough improvement in performance was related to how they defined breakthrough improvement. The 2 participants who defined breakthrough improvement as a significant change in a performance metric believed Lean methods alone were sufficient. The 2 participants who defined breakthrough improvement to be a fundamental redesign tended not to view Lean alone as an effective approach. Rather, they, and the 6 participants who defined breakthrough improvement as having both change-in-metric and process redesign characteristics, viewed human-centered design thinking as the primary or important complementary approach to achieving breakthrough improvement. Participants identified resources, culture change, and leadership commitment beyond what would be required to achieve incremental improvement as the main facilitators and barriers to achieving breakthrough improvements.

CONCLUSION

This research reveals some differences in experts' definitions of breakthrough improvement, and illuminates the value of human-centered design thinking, alone or as a complement to Lean management, in achieving breakthrough improvement in health care organizations. Most of our expert participants agreed that supplementing Lean management methods with the contributions of innovation design and investing significant resources, strengthening the organizational culture to support the necessary changes, and providing stronger leadership commitment to the effort are important facilitators for achieving breakthroughs in organizational performance.

The cross-national applicability of lean implementation measures and hospital performance measures: a case study of Finland and the USA

Background

Health-care organizations around the world are striving to achieve transformational performance improvement, often through adopting process improvement methodologies such as lean management. Indeed, lean management has been implemented in hospitals in many countries. But despite a shared methodology and the potential benefit of benchmarking lean implementation and its effects on hospital performance, cross-national lean benchmarking is rare. Health-care organizations in different countries operate in very different contexts, including different health-care system models, and these differences may be perceived as limiting the ability of improvers to benchmark lean implementation and related organizational performance. However, no empirical research is available on the international relevance and applicability of lean implementation and hospital performance measures. To begin understanding the opportunities and limitations related to cross-national benchmarking of lean in hospitals, we conducted a cross-national case study of the relevance and applicability of measures of lean implementation in hospitals and hospital performance.

Methods

We report an exploratory case study of the relevance of lean implementation measures and the applicability of hospital performance measures using quantitative comparisons of data from Hospital District of Helsinki and Uusimaa (HUS) Helsinki University Hospital in Finland and a sample of 75 large academic hospitals in the USA.

Results

The relevance of lean-related measures was high across the two countries: almost 90% of the items developed for a US survey were relevant and available from HUS. A majority of the US-based measures for financial performance (66.7%), service provision/utilization (100.0%) and service provision/care processes (60.0%) were available from HUS. Differences in patient satisfaction measures prevented comparisons between HUS and the USA. Of 18 clinical outcome measures, only four (22%) were not comparable. Clinical outcome measures were less affected by the differences in health-care system models than measures related to service provision and financial performance.

Conclusions

Lean implementation measures are highly relevant in health-care organizations operating in the USA and Finland, as is the applicability of a variety of performance improvement measures. Cross-national benchmarking in lean healthcare is feasible, but a careful assessment of contextual factors, including the health-care system model, and their impact on the applicability and relevance of chosen benchmarking measures is necessary. The differences between the US and Finnish health-care system models is most clearly reflected in financial performance measures and care process measures.

Lean Management and Hospital Performance: Adoption vs. Implementation

BACKGROUND

The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.

METHODS

A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures.

RESULTS

Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures.

CONCLUSION

Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.

Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

Background

Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists.

Methods

We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare.

Results

We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality.

Conclusions

When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

Healthcare facility-based strategies to improve tuberculosis testing and linkage to care in non-U.S.-born population in the United States: A systematic review

CONTEXT

An estimated 21% of non-U.S.-born persons in the United States have a reactive tuberculin skin test (TST) and are at risk of progressing to TB disease. The effectiveness of strategies by healthcare facilities to improve targeted TB infection testing and linkage to care among this population is unclear.

EVIDENCE ACQUISITION

Following Cochrane guidelines, we searched several sources to identify studies that assessed strategies directed at healthcare providers and/or non-U.S.-born patients in U.S. healthcare facilities.

