Service quality and attrition: an examination of a pediatric obesity program.

OBJECTIVE: To examine the demographic, illness, and quality of care determinants of service attrition in a pediatric obesity program, and to elucidate factors that may promote families' return to care. DESIGN: Cross-sectional survey with semi-structured interviews. SETTING: A regional children's hospital in the United States. STUDY PARTICIPANTS: Caregivers of 163 patients, consecutively enrolled in a pediatric obesity treatment program between January 1998 and September 2000, were contacted by telephone and offered participation in a survey of clinical care experiences. A total of 120 (74%) families participated. MAIN OUTCOME MEASURES: Service attrition as defined as premature discontinuation of treatment before completing phase I of a multi-phase treatment program. RESULTS: Multivariate results indicated that service attrition was associated with both insurance status and perceived quality of care. Patients with government-subsidized insurance were more likely to defect from services than those with commercial insurance. Perceived quality of care was highly associated with attrition after controlling for demographic and health parameters. Caregiver-reported reasons for service attrition included difficulty with adequate insurance coverage (53%), the child's desire to leave the program (50%), and the program taking too much time (32%). The most frequent suggestions to facilitate families' return to the program were: (i) assistance with insurance coverage; (ii) following up with families; and (iii) increasing engagement with the child. CONCLUSIONS: This study found few demographic differences between patients completing the program and those defecting from services. Both families completing the program and those discontinuing prematurely rated the overall quality of the program as high. However, lower quality of care was related to increased service attrition even after controlling for the effects of demographic and health parameters. Although a considerable number of patients discontinued services, very few reported that they would not return to the program. The results provide further support for ongoing audit and examination of families' care perceptions in preventing attrition and promoting service recovery.     

Substance dependent American Indian veterans: a national evaluation.

Demographic, clinical, and treatment episode characteristics of 3,087 American Indian veterans discharged from Department of Veterans Affairs hospitals in fiscal year 1991 were examined. Substance use disorders were diagnosed in 46.3 percent of discharged American Indians, compared with 23.4 percent of discharged veterans overall. More than 97 percent of American Indian substance use diagnoses were for alcohol dependence, while rates of other drug use disorders were low. Substance dependent American Indians were younger, and more likely to be male and unmarried, than nondependent American Indians. Psychiatric disorders, particularly personality disorders, depression, and posttraumatic stress disorders, were more prevalent among American Indians diagnosed with substance use disorders, than among nondependent American Indians. American Indians with substance use disorders were similar demographically to the general population of substance dependent veterans. Rates of diagnosed psychiatric disorders and drug dependencies other than alcohol were lower among American Indians receiving substance (alcohol or drug) use diagnoses than among the general population of substance dependent veterans. Rates of rehospitalization following discharge were higher in substance-abusing American Indian veterans than among their counterparts. Potential explanations for these findings are discussed.     

Supervisory Turnover in Outpatient Substance Abuse Treatment

Staff turnover is a significant issue within substance abuse treatment, with implications for service delivery and organizational health. This study examined factors associated with turnover among supervisors in outpatient substance abuse treatment. Turnover was conceptualized as being an individual response to organizational-level influences, and predictors represent aggregate program measures. Participants included 532 staff (including 467 counselors and 65 clinical/program directors) from 90 programs in four regions of the USA. Using logistic regression, analyses of structural factors indicated that programs affiliated with a parent organization and those providing more counseling hours to clients had higher turnover rates. When measures of job attitudes were included, only parent affiliation and collective appraisal of satisfaction were related to turnover. Subsequent analyses identified a trend toward increased supervisory turnover when satisfaction was low following the departure of a previous supervisor. These findings suggest that organizational-level factors can be influential in supervisory turnover.     

