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IIR 05-021 – HSR&D Study

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IIR 05-021
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

BACKGROUND/RATIONALE:
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).

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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.

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Barbosa PV, Thomas IC, Srinivas S, Buyyounouski MK, Chung BI, Chertow GM, Asch SM, Wagner TH, Brooks JD, Leppert JT. Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable? European Urology. 2016 Aug 1; 70(2):227-30.
  2. Gidwani R, Joyce N, Kinosian B, Faricy-Anderson K, Levy C, Miller SC, Ersek M, Wagner T, Mor V. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. Journal of palliative medicine. 2016 Sep 1; 19(9):957-63.
  3. Wagner TH, Burstin H, Frakt AB, Krein SL, Lorenz K, Maciejewski ML, Pizer SD, Weiner M, Yoon J, Zulman DM, Asch SM. Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine. 2016 Apr 1; 31 Suppl 1:78-83.
  4. Oser M, Cucciare M, McKellar J, Weingardt K. Correlates of hazardous drinking among Veterans with and without hepatitis C. Journal of behavioral medicine. 2012 Dec 1; 35(6):634-41.
  5. McKellar J, Wagner T, Harris A, Oehlert M, Buckley S, Moos R. One-year outcomes of telephone case monitoring for patients with substance use disorder. Addictive Behaviors. 2012 Oct 1; 37(10):1069-74.
  6. Austin J, McKellar JD, Moos R. The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders. Addictive Behaviors. 2011 Sep 1; 36(9):941-4.
  7. Oser ML, McKellar J, Moos BS, Moos RH. Changes in ambivalence mediate the relation between entering treatment and change in alcohol use and problems. Addictive Behaviors. 2010 Apr 1; 35(4):367-9.
Book Chapters

  1. McKellar JD, Finney JW, Moos RH. Psychosocial Treatments for Addictive Disorders: Models, Settings, and Important Roles for Referring Physicians. In: Miller NS, Gold MS, editors. Addictive Disorders in Medical Populations. New York, NY: John Wiley and Sons; 2010. Chapter 34. 525-530 p.
Conference Presentations

  1. Wagner TH, Harris AH, Moos RH, McKellar JD. Assessing the Efficacy of Telephone Monitoring among Veterans with Substance Use Disorders. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  2. Oser ML, Cucciare MA, McKellar JD, Weingardt KR. Correlates of hazardous drinking among Veterans with and without hepatitis C. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 10; Toronto, Canada.
  3. McKellar JD, Carney DV, Reddy S, Moos RH. Randomized Trial of Telephone Case Monitoring. Paper presented at: Treatment of Addictive Behaviors Annual International Conference; 2010 Feb 2; Santa Fe, NM.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational
Keywords: Alcohol, Drug abuse, Telemedicine
MeSH Terms: none