Transcript Open slides - CTN Dissemination Library

The CTN Research Utilization
Committee: Putting
Dissemination Research into
Practice
Jeffrey Selzer, MD
Chair, CTN Research Utilization Committee
Long Island Regional Node, CTN
North Shore-Long Island Jewish Health System
Albert Einstein College of Medicine
National Drug Abuse Treatment
Clinical Trials Network
Washington Node
U. Washington
Northern NE Node
McLean/Harvard
Oregon Node
OHSU
New England Node
Yale
New York Node
NYU
California/Arizona Node
UCSF/U. Arizona
Ohio Valley Node
U. Cincinnati
Pacific Node
UCLA
Long Island Node
Tri state
NY State Psych. Inst.
U. Pittsburgh
Delaware Valley Node
U. Pennsylvania
Mid--Atlantic Node
Mid
JHU/MCV
North Carolina Node
Duke
Southwest Node
U. New Mexico
Texas Node
UT Southwestern
South Carolina Node
MUSC
Florida Node
U. Miami
A research infrastructure of 16 RRTCs & 240 CTPs across 34 States, and Puerto Rico
Missions of the CTN:
A. Conduct studies of behavioral, pharmacological and
integrated behavioral and pharmacological treatment
interventions in rigorous, multi-site clinical trials to
determine effectiveness across a broad range of
community based treatment settings and diversified
patient populations.
B. Timely transfer of the research results to clinicians,
providers, their patients and the policy makers to
improve the quality of drug abuse treatment throughout
the country using science as the vehicle.
CTN strategic plan includes the importance of using the
CTN as an infrastructure to study best approaches to
disseminating treatment innovations.
The CTN Trials (1999 – now)
Pending,
Development &
Review
Recruitment &
Data
Collection
CTN 0022
CTN 0023
CTN 0024
CTN 0025
CTN 0026
CTN 0031
CTN 0032
CTN 0027
CTN 0028
CTN 0029
CTN 0030
Medical Interventions: 9
Behavior Interventions: 11
HIV/HCV Interventions: 4
Others: 3
Follow-Up
CTN 0014
Data Analysis,
Publication, &
Dissemination
CTN 0001
CTN 0002
CTN 0003
CTN 0004
CTN 0005
CTN 0006
CTN 0007
CTN 0008
CTN 0009
CTN 0010
CTN 0011
CTN 0012
CTN 0013
CTN 0015
CTN 0016
CTN 0017
CTN 0018
CTN 0019
CTN 0020
CTN 0021
“I utilize the best from Freud, the best from Jung, and
the best from my Uncle Marty, a very smart fellow.”
Patient Outcomes
Effective intervention practices
+
Effective implementation practices
=
Good outcomes for Patients
Characteristics of an Innovation
Which Is Most Easily Disseminated
(Everett Rogers, 2003):
1. Confers a relative advantage compared
with the current practice
2. Is compatible with other current practices
3. Is relatively simple to learn and implement
4. May be tried before making a commitment
to adoption
5. Positive results are observable by the
adopter
When innovations are adopted, “reinvention is
inevitable.”
Widely Used Dissemination
Approaches:
1.
2.
3.
4.
Conference presentations
Workshops
Distribution of printed manuals
Performance feedback which does not
occur in real-time
None of these commonly used approaches
has been demonstrated to effectively
promote dissemination of innovations .
Effective Strategy For
Implementing a New Intervention
Three-step process
– Provide opportunities to acquire basic knowledge
about intervention
– Provide opportunities for practice with feedback
– Provide expert coaching to improve performance
Not dissimilar from how interventions in research
protocols are implemented (i.e., training with
fidelity monitoring)
Conclusions reached by the RUC:
• Implementation of interventions
throughout the CTN would require
ongoing technical assistance (i.e.,
coaching)
• For implementation to occur,
“maintenance was as important
sales.”
Blending Initiative
• SAMHSA-NIDA Collaboration through ATTCs
• BlendingTeam members include NIDA researchers on
a given intervention, community treatment programs
with experience using the intervention, and Addiction
Technology Transfer Center staff
• Blending products (designed to promote adoption):
→ Buprenorphine Awareness
→ Short-Term Opioid Withdrawal Using
Buprenorphine: Findings and strategies*
→ SMART Treatment Planning: Utilizing the ASI
→ MI Assessment: Supervisory Tools for
Enhancing Proficiency*
→ Promoting Awareness of Motivational Incentives*
*Based on CTN Studies
CTN Research Utilization Workgroups:
• Motivational Interviewing
• Buprenorphine Treatment
• Motivational Incentives
(Selection of interventions based on CTP
needs and by availability of Blending
Products. Opportunity to “kick the tires”
on the Blending Products.)
