RESUMEN
Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.
Asunto(s)
Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas , Insuficiencia Cardíaca/tratamiento farmacológico , Anciano , Femenino , Adhesión a Directriz , Humanos , Masculino , Alta del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina , Mejoramiento de la Calidad , Disfunción Ventricular Izquierda/tratamiento farmacológicoRESUMEN
This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.
Asunto(s)
Trastornos Relacionados con Opioides/rehabilitación , Pacientes/psicología , Centros de Tratamiento de Abuso de Sustancias , Adulto , Negro o Afroamericano , Baltimore , Femenino , Objetivos , Humanos , Estudios Longitudinales , Masculino , Metadona/uso terapéutico , Motivación , Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/psicología , Alta del Paciente , Readmisión del Paciente , Recuperación de la Función , Insuficiencia del Tratamiento , Población BlancaRESUMEN
This study was conducted to determine the psychometric properties of a measure of social support, the Community Assessment Inventory (CAI), and to examine the role of social support in recovery. The CAI and the Addiction Severity Index (ASI) were administered to 196 opioid-dependent adults in (n = 135) or out of (n = 61) methadone treatment in Baltimore, Maryland, between 2004 and 2006. Baseline CAI scale scores indicated a generally high level of internal consistency (alpha scores). Pearson correlations showed that the scales were stable and had good discriminant validity with the ASI composite scores. One-way analysis of variance indicated that in-treatment participants reported significantly more support at baseline than out-of-treatment participants. This study's findings indicate the CAI may be a useful measure of social support and that such support is an important factor in treatment entry.
Asunto(s)
Trastornos Relacionados con Opioides/psicología , Aceptación de la Atención de Salud/psicología , Psicometría/métodos , Apoyo Social , Adulto , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/rehabilitación , Reproducibilidad de los Resultados , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Despite the proven effectiveness of methadone treatment, the majority of heroin-dependent individuals are out-of-treatment. METHODS: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. RESULTS: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. CONCLUSION: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request, and working with corrections agencies to ensure continued methadone treatment upon incarceration.
Asunto(s)
Dependencia de Heroína/rehabilitación , Metadona/uso terapéutico , Aceptación de la Atención de Salud , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Adulto , Baltimore , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Estilo de Vida/etnología , Masculino , Metadona/efectos adversos , Persona de Mediana Edad , Aceptación de la Atención de Salud/etnología , Aceptación de la Atención de Salud/psicología , Negativa a Participar/etnología , Negativa a Participar/psicología , Negativa del Paciente al Tratamiento/etnología , Negativa del Paciente al Tratamiento/psicología , Adulto JovenRESUMEN
Longer retention in drug abuse treatment is associated with better patient outcomes, and research indicates the first 12 months of methadone treatment are critical to patient success. Nevertheless, large-scale multisite longitudinal studies over the past three decades indicate that the majority of patients drop out during the first year of methadone treatment. Through an examination of 42 qualitative interviews with patients prematurely discharged from six methadone treatment programs in Baltimore, this study highlights factors patients describe as contributing to their reasons for being discharged within the first 12 months of the treatment. The two most consistent themes are program-related factors and incarceration. The former factors are richly described through patients' words and underscore the ways in which patients' perceptions of control exerted by the program and by the medication and misunderstandings of program structure can lead to premature discharge. Patients' reasons for discharge were compared to counselors' reasons as indicated in discharge summary forms. An analysis of the patterns of agreement and disagreement are presented. Patient-centered program and policy implications are discussed.
Asunto(s)
Metadona/uso terapéutico , Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/rehabilitación , Alta del Paciente/estadística & datos numéricos , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Adulto , Citas y Horarios , Consejo , Crimen/estadística & datos numéricos , Etnicidad , Femenino , Dependencia de Heroína/rehabilitación , Humanos , Acontecimientos que Cambian la Vida , Estudios Longitudinales , Masculino , Maryland/epidemiología , Metadona/economía , Narcóticos/economía , Trastornos Relacionados con Opioides/economía , Alta del Paciente/economía , Satisfacción del Paciente , Honorarios por Prescripción de Medicamentos , Recurrencia , Factores Socioeconómicos , Centros de Tratamiento de Abuso de Sustancias/economía , Recursos HumanosRESUMEN
This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n = 84) of the total sample (N = 515) reported using diverted (street) methadone two-three times per week for six months or more, and for an average of 7.8 days (SD = 10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps <.01) and had lower ASI Drug Composite scores (p <.05). Participants in our qualitative sub-sample (n = 22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.
Asunto(s)
Buprenorfina/administración & dosificación , Drogas Ilícitas/provisión & distribución , Metadona/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Adulto , Baltimore , Buprenorfina/economía , Femenino , Humanos , Masculino , Maryland , Metadona/economía , Automedicación/estadística & datos numéricos , Índice de Severidad de la EnfermedadRESUMEN
Both heroin-addicted individuals and methadone maintenance patients are likely to face untreated opioid withdrawal while incarcerated. Limited research exists concerning the withdrawal experiences of addicted inmates and their impact on individuals' attitudes and plans concerning drug abuse treatment. In the present study, 53 opioid dependent adults (32 in methadone treatment and 21 out of treatment) were interviewed in an ethnographic investigation of withdrawal experiences during incarceration. When treatment for opioid withdrawal was unavailable, detoxification experiences were usually described as negative and were often associated with a variety of unhealthy behaviors designed to relieve withdrawal symptoms. Negative methadone withdrawal experiences also negatively influenced participants' receptivity to seeking methadone treatment upon release. A minority of participants took a positive view of their withdrawal experience and saw it as an opportunity to detox from heroin or discontinue methadone. Findings support the importance of providing appropriate opioid detoxification and/or maintenance therapy to opioid-dependent inmates.
