The Alcohol Treatment Outcome Measure (ATOM): a new clinical tool for standardising outcome measurement for alcohol treatment

Whilst many instruments have been developed for screening and treatment outcome evaluation studies in the alcohol and other drug treatment (AOD) sector, very few are suitable for routine, ongoing use by clinicians. The aim of the current study was to assess the psychometric properties of the Alcohol Treatment Outcome Measure (ATOM). The ATOM was designed to measure the key outcomes of alcohol treatment whilst remaining a brief and easy to use clinical tool. Participants (N=134) with a concern for their alcohol use were recruited from AOD treatment agencies and interviewed on two occasions one week apart. Results indicate that the ATOM has overall good to excellent test-retest and inter-rater reliability; and satisfactory concurrent validity and internal reliability. The instrument also demonstrated the ability to measure change in client functioning over time. Results suggest that the ATOM can be used successfully and confidently within alcohol treatment services.     

Development of a Brief Treatment Instrument for Routine Clinical Use with Methadone Maintenance Treatment Clients: The Methadone Treatment Index

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.     

An inter-rater reliability study of the Opiate Treatment Index

The development of standardized instruments to evaluate treatment outcome fo opioid dependence is necessary to determine individual patients' progress within a particular treatment programme and to compare treatment outcomes across programmes. This paper reports the results of an inter-rater reliability study utilizing the Opiate Treatment Index (OTI). The OTI questionnaire is a standardized opiate treatment evaluation tool developed within a research setting. The main aim of this study was to determine within the clinical setting of a Methadone Treatment Programme (MTP), whether information given by patients differed significantly according to whether the OTI questionnaire was administered by clinicians working within the service, or by an unknown research assistant. Results indicated that overall there were few differences between the information given to clinicians compared with that given to the research assistant and that in general, inter-rater reliability was good. A number of issues related to the development and use of treatment outcome measures in clinical settings are highlighted and it is proposed that for MTPs a shorter questionnaire, based on the OTI, be developed.     

Psychometric properties of the German version of the Motivational Interviewing Treatment Integrity Code

Motivational interviewing (MI) is effective in the treatment of addictions. To evaluate MI adherence of therapists, the Motivational Interviewing Treatment Integrity Code (MITI) was developed. MI is used in German-speaking countries, but there is no equivalent to the MITI. Our aim was to adapt the MITI for use in German language settings (MITI-d). Twenty-eight session tapes of Alcoholism Specific Psychotherapy utilizing MI were rated by two student raters and the MITI-d instructor. To evaluate interrater reliability, intraclass correlation coefficients (ICCs) were computed. ICCs were good to excellent for relevant MI constructs, except for Complex Reflections, MI-nonadherent Behaviors, Empathy, and MI Spirit. The evaluation of test-retest reliability for the student raters showed good to excellent results. The MITI-d is a psychometrically sound instrument for evaluating basic MI competence in German language settings.     

A revised edition of the Readiness to Change Questionnaire [Treatment Version]

The UK Alcohol Treatment Trial provided an opportunity to examine the factor structure of the Readiness to Change Questionnaire–Treatment Version (RCQ[TV]) in a large sample (N = 742) of individuals in treatment for alcohol problems who were given the RCQ[TV] at baseline, 3-months and 12-months follow-up. Confirmatory factor analysis of the previously reported factor structure (5 items for each of Precontemplation, Contemplation and Action scales) resulted in a relatively poor fit to the data. Removal of one item from each of the scales resulted in a 12-item instrument for which goodness-of-fit indices were improved, without loss of internal consistency of the three scales, on all three measurement occasions. Inspection of relationships between stage allocation by the new instrument and negative alcohol outcome expectancies provided evidence of improved construct validity for the revised edition of the RCQ[TV]. There was also a strong relationship between stage allocation at 3-months follow-up and outcome of treatment at 12 months. The revised edition of the RCQ[TV] offers researchers and clinicians a shorter and improved measurement of stage of change in the alcohol treatment population.     