Depressive symptomatology and early attrition from intensive outpatient substance use treatment

This study examines the relationship between depressive symptoms and attrition from outpatient treatment in a Veterans Affairs facility that had recently moved to intensive outpatient-only treatment for substance abuse. This article focuses on 126 consecutively admitted patients who were enrolled on their last day of a 3- to 4-day outpatient detoxification. Results indicate that severe depressive symptomatology presenting at treatment entry is a significant risk factor for early attrition from intensive outpatient substance use treatment but not later attrition. These data indicate that retention efforts should be directed toward the assessment and management of depressive symptoms early in the treatment process, with interventions targeted to those who report severe symptomatology. The results also indicate that future research should focus on potential distinguishing characteristics between early and later attrition.     

Tobacco Use Among African-American Youth Receiving Behavioral Healthcare Services

African-American youth with behavioral health problems may be particularly vulnerable to tobacco use and dependence; however, little is known about overall prevalence and factors associated with tobacco use in this population. The present study compared rates of tobacco use for African-Americans (aged 13–17) receiving behavioral healthcare services to state and national prevalence rates. In addition, we examined whether tobacco use prevalence was related to treatment characteristics and services rendered. Retrospective chart reviews were conducted at an urban, public behavioral healthcare agency for youth admitted in 2009. Tobacco use rates among African-Americans receiving behavioral healthcare services were similar to, and in some cases, higher than statewide and national prevalence rates. While tobacco users were more likely to be enrolled in a substance abuse program than in a mental health program, only 2 of 55 youth reporting tobacco use had received documented tobacco cessation treatment. Future work should focus on implementing tobacco cessation prevention and treatment for these youth.     

Behavioral Health Treatment Receipt Among a Community Sample of Young Adult Veterans

Young adult veterans are at risk for behavioral health problems such as depression, posttraumatic stress disorder (PTSD), and substance misuse. Despite this, studies of veterans within the Veterans Affairs Healthcare System (VA) indicate that about half of those warranting treatment receive it in any form, with few receiving an adequate dose of care. For this study, the behavioral health screening status and behavioral health usage (including care outside of VA settings) among a community sample of 812 young adult veterans recruited from the Internet is described. Although approximately 70% of the sample screened positive for behavioral health problems, only one fifth to three fifths of those screening positive reported any mental health or substance use treatment in the past year, with one third or less receiving a dose of minimally adequate psychotherapy or psychotropic care. Findings expand on prior work and suggest that more effort is necessary to engage young veterans in behavioral health services.     

Attrition in a behavioral weight-control program: A comparison of dropouts and completers

A major problem in weight-reduction programs is that a significant number of individuals terminate treatment prematurely. To help alleviate some of the problems associated with high attrition, it is important to understand the ways in which treatment dropouts are different from those individuals who complete a weight-reduction program. In the present study 271 obese persons who participated in a Health Maintenance Organization's low-cost behavioral program were evaluated. At the end of the 12-session program, dropouts (N = 161) and completers (N = 110) were identified. Treatment dropouts were compared to treatment completers on the following variables: initial weight, percent overweight, age, sex, occupation, education, number of previous attempts to lose weight, plus scores on the eating questionnaires. The major finding was that dropouts did not differ much from completers. The largest difference between these two groups occurred with respect to reported occupations. The completer group contained significantly more women working in the home than the dropout group. Reasons for this finding were hypothesized. To prevent high attrition rates, further research is recommended, particularly on the role of cognitive factors in weight control.     

Women Veterans’ Attrition from the VA Health Care System

PurposePatient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued to use VA health care.MethodsA sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.ResultsFifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.ConclusionsUnderstanding the drivers of patients’ decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.     

Peer Reviewed: Nicotine Dependence and Its Risk Factors Among Users of Veterans Health Services, 2008-2009

Introduction

Tobacco use is the leading preventable cause of death in the United States and is disproportionately higher among veterans than nonveterans. We examined the prevalence of nicotine dependence and its associated risk factors among veterans who used health services in the US Department of Veterans Affairs (VA) system.

Methods

Using a case-control design, we compared all VA health service users in fiscal year 2008-2009 (N = 5,031,381) who received a nicotine dependence diagnosis with those who did not. Independent risk and protective factors associated with receiving a nicotine dependence diagnosis were identified using logistic regression analysis. We conducted subgroup analyses on 2 groups of particular policy concern: homeless veterans and veterans who served in Iraq and Afghanistan.