Asunto(s)
Dependencia de Heroína/psicología , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/psicología , Prisioneros/psicología , Síndrome de Abstinencia a Sustancias/psicología , Adulto , Femenino , Dependencia de Heroína/tratamiento farmacológico , Humanos , Masculino , Trastornos Relacionados con Opioides/tratamiento farmacológico , Síndrome de Abstinencia a Sustancias/terapia , Negativa del Paciente al TratamientoRESUMEN
OBJECTIVE: Gender differences were explored among 355 in- and out-of-treatment opioid-addicted adults in Baltimore. METHODS: Addiction Severity Index and other variables were compared among: 1) in-treatment women vs. out-of-treatment women; 2) out-of-treatment: women vs. men; and, 3) in-treatment: women vs. men. RESULTS: Analysis indicated that in-treatment and out-of-treatment women worked less and used more cocaine than their male counterparts (ps < .01). Moreover, out-of-treatment women used heroin and cocaine more often, spent more money on drugs, earned more illegal income, and had fewer treatments than in-treatment women (ps < or = .01). CONCLUSIONS: Findings indicate greater severity of drug and employment problems of opioid-addicted women and underline the need for gender-specific drug-treatment services.
Asunto(s)
Analgésicos Opioides/efectos adversos , Dependencia de Heroína/rehabilitación , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/rehabilitación , Caracteres Sexuales , Adolescente , Adulto , Edad de Inicio , Baltimore , Trastornos Relacionados con Cocaína/rehabilitación , Crimen/estadística & datos numéricos , Femenino , Infecciones por VIH/complicaciones , Dependencia de Heroína/complicaciones , Humanos , Masculino , Trastornos Relacionados con Opioides/complicaciones , Índice de Severidad de la EnfermedadRESUMEN
Hospital acquired pressure ulcers are the focus of national attention. We report on a decision support system that notifies clinical nurse specialists of patients with pressure ulcers or risk for developing pressure ulcers. Auto-summed pressure ulcer risk and pressure ulcer occurrence data are embedded in nursing flowsheets, while the expert system technology runs in a separate application and sends a message back to the EMR environment; a system is successfully implemented across 60 inpatient units.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Diagnóstico por Computador/métodos , Sistemas Especialistas , Enfermeras Clínicas , Informática Aplicada a la Enfermería/métodos , Registros de Enfermería , Úlcera por Presión/clasificación , Úlcera por Presión/diagnóstico , Algoritmos , Humanos , MinnesotaRESUMEN
Attitudes and beliefs about drug abuse treatment have long been known to shape response to that treatment. Two major pharmacological alternatives are available for opioid dependence: methadone, which has been available for the past 40 years, and buprenorphine, a recently introduced medication. This mixed-methods study examined the attitudes of opioid-dependent individuals toward methadone and buprenorphine. A total of 195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs and n = 55 who were out-of-treatment) were administered the Attitudes toward Methadone and toward Buprenorphine Scales, and a subset (n = 46) received an ethnographic interview. The in-treatment group had significantly more positive attitudes toward methadone than did the out-of-treatment group (p < .001), while they did not differ in their attitudes toward buprenorphine. Both groups had significantly more positive attitudes toward buprenorphine than methadone. Addressing these attitudes may increase treatment entry and retention.
Asunto(s)
Actitud Frente a la Salud , Buprenorfina/uso terapéutico , Metadona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/rehabilitación , Adolescente , Adulto , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Adulto JovenRESUMEN
This study compared the characteristics of opioid-addicted adults seeking (n = 169) and not seeking (n = 74) methadone treatment in Baltimore, Maryland. Participants entering treatment were recruited from six methadone treatment programs, while out-of-treatment participants were recruited from the streets using targeted sampling methods. Measures included the Addiction Severity Index, a Supplemental Questionnaire, and urine drug test. Data were analyzed using ANOVA, chi(2), and regression, holding key background variables constant. Despite the lack of differences between the samples in demographic characteristics, the out-of-treatment sample reported significantly more days of heroin, cocaine, and alcohol use and spent significantly more money on drugs and earned more illegal income at baseline.
Asunto(s)
Atención Ambulatoria , Crimen/estadística & datos numéricos , Hospitalización , Trastornos Relacionados con Opioides/rehabilitación , Aceptación de la Atención de Salud , Adulto , Factores de Edad , Trastornos Relacionados con Alcohol/diagnóstico , Trastornos Relacionados con Alcohol/epidemiología , Trastornos Relacionados con Cocaína/diagnóstico , Trastornos Relacionados con Cocaína/epidemiología , Femenino , Humanos , Estudios Longitudinales , Masculino , Maryland/epidemiología , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/epidemiología , Selección de Paciente , Análisis de Regresión , Índice de Severidad de la Enfermedad , Detección de Abuso de Sustancias , Encuestas y CuestionariosRESUMEN
The authors conducted an investigation of perceptions of outreach worker credibility using the social network members (N = 20) of indigenous outreach workers in an HIV/AIDS prevention intervention. The network members included in the study received semistructured interviews following the program's completion. Outreach workers who were not actively using illicit drugs were more likely to be described as credible than were those who were using drugs. In general, drug use negatively affected perceptions of credibility via damaged trust in the outreach worker's relationship with his or her network member. Results indicate the complexity of using indigenous drug users as outreach workers, the potential negative perceptions concerning hypocritical behavior, and the need to evaluate social interventions from the standpoint of indirect participants.