Transcript Related Journal Club Presentation

Journal Club
Alcohol, Other Drugs, and Health: Current Evidence
November–December 2013
Featured Article
Chronic care management
for dependence on alcohol
and other drugs: the AHEAD
randomized trial
Saitz R, et al. JAMA. 2013;310(11):1156–1167.
Study Objective
• To determine whether chronic care
management (CCM) for alcohol and
other drug dependence improves
substance use outcomes compared
with usual primary care.
www.aodhealth.org
3
Study Design
• Randomized trial comparing the effect of CCM versus usual
primary care.
• Participants were recruited from a residential detoxification
unit, an urban teaching hospital, and advertisements.
• Subjects were randomized to receive CCM (n=282) or no
CCM (n=281).
• The CCM group received:
– Longitudinal care for substance dependence and related
comorbidities
– Coordination of specialty care with primary care, where necessary
• The primary care-only group received:
– An appointment with a primary care provider
– A list of addiction treatment resources
www.aodhealth.org
4
Assessing Validity of an Article
about Therapy
• Are the results valid?
• What are the results?
• How can I apply the results to patient
care?
www.aodhealth.org
5
Are the Results Valid?
• Were patients randomized?
• Was randomization concealed?
• Were patients analyzed in the groups to
which they were randomized?
• Were patients in the treatment and control
groups similar with respect to known
prognostic variables?
www.aodhealth.org
6
Are the Results Valid? (cont‘d)
• Were patients aware of group allocation?
• Were clinicians aware of group allocation?
• Were outcome assessors aware of group
allocation?
• Was follow-up complete?
www.aodhealth.org
7
Were patients randomized?
• Yes, the study was a randomized controlled
trial.
– Patients were randomly assigned on a 1:1
ratio to CCM or primary care only.
www.aodhealth.org
8
Was randomization concealed?
• Yes.
www.aodhealth.org
9
Were patients analyzed in the groups
to which they were randomized?
• Yes.
www.aodhealth.org
10
Were the patients in the treatment
and control groups similar?
• No.
– Treatment groups differed on race and
depressive symptoms.
www.aodhealth.org
11
Were patients aware of group
allocation?
• Yes.
– Participants were not blinded to
treatments after assignment.
www.aodhealth.org
12
Were clinicians aware of group
allocation?
• Yes.
– Clinicians were not blinded to treatments after
assignment.
www.aodhealth.org
13
Were outcome assessors aware of
group allocation?
• Yes.
www.aodhealth.org
14
Was follow-up complete?
• There was a high rate of follow-up.
– Follow-up was conducted at 3, 6, and 12
months.
– Number of patients who provided 12-month
data for analysis:
• CCM group: 270 of 282 initially enrolled
• Control group: 262 of 281 initially enrolled
www.aodhealth.org
15
What Are the Results?
• How large was the treatment effect?
• How precise was the estimate of the
treatment effect?
www.aodhealth.org
16
How large was the treatment effect?
• There was no significant difference in the
primary outcome measure of 30-day
abstinence from alcohol or other drugs at 12month follow-up between the CCM (44%) and
the control group (42%).
• There was also no significant difference
between the groups in Addiction Severity
Index scores, quality of life measures, and
hospital or emergency department utilization.
www.aodhealth.org
17
How Can I Apply the Results to
Patient Care?
• Were the study patients similar to the
patients in my practice?
• Were all clinically important outcomes
considered?
• Are the likely treatment benefits worth
the potential harm and costs?
www.aodhealth.org
18
Were the study patients similar to
those in my practice?
• The patients came from an urban area.
• All were people with alcohol or other drug
dependence.
• Participant demographics included:
• Mean age of 38 years
• Majority male
• Majority white
• Majority (n=366) with both alcohol and drug
dependence
• Majority (n=332) recently homeless
www.aodhealth.org
19
Were all clinically important
outcomes considered?
• Yes.
www.aodhealth.org
20
Are the likely treatment benefits
worth the potential harm and costs?
• The intervention as delivered did not lead
to discernible benefits.
• No harms were identified and no costs
were presented.
• Further research may determine that
more intensive or longer-term CCM may
provide benefit.
www.aodhealth.org
21