A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients.
Humphreys K., McLellan T. Addiction: 2011, 106, p.2058–2066.

Improving performance of substance use disorder treatment systems is no easy matter and one prone to unintended consequences. All the more welcome then is guidance from leading US experts with top-level experience in the UK and the USA; their favourite tactic, rewarding services for patient progress during treatment, is featured in UK payment-by-results schemes.

Summary
Two US experts who worked at top levels on drug policy for the current US president and have advised the UK government draw on scientific literature and their experiences to offer policy makers an overview of system-level strategies to improve the outcomes of services for substance use disorder patients. Their aim was to stimulate discussion rather than conduct a systematic and comprehensive review of the evidence.

Though they may be used together, the review divides the strategies in to process-focused quality improvement strategies which change how treatment staff work in the expectation that this will improve patient outcomes, and patient-focused strategies which concentrate on outcomes without specifying how those are to be achieved.


Also reviewed in this bulletin (click on URL link above):
• A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers.
Crits-Christoph P., Ring-Kurtz S., McClure Bridget. et al. Journal of Substance Abuse Treatment: 2010, 38, p. 251–262.
It should have improved relationships between counsellors and clients and between counsellors and their clinics, but a sophisticated system for feeding back client progress made no positive difference on any of these measures. A later study helped establish why: counsellors were not told which patient the feedback related to and what they might do about it.

• A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs.
Crits-Christoph P., Ring-Kurtz S., Hamilton J.L. et al. Journal of Substance Abuse Treatment: 2012, p. 301–309.
Confirmation that the failure to improve outcomes of a system for feeding back client progress to counsellors was probably due to aggregating outcomes across the counsellor's caseload rather than enabling them to identify and take recommended actions in respect of individuals doing poorly. Remedying these deficits significantly improved outcomes.

• Does meeting the HEDIS substance abuse treatment engagement criterion predict patient outcomes?
Harris A.H.S , Humphreys K., Bowe T. et al. Journal of Behavioral Health Services and Research: 2010, 37(1), p. 25–39.
This first major multi-modality test of a treatment engagement indicator widely used as a quality control yardstick in the USA found it was only very weakly related to patient improvement seven months after starting treatment, confirmation that simple measures of what happens during treatment struggle to capture what really makes treatment effective.

• Performance-based contracting within a state substance abuse treatment system: a preliminary exploration of differences in client access and client outcomes.
Brucker D.L., Stewart M. Journal of Behavioral Health Services and Research: 2011, 38(3), p. 383–397.
In 2007–08 the US state of Maine introduced a new scheme directly linking funding for outpatient treatment services to performance in terms of waiting times and retention, but financial and service delivery impacts were negligible. Were the incentives too weak, or were services already doing as well as they could?

• Advancing recovery: implementing evidence-based treatment for substance use disorders at the systems level.
Schmidt L.A., Rieckmann T., Abraham A. et al. Journal of Studies on Alcohol and Drugs: 2012, 73(3), p. 413–422.
In the US homeland of competition and private health care, it was cooperation and coordination which led to the introduction of new medications and innovations to promote continuing care – plus the exercise of regulatory and financial muscle and the salutary experience of senior staff who placed themselves in the patient's shoes.