Exploring variability and sources of measurement error in alcohol expectancy questionnaire reliability coefficients: a meta-analytic reliability generalization study

OBJECTIVE: Reliability Generalization, a relatively new meta-analytic score reliability technique, was used to examine reliability coefficients for Alcohol Expectancy Questionnaire (AEQ) subscales in published research. Specifically, the present study identified the typical reliability coefficients of scores on AEQ subscales across published studies and examined sources of measurement error across AEQ subscales and studies. METHOD: Based on literature reviews of PsyclNFO and PubMed, a total of 71 studies were analyzed and coded on 10 different dimensions believed to affect score reliability. RESULTS: Only 37% of the studies surveyed reported reliability coefficients for the data in hand. Analysis of these studies revealed that the average score reliability across studies varied considerably in subscales and samples, with the Arousal/Interpersonal Power and Sexual Enhancement subscales evidencing the greatest variability. Gender homogeneity and racial homogeneity were found to be the two most important predictors of the magnitude of score reliability coefficients across subscales and studies. CONCLUSIONS: Results of the study indicate that the AEQ tends to generate reliable scores, with some noted exceptions. Because the Arousal/Interpersonal Power and Sexual Enhancement subscales tend to generate unacceptably low reliability coefficients and because the AEQ holds promise in furthering prevention and treatment outcome research, it is suggested that future research with the AEQ explore instrument factor structure and item consistency. Because reliability estimates can influence substantive statistical analyses, it is recommended that authors using the AEQ report reliability information in their published work.     

The Spanish Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability and concordance with clinical diagnoses in a Hispanic population

OBJECTIVE: The study reports the process of translation into Spanish and adaptation to the Hispanic culture of the Alcohol Use Disorder and Associated Disabilities Schedule (AUDADIS). This instrument is a structured diagnostic interview schedule specifically developed for the assessment of substance-related disorders and their comorbid disorders and disabilities. METHOD: A random sample (N = 169) of adults from a primary health care clinic in Puerto Rico was selected. The test-retest reliability of the instrument was examined across time and across interviewers, and the validity was assessed by comparing computer-derived diagnoses obtained through the administration of lay interviewers with best estimate diagnoses given by board-certified psychiatrists. RESULTS: For most diagnoses and symptoms studied, as well as for most of the alcohol consumption measures, the test-retest reliability of the Spanish AUDADIS was consistent with results reported in other national and international studies using this instrument. Good to excellent test-retest reliability was obtained for the diagnoses of alcohol dependence and major depression. Similarly, good to excellent agreement was obtained between the lay administered AUDADIS and best estimate diagnoses for most diagnostic categories, with the exception of dysthymia. As in other studies, the reliability and validity of the substance abuse category was poor. When agreement for this category was estimated independent of lifetime dependence, both the reliability and validity coefficients were considerably improved. CONCLUSIONS: The Spanish AUDADIS generally demonstrates good to excellent levels of reliability and validity that are comparable to findings reported for this instrument in other national and international studies.     

中文版成瘾严重性指数量表在参加美沙酮维持治疗的海洛因成瘾者中的信度和效度评价

背景:为遏制艾滋病病毒在海洛因成瘾者中的传播,我国于2004年开始选用美沙酮口服液作为海洛因的替代药物,对海洛因成瘾者进行长期维持治疗。为更好地评价美沙酮维持治疗(methadone maintenance treatment,MMT)的效果,研究者引进和翻译了在国外广泛用于评价药物成瘾的一种工具《成瘾严重性指数量表》(Addiction Severity Index,ASI)第5版。目的:评价中文版ASI(ASI-C)在接受MMT的海洛因成瘾者中应用的信度和效度。方法:对1005名(男744名,女261名)MMT受治者用ASI-C进行面对面访谈,其中35名受治者接受了间隔7d的重复测量,分析ASI的信度和效度。结果:ASI-C与原量表具有相近的结构,通过因子分析,有7个因子的特征值大于1,ASI-C萃取出7个维度;通过与相关效度条目的检验,ASI-C具有较好的区分效度,各效度检验条目与维度评分间相关系数在0.09-0.80。内部一致性信度测量显示平均Cronbach’α为0.68(0.52-0.88),有5个维度Cronbach’α大于0.60。相隔7d的重测信度达到可接受的水平。结论:ASI-C在参加美沙酮维持治疗的海洛因成瘾者中应用,具有较好的结构效度和区分效度,5个维度的内部一致性信度Cronbach’α达到可接受的水平,2维度上还有待提高。初步测量的重测信度达到可接受水平。     