Results

Among all recent VA health service users, 15% (n = 749,353) received a diagnosis of nicotine dependence. Substance abuse, other mental health diagnoses, and homelessness were identified as major risk factors. Veterans who served in Iraq and Afghanistan were not found to be at increased risk compared to veterans from other war eras. Major risk and protective factors within the subgroups of homeless veterans and veterans who served in Iraq and Afghanistan were broadly similar to those in the general VA population.

Conclusion

Given that other studies have found higher rates of nicotine dependence among veterans, this risk behavior may be underdiagnosed in VA medical records. Veterans who are homeless or have mental health or substance abuse problems are at highest risk and should be targeted for smoking prevention and cessation interventions. These results support, in principle, efforts to integrate smoking cessation programs with mental health and homeless services.     

The interactive role of exercise and sleep on veteran recovery from symptoms of PTSD

IntroductionPosttraumatic Stress Disorder (PTSD) is prevalent among military veterans and is associated with a number of negative outcomes. Despite available treatments, rates of recovery are poor and many symptoms persist post-treatment. Previous research suggests that exercise functions to reduce symptoms of anxiety and improve sleep quality, though its effects are understudied among those with PTSD.MethodWe sought to assess the extent to which exercise and sleep interactively impact changes in PTSD severity. Participants were 217 veterans in residential PTSD treatment who were offered the opportunity to participate in a bike-exercise program. Data were collected at treatment intake and discharge.ResultsExercise (defined as total volume of cycling completed over the course of treatment) was associated with greater reductions in PTSD hyperarousal symptoms at discharge only among veterans with poor intake sleep quality.ConclusionsOverall, exercise may be a beneficial adjunctive treatment for reducing hyperarousal symptoms among individuals with PTSD and poor sleep.     

Completion rates and psychosocial intervention effectiveness in an Australian substance use therapeutic community

Background

Program attrition is a major problem in substance use treatment. It is not clear which client and treatment variables are related to successful completion. This study aimed to identify client variables associated with Therapeutic Community (TC) completion. A secondary aim was to investigate changes in entry and exit scores on psychosocial outcome measures.

Methods

Retrospective quantitative analysis of data collected from 193 Australian TC residents, over 3.5 years. Variables measured included: demographics; Depression, Anxiety, Stress Score (DASS-21) and World Health Organisation Quality of Life 8 questions (WHOQOL-8).

Results

Completion rates were 30.6%. High Money WHOQOL-8 scores, suggestive of minimal financial stressors, positively predicted completion. Multivariate analyses showed that negative predictors of completion were: amphetamine being primary substance of concern, aggression, high Relationship WHOQOL-8 scores, suggestive of positive relationships, and younger or older age. Those in the program demonstrated clinically significant psychological improvement and significant improvement in all quality of life scores over time. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems.

Conclusion

The findings provide an understanding of specific predictors of program completion which may help to identify high-risk clients and inform program improvement. Early attrition rates may be reduced by monitoring and supporting high-risk clients. Overall, psychometric improvement occurred amongst both completers and non-completers overtime but is most prominent amongst course completers, with the exception of depression, stress, and money problems. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention.

     

Predictors of homeless veterans' irregular discharge status from a domiciliary care program

This study addresses the relationship of homeless veterans' discharge status from a domiciliary care program to biopsychosocial characteristics presented at admission into the program. Hypotheses were that younger age, less education, and substance abuse or psychiatric disorder would predict an irregular discharge. Research participants were 367 homeless male veterans who had been admitted to a domiciliary care program at the West Los Angeles Veterans Affairs Medical Center for treatment of medical, psychiatric, or substance disorders. Status of veterans' program discharge (regular or irregular) served as the outcome measure. Logistic regression analysis revealed that irregular discharge from the program was more likely among veterans who were black, who had poor employment histories, or who had problems with alcohol. Results are discussed in light of the need to maintain homeless veterans in treatment programs so that they can achieve maximum benefit from available programs.     

