The VA HSR&D SUD QUERI and the VA Offices of Mental Health Services (OMHS) and Operations (OMHO) recognize the crucial need to improve services for Veterans receiving detoxification (detox). The aims of this project are directly aligned with their objectives. Specifically, this project is responsive to the SUD QUERI's Strategic Plan's goal to improve quality and reduce undesirable variability in services, with a focus on detox, in terms of access, effectiveness, and successful transitions to the next level of care.
All VA facilities must make detox (medically-supervised withdrawal management) available for Veterans who require it, and a single follow-up appointment must be provided within one week post-detox. Each year, high numbers of Veterans receive detox on an outpatient or inpatient basis. However, many Veterans who need detox do not receive it. Notably, detox is unlikely to be effective (that is, help Veterans achieve alcohol and drug abstinence and its related benefits) if the Veteran does not adhere to the detox follow-up appointment and also transition to specialty SUD care. However, many VA detox patients do not attend the required 1-week follow-up appointment, and many do not enter SUD care.
The goal of this project was to examine variations in VA facilities' practices for detox patients to increase Veterans' access to detox, adherence to detox follow-up, and transition to specialty SUD treatment. To achieve this goal, objectives were: 1. Use VA administrative databases to examine patient and program predictors of facility-level variation in numbers of Veterans: (a) who are substance-dependent and receive outpatient and inpatient detox services; (b) in outpatient and inpatient detox who attend the required follow-up visit; and (c) who, after detox, enter specialty SUD treatment. 2. Draw on the RE-AIM implementation framework to use formative evaluation methods (phone interviews and site visits with detox staff) to understand why some facilities have especially: (a) low or high numbers of detox patients, (b) low or high rates of detox patients returning for the required follow-up visit, and (c) low or high rates of detox patients entering specialty SUD treatment.
First, we used VA administrative databases to examine patient and program predictors of facility-level variation in numbers of Veterans using detox-related services. Secondly, for each question regarding access, follow-up, and transition to treatment, we randomly selected 15 facilities from the lowest, and 15 from the highest, quartile used to categorize facilities across the VA system and interviewed detox directors from those facilities. Together, methods allowed us to determine the patient-, provider-, and system-level barriers to, and facilitators of, Veterans (a) having access to needed detox services, (b) attending detox follow-up appointments, and (c) entering SUD treatment.
To date, we have two main sets of findings, one from quantitative analyses of VA administrative data (under review, Psychiatric Services), and the second from qualitative analyses of interview data (under review, Journal of Substance Abuse Treatment). The first set examined service utilization patterns related to detox in FY2013 at VHA facilities (N=141). VHA data were used to identify 266,908 patients with a diagnosis of alcohol or opiate dependence. Examined were rates and predictors of (1) receiving detoxification in patients with these diagnoses, (2) patients obtaining a required 1-week follow-up appointment after detoxification, and (3) patients entering substance use disorder specialty treatment within 60 days of the detoxification episode. Multilevel, mixed-effects logistic regression models examined associations between patient and facility characteristics and each of these three aspects of service utilization. Results were that, nationally, 8.0% of VHA patients with alcohol or opiate dependence utilized detox services in FY2013. Use of detox by this patient population at VHA facilities ranged from 0.1% to 20.4%. Of VHA patients obtaining detox, 43.1% received follow-up care within 7 days (facility range=11.1% to 76.4%), and 49.9% engaged in SUD specialty treatment after initial follow-up (facility range=13.0% to 77.2%). In fully adjusted analyses, obtaining detox was more likely among male, younger, white, and homeless patients, and in facilities with fewer vacant Addiction Therapist positions. Post-detox follow-up and specialty treatment were more likely among younger, homeless patients having fewer comorbid medical conditions, previous specialty treatment, and an alcohol use disorder documented in the medical record, and when the facility had fewer staff vacancies. Thus, detox-related service utilization patterns are highly variable across the VHA system. In addition, interventions are needed to optimize use of these services.
The second main set of findings centered on detox often being the entry point to SUD treatment, such that it is critical to provide ready access to detox services. We reported our examination of patient, program, and system factors that serve as barriers or facilitators to detox access within VHA. Providers from 31 different detox programs were interviewed. Qualitative analyses identified six facilitators and 12 barriers to detox access. Facilitators included program staff and program characteristics, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including a lack of available detox services, program eligibility or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of detox-related education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities. To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, and educating patients on available detox services and the detox process. In addition, detox programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, which in turn improves outcomes and reduces utilization of high-cost services.
These aims addressed ultimate goals of SUD QUERI, OMHS and OMHO: Facilitate that all Veterans who need and want detox access it, that more detox patients attend the required follow-up appointment, and that more detox patients enter specialty SUD treatment. Knowledge gained from the proposed project is allowing for, in subsequent projects (QUERI SDPs), the development of targeted implementation efforts aimed at increasing rates of detox by Veterans who would benefit from it, follow-up adherence, and utilization of existing SUD treatments among detox patients, consistent with the goals of SUD QUERI and OMHS/OMHO. Also, this project informed our new VA HSR&D CREATE project on facilitating detox inpatients' transition to SUD treatment by further documenting detox programs' usual care practices. Understanding implementation barriers to and facilitators of appropriate follow-up and SUD treatment among Veterans undergoing detox should help Veterans with SUDs achieve recovery and use less of VA's costly SUD and medical treatment services.
- Schultz NR, Martinez R, Cucciare MA, Timko C. Patient, Program, and System Barriers and Facilitators to Detoxification Services in the U.S. Veterans Health Administration: A Qualitative Study of Provider Perspectives. Substance use & misuse. 2016 Aug 23; 51(10):1330-41.
- Timko C, Gupta S, Schultz N, Harris AH. Veterans' Service Utilization Patterns After Alcohol and Opioid Detoxification in VHA Care. Psychiatric services (Washington, D.C.). 2016 Apr 1; 67(4):460-4.
- Timko C, Schultz NR, Cucciare MA, Vittorio L, Garrison-Diehn C. Retention in medication-assisted treatment for opiate dependence: A systematic review. Journal of addictive diseases. 2015 Oct 14; 35(1):22-35.