Development and validation of a brief instrument for routine outcome monitoring in opioid maintenance pharmacotherapy services: the brief treatment outcome measure (BTOM)

AIM: To develop a brief, multi-dimensional instrument for routine, on-going treatment outcome monitoring in alcohol and other drug (AOD) services in Australia and examine the underlying psychometric properties. This study focuses on opioid maintenance pharmacotherapy (OMP) services. DESIGN: Researcher-administered test-retest interviews and clinician administered interviews. SETTING: The test-retest interviews took place in two private and two public OMP clinics in Sydney, Australia. The clinician-administered interviews took place in 37 metropolitan, rural and prison OMP services in New South Wales, Australia. PARTICIPANTS: One hundred and sixty current OMP clients for the test-retest interviews and 2004 clients commencing OMP treatment for the clinician-administered interviews. MEASURES: Thirty-two items across the domains of dependence, blood-borne virus exposure risk, drug use, health/psychological functioning and social functioning. FINDINGS: The internal reliability of the brief treatment outcome measure (BTOM) is satisfactory. Retest reliabilities for the scales and drug use scores are good to excellent indicating their consistency with multiple measurements across time and different interviewers and concurrent validation of BTOM scales with analogous scales from similar instruments yielded acceptable agreement. Average completion times of the BTOM were 14.5 min, when administered in a research context and 21 min in a clinical context. CONCLUSIONS: A brief, valid and reliable questionnaire has been developed for monitoring treatment outcome over the range of OMP services. The BTOM contains a core set of outcome measures, which can be easily adapted for integration into routine clinical practice across the range of AOD services.     

Longitudinal Treatment Effects Among Cocaine Users: A Growth Curve Modeling Approach

This study examined longitudinal treatment effects among cocaine users. The study examined a sample of 371 cocaine users screened from arrestees in jails and from patients in sexually transmitted disease clinics and emergency rooms—all in Los Angeles County during 1992–1994. Of the 371 subjects, 121 had never been in treatment and 250 reported a history of participation in drug user treatment (145 subjects' first treatment was for cocaine use and 105 were in treatment for a drug other than cocaine). Data were collected during face-to-face interviews using a natural history interview instrument. We applied a series of growth curve models to investigate treatment effects on cocaine use. For those who had been in treatment for cocaine use, use of cocaine decreased from approximately 70% before treatment to 12% after treatment entry, while no such changes were observed among those who had never been in treatment or those in treatment for other drugs. Relative to nontreated users, cocaine-treated participants showed a greater likelihood of pretreatment use for both initial status (OR = 3.58) and growth rate (OR = 1.05). After treatment entry, cocaine-treated participants as compared to nontreated participants had a lower likelihood of use (OR = 0.27), although their cocaine use after the initial status increased at a greater rate (OR = 1.03). Treated users were five times less likely to use when they were in treatment than when they were out of treatment. Longer treatment retention was related to initially reduced use but not to later rates of change in cocaine use. The study findings support that treatment for cocaine use is effective in reducing cocaine use. Longitudinal models provide opportunities to demonstrate the dynamic relationships between treatment and outcome.     

Treatment Outcome for Impoverished Alcoholics in an Abstinence-Based Program

Positive patient characteristics have been assumed important in determining treatment outcome for the abstinence-based method of addiction treatment. Thus far, controlled and uncontrolled studies of the abstinence-based method have examined predominantly employed, White, and married populations of alcoholics. We present a treatment outcome study of the abstinence-based method of treatment in unemployed, Black, and unmarried population of alcoholics. The negative patient characteristics in our study did not predict an unfavorable outcome in comparison to those in other studies that included positive patient characteristics.     

The reliability of the Shona version of the EQ-5D

BACKGROUND: There is an increasing need to have locally applicable health related quality of life outcome measures that are both reliable and valid. The aim of this paper was to present the Shona version of a Health Related Quality of Life Measure, the EQ-5D (Euro Quality of Life--5 Dimensions) and to examine the reliability and validity of the translated instrument. METHOD: Thirty eight test-retest responses from randomly selected members of a high density suburb in Harare were analysed. The measures of agreement (Kappa statistic) between the two sets of scores were very high and ranged from 0.78 to 1.00 for different domains of activity. The correlation between the two sets of scores in the section of the instrument that calls for valuation of health state on a visual analogue scale (VAS) was high (Spearman's rho = 0.793). It is suggested that, based on this small sample, the EQ-5D is a reliable measure of HRQoL and can be utilised in studies in a high density Shona speaking population.     