EVIDENCE SYNTHESIS

Seven studies were eligible. In a randomized controlled trial (RCT), patients with reactive TST who received reminders for follow-up appointments were more likely to attend appointments (risk ratio, RR = 1.05, 95% confidence interval 1.00-1.10), but rates of return in a quasi-RCT study using patient reminders did not significantly differ between study arms (P = 0.520). Patient-provider language concordance in a retrospective cohort study did not increase provider referrals for testing (P = 0.121) or patient testing uptake (P = 0.159). Of three studies evaluating pre and post multifaceted interventions, two increased TB infection testing (from 0% to 77%, p < .001 and RR 2.28, 1.08-4.80) and one increased provider referrals for TST (RR 24.6, 3.5-174). In another pre-post study, electronic reminders to providers increased reading of TSTs (RR 2.84, 1.53-5.25), but only to 25%. All seven studies were at high risk of bias.

CONCLUSIONS

Multifaceted strategies targeting providers may improve targeted TB infection testing in non-U.S.-born populations visiting U.S. healthcare facilities; uncertainties exist due to low-quality evidence. Additional high-quality studies on this topic are needed.

Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis

BACKGROUND

Despite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood.

METHODS

We systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986-2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE.

RESULTS

We reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: "Ongoing" (unlimited access to condoms), "Ongoing-plus" (unlimited access to condoms, with co-interventions), and "Coupon-based" (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was "very low" for all outcomes.

CONCLUSIONS

CDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence.

Risk of Recidivism Among Justice-Involved Veterans

Empirical research on recidivism risk among justice-involved veterans (JIVs) is limited. Using the risk-need-responsivity model, we conducted a systematic review of research on risk factors for recidivism among JIVs to identify the gaps in this literature and provide recommendations for future research. Substance abuse and indicators of antisociality were consistently linked to justice involvement in veterans; however, the evidence for negative family/marital circumstances and lack of positive school/work involvement was mixed. Several known risk factors for reoffending among civilian offenders (i.e., antisocial cognitions and associates; lack of prosocial activities) were marked by little to no empirical studies among veterans. Posttraumatic stress and traumatic brain injury, particularly when combined with anger and irritability issues, may be veteran-specific risk factors for violent offending. The implications of these findings for policy and practice and challenges to implementing risk assessments with JIVs are discussed.

The exclusion of people with psychiatric disorders from medical research

People with psychiatric disorders are excluded from medical research to an unknown degree with unknown effects. We examined the prevalence of reported psychiatric exclusion criteria using a sample of 400 highly-cited randomized trials (2002-2010) across 20 common chronic disorders (6 psychiatric and 14 other medical disorders). Two coders rated the presence of psychiatric exclusion criteria for each trial. Half of all trials (and 84% of psychiatric disorder treatment trials) reported possible or definite psychiatric exclusion criteria, with significant variation across disorders (p < .001). Non-psychiatric conditions with high rates of reported psychiatric exclusion criteria included low back pain (75%), osteoarthritis (57%), COPD (55%), and diabetes (55%). The most commonly reported type of psychiatric exclusion criteria were those related to substance use disorders (reported in 48% of trials reporting at least one psychiatric exclusion criteria). General psychiatric exclusions (e.g., "any serious psychiatric disorder") were also prevalent (38% of trials). Psychiatric disorder trials were more likely than other medical disorder trials to report each specific type of psychiatric exclusion (p's < .001). Because published clinical trial reports do not always fully describe exclusion criteria, this study's estimates of the prevalence of psychiatric exclusion criteria are conservative. Clinical trials greatly influence state-of-the-art medical care, yet individuals with psychiatric disorders are often actively excluded from these trials. This pattern of exclusion represents an under-recognized and worrisome cause of health inequity. Further attention should be paid to how individuals with psychiatric disorders can be safely included in medical research to address this important clinical and social justice issue.

Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials

BACKGROUND

Observational studies of Alcoholics Anonymous' (AA) effectiveness are vulnerable to self-selection bias because individuals choose whether or not to attend AA. The present study, therefore, employed an innovative statistical technique to derive a selection bias-free estimate of AA's impact.