Lifetime prevalence of pathological gambling among american Indian and Hispanic American Veterans

OBJECTIVES: We examined the prevalence and clinical correlates of pathological gambling among 1228 American Indian and Hispanic American veterans in the southwest and north central regions of the United States. METHODS: We surveyed a community sample of American Indian and Hispanic American veterans to obtain data on psychiatric disorder and treatment. RESULTS: American Indian veterans had a 10% lifetime prevalence of pathological gambling. The Hispanic American lifetime prevalence was less than that of the American Indian veterans but higher than the prevalence found for Hispanic American veterans in other surveys. Comorbid conditions associated with pathological gambling included substance, mood, and antisocial personality disorders. Ready access to casino gambling may encourage, support, or contribute to high rates of pathological gambling in both men and women. CONCLUSIONS: A 70% lifetime comorbidity of psychiatric disorders suggests that early interventions for pathological gambling should consider common psychiatric conditions rather than focusing on pathological gambling alone.     

Implementation of Network for the Improvement of Addiction Treatment (NIATx) Processes in Substance Use Disorder Treatment Centers

Internal process improvements embedded within the Network for Improvement of Addiction Treatment (NIATx) program are promising innovations for improving substance use disorder (SUD) treatment performance, such as engagement and retention. To date, few studies have examined the variables that may increase diffusion and implementation of NIATx innovations. This study investigates organizational characteristics associated with SUD treatment center utilization of NIATx process improvements in a sample of 458 treatment programs. Overall, 19% had utilized NIATx process improvements. After statistically controlling environmental factors, five organizational variables were associated with the likelihood that treatment centers used NIATx processes. Organization size, administrative intensity, membership in a provider association, and participation in National Institute on Drug Abuse’s Clinical Trials Network were positively associated with the odds of utilizing NIATx processes, while the association for the level of slack resources was negative. The findings suggest that policies and related supportive efforts may be required to facilitate diffusion and implementation of NIATx processes to affect SUD treatment center performance and capacity.     

Inequitable access to substance abuse treatment services in Cape Town,South Africa

Background  

Despite high levels of substance use disorders in Cape Town, substance abuse treatment utilization is low among people from disadvantaged communities in Cape Town, South Africa. To improve substance abuse treatment utilization, it is important to identify any potential barriers to treatment initiation so that interventions to reduce these barriers can be implemented. To date, substance abuse research has not examined the factors associated with substance abuse treatment utilization within developing countries. Using the Behavioural Model of Health Services Utilization as an analytic framework, this study aimed to redress this gap by examining whether access to substance abuse treatment is equitable and the profile of variables associated with treatment utilization for people from poor communities in Cape Town, South Africa.     

Associations between health-related quality of life and financial barriers to care among women veterans and women non-veterans

The authors of this study examined the association between health-related quality of life and financial barriers to care, defined as not getting the needed care due to cost considerations. To better understand health-related quality of life among women veterans, the authors compared women veterans to women non-veterans. The authors conducted cross-sectional analyses using data from the 2009 Behavioral Risk Factor Surveillance System survey. The authors assessed four health-related quality of life measures: (1) general health; (2) physical health; (3) mental health; and (4) functional status. The authors performed multinomial logistic regressions to examine the relationship between financial barriers to receiving healthcare and health-related quality of life measures after controlling for other independent variables. The authors included women veterans not in active military duty (N = 3,747) and a matched sample of women non-veterans (N = 3,747), selected using a propensity score method so that they would have distributions of demographic and socioeconomic characteristics similar to those of the veterans. Overall, 14% of women reported financial barriers. Women who reported financial barriers to receiving healthcare were more likely to have poor health-related quality of life in all four dimensions than those who did not report such barriers. Compared to women non-veterans, women veterans did not differ in reported financial barriers but were more likely to report poor health-related quality of life. Reporting financial barriers to receiving needed healthcare was significantly associated with poor health-related quality of life among women. Veteran status was also significantly associated with poor health-related quality of life. These findings suggest the need for healthcare policy makers and practitioners to align emerging new models of healthcare delivery to improve health-related quality of life for women veterans.     