Initial reliability and validity studies of the revised Treatment Services Review (TSR-6)

OBJECTIVE: Report the results of initial reliability and validity analyses for a revised Treatment Services Review (TSR-6) instrument which measures a broader range of services than the original TSR. METHOD: First, the number of services for a 28-day period was compared for three versions of the instrument varying in their reporting timeframes. Accordingly, four successive 7-day TSR-6s, two 14-day TSR-6s, or one 28-day TSR-6 were administered to more than 300 clients (30% women) in substance abuse treatment (SAT). Second, short-term (2-5 days) test-retest reliabilities were compared for an initial 7-, 14-, or 28-day version of the TSR-6. Third, test-retest reliabilities were compared when an initial in-person (IP) administration was followed by either IP or telephone (TEL) TSR-6 administration. Finally, preliminary discriminative validity analyses were conducted. RESULTS: Few differences in the quantity of services reported for a 4-week period were found with versions of the TSR-6 that used different timeframes. Also, comparisons of test-retest reliabilities for the different version of the TSR-6 revealed few differences. Test-retest reliabilities were generally comparable for the IP-TEL and IP-IP conditions. Finally, analyses demonstrated preliminary discriminative validity for the instrument when services for three distinctive forms of treatment: intensive outpatient, methadone and residential were compared. CONCLUSIONS: The findings of this study support the reliability and validity of the TSR-6 and suggest that a version with a 28-day reporting period can provide information comparable to that obtained with versions using shorter reporting periods.     

Association Among Outcomes in a Naturalistic Statewide Assessment of Substance User Treatment

Substance user treatment outcome measurement is important for research and policy questions, yet little literature has addressed the relationships among outcome measures of treatment success. Ideally, treatment outcomes would correlate to at least a moderate degree. The Iowa Department of Public health requires substance user treatment programs receiving public funds to provide client information. Demographic information, “substance abuse” history, current use, arrests, and hospitalizations were ascertained at admission and a 6-month follow-up for 1374 clients (from January 1999 to December 2000). Abstinence, arrests, and hospitalizations were good outcome measures of substance user treatment success. Reduction in frequency of use was negatively associated with arrests, substance use-related hospitalizations, and increased income. Full-time employment at follow-up produced different results depending on the client's sex. However, all associations among outcomes were modest. Specificity may be reasonable in some instances; however, other situations might require a broad-spectrum approach that ideally would produce a wide range of benefits.     

改良痔切缝术治疗重度混合痔125例临床观察

目的 探讨改良痔切缝术治疗混合痔的疗效.方法 对Ⅲ、Ⅳ期内痔、混合痔125例采用改良痔切缝术进行分析总结.结果 125例全部愈合,疗效满意,随访1-2年,无复发.结论 该手术方法是安全、可靠、痛苦小、恢复快、并发症少的理想术式,远期疗效肯定.     

Alcoholism Treatment and Evaluation: In Search of Methods. II. Collation of Two-Year Follow-up Studies

This study collated 23 articles reporting outcome of alcoholism treatment efforts over a 2-year follow-up period. Broad conclusions reached by Costello (1975) in a similar collation of studies reporting on a 1-year follow-up interval found general support. Similar consistencies were noted across studies within groups described as having good outcome profiles as was noted by the previous collation. Good outcome results from matching relatively better prognostic cases with programs with broad treatment resources. Multiple baselines were offered as guidelines for program evaluation. Baselines were generated in the process of collation by hierachal grouping of outcome profiles. Different baseline to measure effectiveness of performance should prove appropriate for different measuring tasks. No one baseline is appropriate for all measuring tasks.     