METHODS

Six data sets from 5 National Institutes of Health-funded randomized trials (1 with 2 independent parallel arms) of AA facilitation interventions were analyzed using instrumental variables models. Alcohol-dependent individuals in one of the data sets (n = 774) were analyzed separately from the rest of sample (n = 1,582 individuals pooled from 5 data sets) because of heterogeneity in sample parameters. Randomization itself was used as the instrumental variable.

RESULTS

Randomization was a good instrument in both samples, effectively predicting increased AA attendance that could not be attributed to self-selection. In 5 of the 6 data sets, which were pooled for analysis, increased AA attendance that was attributable to randomization (i.e., free of self-selection bias) was effective at increasing days of abstinence at 3-month (B = 0.38, p = 0.001) and 15-month (B = 0.42, p = 0.04) follow-up. However, in the remaining data set, in which preexisting AA attendance was much higher, further increases in AA involvement caused by the randomly assigned facilitation intervention did not affect drinking outcome.

CONCLUSIONS

For most individuals seeking help for alcohol problems, increasing AA attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection. However, for populations with high preexisting AA involvement, further increases in AA attendance may have little impact.

Sex differences in mental health and substance use disorders and treatment entry among justice-involved Veterans in the Veterans Health Administration

BACKGROUND

Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.

OBJECTIVES

To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.

RESEARCH DESIGN

Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.

SUBJECTS

A total of 1535 females and 30,478 male veterans were included.

MEASURES

Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).

RESULTS

Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).

CONCLUSIONS

Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

Representativeness of patients enrolled in influential clinical trials: a comparison of substance dependence with other medical disorders

OBJECTIVE

The purpose of this study was to determine whether randomized trials of treatments for substance dependence differ from those for other medical disorders on quality of enrollment information reporting and sample representativeness.

METHOD

Twenty highly cited clinical trials (publication date 2002-2010) of treatments for each of 14 prevalent disorders were identified by structured literature search. The disorders were alcohol dependence, drug dependence, nicotine dependence, Alzheimer's disease, breast cancer, colorectal cancer, chronic obstructive pulmonary disease, depression, diabetes, HIV/AIDS, hypertension, ischemic heart disease, lung cancer, and schizophrenia. The 280 clinical trials were coded for number of individuals screened for eligibility, number of screened individuals meeting eligibility criteria, and number of eligible individuals refusing to participate.

RESULTS

Substance-dependence treatment trials were significantly more likely to track and report enrollment information (75% vs. 45% of clinical trials for other disorders, p < .001). Substance-dependence trials did not differ from trials focused on other disorders on mean rate of non-enrollment. Across disorders, the primary driver of non-enrollment appeared to be clinical trial exclusion criteria rather than eligible patients refusing to enroll.

CONCLUSIONS

Relative to other disorders, trials in the substance-dependence field do a better (although imperfect) job of tracking and reporting enrollment information. Low enrollment rates and unrepresentative samples are not challenges unique to treatment outcome studies in the substance-dependence field. Across a range of disorders, clinical trials that use eligibility criteria judiciously are more likely to produce findings that generalize to front-line clinical practice than are trials that restrict enrollment to a small and unrepresentative subset of patients.

A meta-analysis of topiramate's effects for individuals with alcohol use disorders

BACKGROUND

Influenced by several trials and reviews highlighting positive outcomes, topiramate is increasingly prescribed as a treatment for alcohol use disorders (AUDs). The only previously published meta-analysis of topiramate for AUDs was limited by a sample of only 3 randomized, placebo-controlled trials (RCTs).

METHODS

A systematic search identified 7 RCTs (including a total of 1,125 participants) that compared topiramate to placebo for the treatment for AUDs. This meta-analysis estimated the overall effects of topiramate on abstinence, heavy drinking, craving, and γ-glutamyltranspeptidase (GGT) outcomes and included several sensitivity analyses to account for the small sample of studies.

