Alcohol Outcome Measures

1. Alcohol Outcome Measures Scoping the outcome measures available for alcohol treatment services November 2009 DH Sue Baker Cascade Health sue@cascadehealth.org.uk 07957174661

2. 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

3. 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

4. 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

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

6. 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)

7. 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

8. 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

9. 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

10. 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 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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 ?

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

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

22. 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

23. 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

24. 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

25. Outcome Measure Short Rel for alcohol Uni/Reliab/valid Independent Tiers Stakeholder interest covered CDP No Yes Yes No 3, 4 Clinical ASI No ? Yes Yes 3, 4, Clinical MAP Yes No Yes No 2,3, 4 Clinical Commissioner but client interest tool is available as an add on RESULT Yes Yes Yes No 2,3, 4 Clinical, User & Commissioner CISS Yes ? Yes No 2,3, 4 Clinical TOPs Yes No ? No 2,3, 4 Clinical Commissioner Alcohol Spider Yes Yes Not tested No 3, 4 Clinical Commissioner Alcohol Star Yes Yes Not tested No 3, 4 Clinical Commissioner ATOM Yes Yes Yes No 2,3 & 4 Clinical, Commissioner

26. 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)

27. 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

28. 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

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

30. Alcohol Outcome Measures Sue Baker Cascade Health sue@cascade.org.uk 07957 174661