How system-based treatment monitoring can inform decision makers a Nordic view. Kerstin Stenius

Transcription

1 How system-based treatment monitoring can inform decision makers a Nordic view Kerstin Stenius

2 Disposition 1. Against the background of a conceptual model, we can identify dimensions of a substance abuse treatment (SUT) system that we would like to gain information about when estimating the effects of a system. What we have (or even can have) information about is far from that, and the available data vary from country to country. 2. Each nation has its own (changing) conceptualisation of the SUT system. Further, all countries seem to have considerable regional/local system variations, especially in non-medical treatment. What could be the possible roles and functions of national measures of treatment systems in informing decision makers? Can/should national monitoring be complemented by regional/local monitoring? 3. How can information about systems or monitoring inform decision makers? 4. What measures of systems effects/functioning would be most important and realistic to start develop for more informed system decision making? Esityksen nimi / Tekijä 2

3 SUT policy: Planning Financing Monitoring Regulations SYSTEM Resources Facilities.Programs. Staff Qualities Equity Efficiency Economy Population health and welfare Moderating factors : USE Culture/CASE MIX DEMOGRAPHIC FACTORS Social Capital OTHER CARE or CONTROL (Babor, Stenius, Romelsjö. 2008)

4 Effectiveness-calculations Measure cumulative effect of successful individual treatments (clients who receive good treatment means improved population health) Also efforts to estimate impact of system regulations/qualities on treatment offered on population effects: two-step reasoning, f.i. effects of different kinds of funding mechanisms, effects of move to outpatient tx, of integrated SUT and mental health Esityksen nimi / Tekijä 4

5 KS3 The Nordic systems SUT policy: National and local planning Tax funding Special laws (Little monitoring) BIG SYSTEM (fuzzy) Much resources,( shrinking) Quality? Equity Efficiency Economy unknown or questioned Population health and welfare Moderating factors : USE Culture/CASE MIX DEMOGRAPHIC FACTORS Social Capital OTHER CARE or CONTROL (Babor, Stenius, Romelsjö. 2008)

6 Slide 5 KS3 Kerstin Stenius, 22/09/2014

7 Big reforms in Nordic systems Centralisation of responsibilitiy: to 98 bigger municipal social services (Denmark 2007), to 4 state hospital enterprises (Norway 2004), centralisation and integration of health care and social services to 5 areas (Finland 2016), dual responsibility (regional health care, municipal social services) in Sweden (no change). At the same time emphases on universal availability and outpatient settings Organisational arguments related to costs (bigger and more integrated outpatient administrations viewed as cost-efficient) and diversity - universalism Clinical arguments favor medicalisation ( evidence-based (medical) treatment, more stigma in social services, patients have more rights than clients, increased substitution treatment, increased focus on comorbidity) Client/patient/consumer/peer-participation advocated in documents but weakly implemented Population effect arguments for reforms: mortality and morbidity BUT: Reforms in Nordic countries have been by-products of larger administrative reforms, no systematic attempts to evaluate need for reforms,(in)effectiveness of the existing systems or to evaluate the reforms - in spite of possibilities to compare with quantitative and qualitative measures

8 Major challenges for arguing for better (regional and national) treatment monitoring system Monitoring of resources: Moving targets: Delineation of the system changes constantly (increasing integration with health care, mental health, elderly care etc., punishment vs treatment, treatment vs care, marginalisation of social care, between centralisation and decentralisation). Different registers for different parts of the system Representativity: Big regional/local variations within national systems Monitoring of quality: Need versus demand is not well known: unment need? What tx units say they do is not what they do the black box Most used methods or care are not (cannot be) evidence based and we do not know much about what works We have bad or no registers for picturing process quality, and difficulties to measure outcomes (i.a. due to time frame) Costs are difficult to measure, due to delineation problems Esityksen nimi / Tekijä 7

9 What can national comparisons teach Nordic decision makers Tradition of comparison. We understand our differentsystems. Comparisons between similar national (local) systems can really inform decision making Ex Nordic substitution treatment (regulation, access, outcome); local development project (reasons for discontinued substitution tx) Monitoring in itself is a learning process: promote system thinking Decision makers need interactive implementation involve regional local levels, practitioners Comparisons between dissimilar countries give perspective on your own country (challenge pre-judices) but require even more careful contextualisation Esityksen nimi / Tekijä 8

10 Research (monitoring) and decision making Instrumental use (rare) Political or symbolic use Conceptual or enlightenment use (Ritter 2013) Esityksen nimi / Tekijä 9

