Improving Longterm SUD Outcomes with Telephone Case Monitoring
John D. McKellar PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: August 2006 - January 2010
Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. Providers, even those who support the continuing care-oriented model, are often pressed to find sufficient staff to implement a long-term care model. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM).
To test, in a clinical trial, whether patients randomized to telephone-based case monitoring achieve better SUD outcomes compared to patients randomized to face-to-face continuing care as usual. In addition, we investigated if telephone case monitoring (TCM) produces increasingly stronger results relative to continuing care as usual (CCAU) as distance from care increases.
The current study randomized 667 VA patients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3, 6 and 12 months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, and quality of life. We also measured patient satisfaction during the telephone intervention. Analyses were conducted using hierarchical linear modeling. Slopes of all outcomes were completed as well as follow-up tests of individual data points. In addition, we tested for potential moderator effects with regard to distance to care, psychiatric comorbidity, and severity of substance use disorder.
We have completed data collection for this project and conducted analyses of our primary 1-year outcome. Slope analyses failed to find any differences between intervention conditions, or any site by condition differences. At 3 month follow-up participants in the TCM group reported significantly more percent days abstinent from alcohol and drugs but no further differences were found at 6 or 12 month follow-up. Psychiatric symptoms showed a similar pattern with better functioning at 3 month follow-up and no differences at 6 or 12 month follow-up. Quality of life as measured by the SF-12v did not follow this pattern; we found no significant differences between groups at 3, 6, or 12-months. Patient satisfaction with treatment at 3 month follow-up was significantly higher in the TCM group that CCAU (mean difference = .9, 95% CI -1.76 - -.67). The results were very robust to the choice of statistical model. We tested for and found no evidence of intervention by distance to treatment interaction, intervention by psychiatric comorbidity interaction effect, or an intervention by higher substance use disorder severity interaction effect. We also note, however, that patients randomized to telephone care attended as many standard group drug and alcohol outpatient visits as those in the standard care condition. To estimate the impact of telephone sessions, given the high attendance of standard group treatment in the telephone condition, we used instrumental variable analysis. The instrumental variables results were consistent with the intent-to-treat analysis. There was a 0.51 increase in the percent days of abstinence from alcohol at 3 months for each additional telephone call.
Patients randomized to telephone care achieved better short term outcomes in terms of substance use and psychiatric symptoms than those randomized to CCAU and reported greater treatment satisfaction. The findings of better during-treatment outcomes within the TCM condition suggest that the benefit of the brief phone calls may have been due to providing repeated outcome assessment. Patients found telephone care to be accessible and rated it high on measures of satisfaction. For the most part, those in the telephone condition did not choose to substitute telephone visits for face-to-face care.
DRA: Substance Abuse and Addiction, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Alcohol, Drug abuse, Telemedicine
MeSH Terms: none