CTN Motivational Interviewing Trial
• Patients (n=423) assigned to MI at intake
subsequently completed more counseling
sessions (mean=5.02, sd=5.15) than
Standard Care patients (mean=4.03,
sd=4.21) during 28 days after
randomization (p<.05)
• MI patients more likely (84%) to still be
enrolled at the program after one month
than Standard Care patients (75%) (p<.04)
Agreement about Occurrence
M
I
A
STEP
Motivational
Interviewing
Assessment:
Supervisory Tools for
Enhancing Proficiency
MIA: STEP is…
– A multi-media tool kit for enhancing MI proficiency in
clinicians already knowledgeable about MI (“The last
thing we need is another MI training manual.” Bill
Miller)
– A resource for supervisors to help them become
more effective supervisors
– A supervisory model which emphasizes fidelity to the
intervention and bringing actual clinical material into
supervision
16 Rating Items
MI Consistent
MI Inconsistent
•
MI Style or Spirit
• Unsolicited Advice
•
Open-ended Questions
•
• Emphasize Abstinence
Affirmations
•
Reflections
•
Fostering Collaboration
•
Motivation to Change
•
Developing Discrepancies
• Asserting Authority
•
Pros, Cons, and Ambivalence
• Closed-ended Questions
•
Change Planning Discussion
•
Client-centered Feedback
• Direct Confrontation
• Powerlessness/Loss of
Control
Motivational Interviewing Workgroup:
Bill Miller (Researcher who developed MI)
Steve Martino (Researcher in CTN MI study)
Steve Gallon (ATTC Director)
Chris Farentinos (CTP Representative)
Train-the-Trainer in Use of the
Blending Product
• Applicants from CTN Nodes and ATTCs had to
first demonstrate MI proficiency using the MITI
system.
• 51 applicants + 3 MIA: STEP trainers
• 1/3 of the applicants were unable to demonstrate
MI proficiency in the first round
• 26 passed from CTN/18 passed from ATTC by
the second round
• Trained 42 individuals as MIA: STEP trainers
Training
• 2.5 days in Kansas City – sponsored by
the ATTC National Office
• Product overview
• Step-by-step experiential walk-through of
MIA: STEP
• Discussion of implementation issues
Roll-outs completed
• Prince William County Community Services Board,
Virginia N = 17
• North Carolina Alcohol Drug Abuse Treatment
Centers
N = 39
– Included psychiatrists, medical doctors, nurses,
recreational therapists, SA counselors, social
workers at three sites
• Hawaii State Providers N = 25
• ChangePoint, Oregon N = 5
• Baltimore, Maryland N = 6
Roll-outs completed
• Miami-Dade County/South Florida
Provider Coalition, 240 supervisors trained
• 100 hardcopies with CDs have been
distributed; NFATTC and Mid-Atlantic
ATTC both have 200 copies.
• http://www.motivationalinterview.org/lib
rary/MIA-STEP.pdf is averaging 12,000
downloads per week!
Implementation Considerations
•
•
•
•
•
•
•
MI training prerequisites
Individual vs. group supervision
Frequency
Setting-specific modifications
Agency support
State support
Curriculum/On-going consultations (CEUs)
• Support to train MIA: STEP
Where do we go from here?
• Listserv – Mid-Atlantic ATTC?
• Ongoing technical assistance for trainers, including
more practice sessions/co-ratings?
• Quarterly conference calls open to trainers and
supervisors?
• Obligations of trainers and $ to support them?
• Annual training of trainers or link training to
Blending Conference
• MI Proficiency standards: MITI or MIA: STEP and
with what support?
• Establish point person for ATTC (Gallon?) and CTN
(Martino?)
• How to monitor effectiveness of strategy?
What is missing?
99% = Investment in Intervention
Research to develop solutions
1% = Investment in Implementation
Research to make effective use of
those solutions (Up from ¼% in 1977)
Implementation Research Underway in
the CTN
• 7 Nodes
• 12 Studies underway
• Interventions: Motivational Interviewing; CBT;
TSF; Motivational Incentives; Process
Improvement Strategies
• Implementation variables: role of fidelity
measures; cultural adaptations; Web-based and
interactive CD Rom-based training; factors
promoting adoption after the end of CTN trials
Many thanks for your
attention!