Alcohol Outcome Measures Scoping the outcome measures available for alcohol treatment services November 2009 DH Sue Baker Cascade Health

Alcohol Outcome Measures Scope of the review Focus was on outcome measures for treatment interventions for people with alcohol problems This presentation is based on a report of the scoping study

Alcohol Outcome Measures Work Undertaken Desk research on the literature available Checking out with some of the key academics Contacting the alcohol leads Conversations with services and commissioners

Alcohol Outcome Measures Review of effectiveness of treatment – Duncan Raistrick, Nick Heather and Christine Godfrey, NHS/NTA Nov 2006 Identifies 5 packages Discusses factors important to the development of a good package in addition to validity and reliability

Alcohol Outcome Measures Comprehensive Drinker Profile Addiction Severity Index MAP Result Christo Inventory for Substance Misuse Services

Alcohol Outcome Measures Comprehensive Drinking Profile (Miller and Marlatt 1987) Developed in late 80’s A detailed tool - assessment and treatment planning tool with a follow up facility Covers 88 items and incorporates validated assessment tools such as MAST Very alcohol focused and incorporates space for client concerns and issues. Down side is size (despite a shorter version being available)

Alcohol Outcome Measures The Addiction Severity Index (McLellan et al 1980, updated in 1992) Another detailed assessment tool covering alcohol and drug dependence plus 5 other common problem areas Uses a 30 day period to establish base line Said to be widely used in treatment and research The alcohol component was included in respect of drug users but is considered to cover the issues know to be seen in people with alcohol problems

Alcohol Outcome Measures Maudsley Addiction Profile (MAP) (Marsden et al 1998) Short 60 items in 4 domains using a 30 day period Developed and tested for use with drug and alcohol misusers in tier 3 and 4 Some limitations for alcohol misusers Widely used

RESULT (Raistrick and Tober 2003 ) Combines a range of validated measures in packages to suit different outcome measure requirements Incorporates QALYS, ICD-10; LDQ,CORE, SSQ; QF + Agency Det Draws on measures from the field and beyond – very credible Adaptable

Alcohol Outcome Measures Christo Inventory for Substance Misuse Services (Christo et al 2000) One page tool covering 10 domains Simple scoring system 0-2 leading to a single overall score Validated Limitations re sensitivity for example Popular use to ease of use A one page evaluation tool completed by the therapist following direct contact with a client or from case notes. It covers social function, health, risk behaviour, psychological wellbeing, occupation, criminal activity, substance use, support, treatment compliance and therapeutic alliance.

Alcohol Outcome Measures Since the Effectiveness Review? TOPs Outcome spider Outcome Star ATOM

Alcohol Outcome Measures TOPs Designed as a drug treatment outcome measurement tool Said to be equally appropriate for alcohol 4 domains covering substance misuse, injecting behaviour, crime and health and social functioning Widely used, short and concise Disliked by many alcohol services

Alcohol Outcome Measures Alcohol Star Adapted from the alcohol spider Measures change by quantifying steps on the client journey across 8 domains Does not include measure of alcohol misuse Service find it combines well with key working

Alcohol Outcome Measures ATOM/AATOM-C New tool developed in Australia Overall approach has commonalities with RESULT building a range of existing measures Alcohol focused 5 domains inc client demographics Short and validated Possible over reliance on client’s view of situation Difficult to assess applicability to UK

Alcohol Outcome Measures Similarities Change is measure by comparing a period of time (usually 1 month) with a previous point in time Increasing convergence in the domains covered – substance misuse, relationships, economic issues, crime, physical and psychological health

Alcohol Outcome Measures Differences Combinations of areas within domains Choices re rating scales Focus on alcohol Client centred/purpose Length of time to complete Method of completion

Alcohol Outcome Measures Issues a)What are we wanting to measure and why Effectiveness of treatment? Investment aims? Clients concerns?

Alcohol Outcome Measures b) Agency ownership Tie in with what they aim to do Have value for clients Fit in with assessment and data collection systems Needs to be simple as possible and short

Alcohol Outcome Measures c) Client needs to be comfortable Follow up and confidentiality Question relevant to them One key issue is: are we interested in people with alcohol problems or the clients of services ?

d) different services Is there/could there be a one size fits all (across the tiers)?

e) Be reliable and valid Universal Proven validity and reliability Sensitive to change Easy readable and neutral language (Raistrick, Heather and Godfrey 2006)

Alcohol Outcome Measures What are services doing and saying? Using measures as required by commissioners TOPs not popular with alcohol services Most rely on indicators of output not outcomes plus qualitative info Long term follow up difficult BI – might need to stick with repeated use of assessment tool

Alcohol Outcome Measures What are services doing and saying? Using measures as required by commissioners TOPs not popular with alcohol services Most rely on indicators of output, not outcomes plus qualitative info Long term follow up difficult BI – might need to stick with repeated use of assessment tool

Alcohol Outcome Measures What are commissioners doing? Reconsidering TOPs for alcohol services Some evidence of working with services to devise tools and dash boards Balancing tensions within PCT and with what services can deliver

Outcome Measure ShortRel for alcohol Uni/Relia b/valid IndependentTiersStakeholder interest covered CDP NoYes No3, 4Clinical ASINo?Yes 3, 4,Clinical MAPYesNoYesNo2,3, 4 Clinical Commissioner but client interest tool is available as an add on RESULTYes No2,3, 4 Clinical, User & Commissioner CISSYes? No2,3, 4Clinical TOPsYesNo? 2,3, 4 Clinical Commissioner Alcohol SpiderYes Not testedNo3, 4 Clinical Commissioner Alcohol StarYes Not testedNo3, 4 Clinical Commissioner ATOMYes No 2,3 & 4 Clinical, Commissioner

Conclusions No single tool exists that ticks all boxes Agreement about the kinds of domains that are relevant (alcohol misuse, other substances, physical and mental health, use of time, relationships and something around economic status/housing)

Alcohol Outcome Measures Need to increase universality for alcohol misusers Package approach is required to cover the needs of all stakeholders and is likely to be achievable It might be that outcomes measure for BIs are not in many settings achievable other than repeating the assessment tool

Alcohol Outcome Measures Its a complex business and we need to not loose sight of main goal Outcome measurement is no worst here than in other parts of the health care system One approach might be to consider a Quality Account Approach - Patient Safety, Effectiveness & Client Satisfaction

Alcohol Outcome Measures Cornerstone points:- Client Focus User friendly Indicates public benefit from the investment

Alcohol Outcome Measures Sue Baker Cascade Health