Predicting posttreatment cocaine abstinence for first-time admissions and treatment repeaters

OBJECTIVES: This study examined client and program characteristics that predict posttreatment cocaine abstinence among cocaine abusers with different treatment histories. METHODS: Cocaine abusers (n = 507) treated in 18 residential programs were interviewed at intake and 1-year follow-up as part of the nationwide Drug Abuse Treatment Outcome Study (DATOS). Program directors provided the program-level data in a mail survey. We applied the hierarchical linear modeling approach for the analysis. RESULTS: No prior treatment and longer retention in DATOS programs were positive predictors of posttreatment abstinence. The interactive effect of these 2 variables was also significantly positive. Program that offered legal services and included recovering staff increased their clients' likelihood of cocaine abstinence. Crack use at both the client and program level predicted negative impact. None of the program variables assessed differentially affected the outcomes of first-timers and repeaters. CONCLUSIONS: Although treatment repeaters were relatively difficult to treat, their likelihood of achieving abstinence was similar to that of first-timers if they were retained in treatment for a sufficient time. First-timers and repeaters responded similarly to the treatment program characteristics examined. The treatment and policy implications of these findings are discussed.     

Engagement in Outpatient Substance Abuse Treatment and Employment Outcomes

This study, a collaboration between an academic research center and Washington State’s health, employment, and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly funded treatment. The first stage predicted employment in the year following the first treatment visit, and three separate second-stage models predicted the number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.     

Childhood Conduct Problems and Other Early Risk Factors in Rural Adult Stimulant Users

ABSTRACT:  Context: Understanding childhood risk factors associated with adult substance use and legal problems is important for treatment and prevention. Purpose: To examine the relationship of early substance use, conduct problems before age 15, and family history of substance abuse on adult outcomes in rural, stimulant users. Methods: Adult cocaine and methamphetamine users (N = 544) in rural Arkansas and Kentucky were interviewed. Data were analyzed using both bivariate analyses and multiple logistic and log-linear regression models, with dependent variables being any substance abuse/dependence, stimulant abuse/dependence, total number of arrests since age 18 and days incarcerated since age 18. Findings: One third reported 3 or more conduct disorder problems prior to age 15; half reported initiation of substances (excluding alcohol) before age 15; and 60% reported family history of substance problems. All 3 variables were associated with adult substance abuse/dependence but only the latter two were associated with stimulant abuse/dependence. Conclusions: This study highlights early risk factors for adult substance abuse/dependence among rural stimulant users.     

Unprotected sex as a function of alcohol and marijuana use among adolescent detainees.

PURPOSE: To examine the relationship between the use of two substances (alcohol and marijuana) and the occurrence of unprotected sexual intercourse among adolescent detainees. METHODS: Participants were asked about their use of alcohol, marijuana, and condoms. In addition to comparing levels of alcohol and marijuana use, the study examined relationships among the following variables: (a) the number of days that each substance was used and the number of unprotected episodes of sexual intercourse in the 30 days preceding admission to a youth detention center; (b) the number of times that each substance was used before or during sexual intercourse and the number of unprotected episodes in the same time period; (c) the use of each substance and unprotected intercourse at the last sexual episode; and (d) intentions to use each substance in the context of sex and to have unprotected intercourse in the future. Relationships among these variables were assessed in four regression models, each of which included participants' demographic characteristics, AIDS knowledge, attitudes toward condoms, and future orientation as covariates. RESULTS: Results of all four regression models indicated that marijuana use was associated with unprotected sexual intercourse. Adolescents who used more marijuana in general as well as specifically in sexual episodes in the 30 days preceding detention reported higher levels of unprotected sex. In addition, marijuana use in the last episode was related to the occurrence of unprotected sex during that episode. Moreover, intentions to use marijuana in future sexual episodes was associated with intentions to have unprotected intercourse in the future. CONCLUSIONS: Future studies should use more rigorous research designs to clarify the nature of the relationship between marijuana use and risky sex.