11 A suggestion for measurement priorities SYSTEM EFFECT MEASURES: accessibility retention reduction of population substance abuse problems (and other health or social problems) long and short term THESE MEASURES REQUIRE LESS CONTEXTUALISATION QUALITY MEASURES: Economy (cost-effective services) Efficiency (appropriate mix of services) Continuity and coordination Concurrent recovery monitoring Competencies (Mads Uffe Pedersen, 2012) Priority Esityksen nimi / Tekijä 10

12 1. A system that reaches many is better Long term outcomes show that drug users in treatment improve their situation Thousands of deaths can be avoided if evidence based alcohol treatment of AUD in Europe increased from below 10 %. Not only abstinence but also a small or temporary reduction of consumption implies reduced mortality. Alcohol policy should additionally comprise changes to increase treatment rates, for ethical reasons but alco for public health reasons (Jurgen Rehm, presentation in Oslo, November 2013) No reason to argue differently for drugs Access to treatment can be seen as an important quality indicator but even as a proxy measure of system effectiveness Esityksen nimi / Tekijä 11

13 2. Clients know much about access and quality Do (all) drug users have equally acceptable and accessible tx? What kind of treatment is really offered? What reasons behind discontinuation of treatment, what works in treatment, and what kind of aftercare is given? Client evaluations/surveys is possibly the best way to get information about accessibility and acceptability of services, and factors behind successful completion of treatment, continuity and good aftercare, (but we do not need happy sheets Ritter, 2014) Esityksen nimi / Tekijä 12

14 Nordic countries take model from Africa? The SACENDU project started in South Africa in1996 with the development and use of a brief form (19 questions) gathered from each patient at admission, to monitor demand. Reported back to units every six month. Used in decision making to determine where to establish new centers, to inform about changing patterns of use, inform about training needs, strengthened research and development of local multiprofessional networks. Challenges: funding, continuous training needs, estimations of treatment needs (Parry et al. 2009) From 2000, regional African network to improve the information base for policy makers with a view to addressing the health, social and economic burden caused by the misuse of alcohol and other drugs, through stakeholdes network, agreement on indicators and data collection Esityksen nimi / Tekijä 13

15 Quality measurement in Africa Now developing a service quality measure Esityksen nimi / Tekijä 14

16 Domain Effectiveness Efficiency Access Quality Example of indicator Substance use outcomes Social connectedness Quality of life HIV riskbehaviour Proportion of clients that completed treatment successfully Treatment occupancy rates Affordability Geographic access Location of services Satisfaction with services, quality Method of measurement SAATSA s instruments plus administrative data (very short) Administrative data from addmission and discharge forms Access scale and administrative data Quality scale FromEsityksen nimi / TekijäFPic

17 Esityksen nimi / Tekijä 16

18 How and with what use can this be implemented in the Nordic countries? Treatment system reforms and centralisation increases interest in monitoring Increased emphases on client involvelment Test out and develop Nordic version(s) of the SAATSA instruments (admission, discharge and quality scale). Use first for intra-national quality assessments, or regional comparisons (possibly Nordic network of municipalities). Relying on both administrative data and clients assessments Develop a simple client discharge questionnaire and a quality instrument Devlop model for feed-back First emphases on discontinued substitution treatment? (Action Grant 2014 DG Justice?) Esityksen nimi / Tekijä 17

19 Sources T. Babor, K. Stenius & A. Romelsjö: Alcohol and drug treatment systems in public health perspectives. International Journal of Methods in Psychiatric Research, 2008: 17, S1, S50-S59 B. Myers et al. Identifying perceived barriers to monitoring service quality among substance abuse treatment proivedrs in South Africa. BMC Psychiatry 2014, 14: 31, 1-10 B. Myers et al. : Building an accountable and person-centered substance abuse treatment system in South Africa: The SQM Intitiave (power point-presentation). Contemporary Drug Problems 36/ Fall-Winter 2009, Parry, C. Monitoring alcohol and drug abuse trends in South Africa ( ): Reflection on treatment demand trends. Contemporary Drug Problems 36/Fall-Winter M. U. Pedersen: Categories and levels of outcomes in psychosocial abuse treatment of clients with multiple needs.? J. Rehm: Alcohol treatment: Why is treatment for alcohol dependence so important. Paper presented in Oslo, Norway, December 2013 A. Ritter, K. Lancaster: Measuring research influence on drug policy: A case example of two epidemiological monitoring systems. International Journal of Drug Policy 24 (2013): Special thanks to Alison Ritter, Charles Parry and Bromwyn Myers Esityksen nimi / Tekijä 18