RESULTS

Overall, the small to moderate effects favored topiramate, although the effect on craving was not quite significantly different from 0. The largest effect was found on abstinence (g = 0.468, p < 0.01), followed by heavy drinking (g = 0.406, p < 0.01), GGT (g = 0.324, p = 0.02), and craving (g = 0.312, p = 0.07) outcomes. Sensitivity analyses did not change the magnitude or direction of the results, and tests did not indicate significant publication bias. The small sample size did not allow for examination of specific moderators of the effects of topiramate.

CONCLUSIONS

Topiramate can be a useful tool in the treatment of AUDs. Its efficacy, based on the current sample of studies, seems to be of somewhat greater magnitude than that of the most commonly prescribed medications for AUDs (naltrexone and acamprosate). Further research will help to identify the contexts in which topiramate is most beneficial (e.g., dose, concurrent psychotherapy, patient characteristics).

U.S. Department of Veterans Affairs Veterans Justice Outreach Program: Connecting Justice-Involved Veterans with Mental Health and Substance Use Disorder Treatment

The Veterans Justice Outreach (VJO) program of the U.S. Veterans Health Administration has a primary mission of linking military veterans in jails, courts, or in contact with law enforcement to mental health and substance use disorder treatment. National data of veterans with VJO contact were used to describe demographic characteristics, and mental health and substance use disorder diagnoses and treatment use and test correlates of treatment entry and engagement using multi-level logistic regression models. Of the 37,542 VJO veterans, treatment entry was associated with being homeless and having a mental health disorder or both a mental health and a substance use disorder versus a substance use disorder only. Being American Indian/Alaskan Native was associated with lower odds of treatment entry. Engagement was associated with female gender, older age, Asian race, urban residence, and homeless status. Increased utilization of substance use disorder treatment, especially pharmacotherapy, is an important quality improvement target.

Intention-to-treat analyses and missing data approaches in pharmacotherapy trials for alcohol use disorders

OBJECTIVES

Intention to treat (ITT) is an analytic strategy for reducing potential bias in treatment effects arising from missing data in randomised controlled trials (RCTs). Currently, no universally accepted definition of ITT exists, although many researchers consider it to require either no attrition or a strategy to handle missing data. Using the reports of a large pool of RCTs, we examined discrepancies between the types of analyses that alcohol pharmacotherapy researchers stated they used versus those they actually used. We also examined the linkage between analytic strategy (ie, ITT or not) and how missing data on outcomes were handled (if at all), and whether data analytic and missing data strategies have changed over time.

DESIGN

Descriptive statistics were generated for reported and actual data analytic strategy and for missing data strategy. In addition, generalised linear models determined changes over time in the use of ITT analyses and missing data strategies.

PARTICIPANTS

165 RCTs of pharmacotherapy for alcohol use disorders.

RESULTS

Of the 165 studies, 74 reported using an ITT strategy. However, less than 40% of the studies actually conducted ITT according to the rigorous definition above. Whereas no change in the use of ITT analyses over time was found, censored (last follow-up completed) and imputed missing data strategies have increased over time, while analyses of data only for the sample actually followed have decreased.

CONCLUSIONS

Discrepancies in reporting versus actually conducting ITT analyses were found in this body of RCTs. Lack of clarity regarding the missing data strategy used was common. Consensus on a definition of ITT is important for an adequate understanding of research findings. Clearer reporting standards for analyses and the handling of missing data in pharmacotherapy trials and other intervention studies are needed.

How effective is continuing care for substance use disorders? A meta-analytic review

Given the often chronic nature of substance use disorders, patients sometimes receive less intensive continuing care following an initial period of more intensive treatment. This meta-analysis estimated the effect of continuing care and formally tested several proposed moderators (intervention duration, intensity, modality, and setting) of that effect. A systematic search identified 33 controlled trials of continuing care; 19 included a no/minimal treatment condition and were analyzed to assess the overall effect of continuing care versus control. Continuing care had a small, but significant, positive effect size, both at the end of the continuing care interventions (g=0.187, p<0.001) and at follow-up (g=0.271, p<0.01). Limited by a small number of studies, analyses did not identify any significant moderators of overall effects. These results show that continuing care can provide at least modest benefit after initial treatment. We discuss study characteristics that may have reduced the magnitude of the overall continuing care effect estimate.

Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?

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.