Estimating the Optimal Personalized Treatment Strategy Based on Selected Variables to Prolong Survival via Random Survival Forest with Weighted Bootstrap

ABSTRACT

A personalized treatment policy requires defining the optimal treatment for each patient based on their clinical and other characteristics. Here we consider a commonly encountered situation in practice, when analyzing data from observational cohorts, that there are auxiliary variables which affect both the treatment and the outcome, yet these variables are not of primary interest to be included in a generalizable treatment strategy. Furthermore, there is not enough prior knowledge of the effect of the treatments or of the importance of the covariates for us to explicitly specify the dependency between the outcome and different covariates, thus we choose a model that is flexible enough to accommodate the possibly complex association of the outcome on the covariates. We consider observational studies with a survival outcome and propose to use Random Survival Forest with Weighted Bootstrap (RSFWB) to model the counterfactual outcomes while marginalizing over the auxiliary covariates. By maximizing the restricted mean survival time, we estimate the optimal regime for a target population based on a selected set of covariates. Simulation studies illustrate that the proposed method performs reliably across a range of different scenarios. We further apply RSFWB to a prostate cancer study.     

Performance evaluation of regression splines for propensity score adjustment in post-market safety analysis with multiple treatments

ABSTRACT

Observational studies provide a core resource in assessing post-market drug safety and effectiveness. Propensity scores are a predominant method for confounding adjustment to achieve unbiased estimation of average treatment effects in observational data. However, the use of propensity score methods has been limited to comparing two treatment groups, while medical situations frequently present with multiple treatment options. Inverse probability of treatment weighting (IPTW) is a popular propensity score adjustment method, but its performance degrades with decreased positivity leading to extreme weights, a problem that can be amplified with multiple treatment groups. Meanwhile, regression on a spline of the propensity score has shown favorable performance compared to other propensity score methods in recent studies involving two treatments. This project utilizes a simulation study to compare IPTW and propensity score splines as adjustment methods in a three-treatment setting. We test a variety of spline methods, including natural cubic splines with varying numbers of interior knots, and thin-plate regression splines. We vary several parameters across simulations, including the degree of propensity score overlap among treatment groups, treatment prevalence, outcome prevalence, and true marginal relative risk. We assess methods based on their bias, root mean squared error, and coverage of the true marginal relative risk across simulations. We find that all methods perform similarly well when there is good propensity score distribution overlap. However, with even moderate decrease in overlap or low outcome prevalence, IPTW produces more biased estimates and higher variance than propensity score splines. Low treatment prevalence or unequal treatment prevalences across groups also worsens IPTW performance. Overall, a natural cubic spline with a relatively small number of interior knots provides good performance across a range of simulations.     

乳晕环切口治疗乳腺良性肿瘤的临床探析

目的探讨采用乳晕环形切口手术治疗乳腺良性肿瘤的临床疗效。方法将我院2009年2月至2012年6月接待的100例乳腺良性肿瘤病患作为研究对象,并将她们随机分为两组:研究组(50)和对照组(50),其中对研究组采用乳晕环形切口手术治疗,对照组则采用传统的切口手术治疗,然后对两组临床结果进行回顾性的对比与分析。结果两组都顺利通过了手术,在1年后对这些对象进行随访观察,其中研究组50例病患乳房外观保持较好,病患术后瘢痕满意46例,一般4例,并没有出现不满意的病例;对照组病患在术后瘢痕的满意上仅有20例,一般19例,不满意的也有11例。两组病患在术后瘢痕满意度上有着明显的差异,因此具有统计学意义(P<0.05)。结论对乳腺良性肿瘤病患采用乳晕环形切口手术进行治疗,治疗效果很好,瘢痕十分隐蔽,对于乳房的美观没有太大影响,值得推广应用。     

Improving the quality of reporting alcohol outcome studies: Effects of the CONSORT statement

It is critical that the reporting of randomized controlled trials (RCTs) be transparent and comprehensive. The aim of this study was to examine if adopting standards of reporting, the Consolidated Standards of Reporting Trials (CONSORT), improved the quality of reporting of alcohol treatment outcome studies. RCTs were identified from eight journals publishing a substantial number of alcohol treatment outcome studies (n = 127 RCTs) and coded for the quality of reporting according to the CONSORT guidelines. Both CONSORT adopter and non-adopter journals showed significant improvements in the quality of reporting of alcohol treatment outcome studies over time. While overall results suggested a non-significant trend for more improvement over time in the quality of reporting for adopter compared to non-adopter journals, comparison of effects sizes suggested that specific areas of reporting did significantly improve for the adopter journals. Results suggest that efforts to improve reporting such as the CONSORT guidelines can be useful and influential.