How Does Practice Change for the Clinician, the Organization, and the

System?

Joseph GuydishUniversity of California, San Francisco

joseph.guydish@ucsf.edu

39th Semi-Annual SARC Meeting, Burbank, California 40th Semi-Annual SARC Meeting, Sacramento, California

This work was supported by NIDA (R01 DA020705, R01 DA-14470), by the California-Arizona Node of the Clinical Trials Network (U10 DA015815), and by the NIDA San

Francisco Treatment Research Center (P50 DA009253).

Practice Change at Different Levels

IndividualOrganizationalSystem

State Licensing and regulatory Counselor training

Clinical Trial

ResourcesAdherence

ProjectStaffAdmin

SettingUsual Staff

Training InterventionIntervention

MotivationsInterests Supervisor

Adoption of new practices in the context of clinical trials

Motivational Interviewing/Enhancement (MI/MET) Study of Adoption

2 NIDA multi-site clinical trials within Clinical Trials Network (CTN): – Motivational Interviewing (MI)– Motivational Enhancement (MET)

11 sites nationally, we studied 5

5 clinic sites (California, Oregon)

Qualitative Methods to study adoption in clinical trials

Sequential qualitative study of two clinical trials

29 interviews at 7 organizational levels

Data coded according to emerging themes

Team discussion of coding results

Data interpretation based on analytic memos and theoretical frameworks of organizational change

Adoption• ... we saw something ...that fit our philosophy about how you treat people. And, we trained our

staff... in the ‘Changing for Good’ book. [We] ... did a chapter a month, had different people leading the discussions… and assigned people reading time and reduced some of their workload in order to give them time to do it...

Clinic Director• Even with the data that we already got in [the clinic], we feel good enough to say, “Well, it’s not a

bad intervention,” ... . But it actually shows a little better, ...retention and completion rates [relative advantage]... we want to be able to …implement the MI… assessment for the whole clinic. But... we have to wait now to finish this other [study] .... At that point... we will have done the training for everybody... And then, we…want to do ... the MI piece, and make that be our assessment. ... we’re going to really implement it. Probably not with the rigors of research, but ...

Clinical Supervisor• ... in my assessments... even the design of the domestic violence part of the assessment is very

motivational interviewing. And... I’ve redesigned most of the ...assignments [adaptation], to really work with... the... ambivalence... and have really tried to use [MI] … in the written assignments.

Counselor

No Adoption• There was a three-session manual, but people are always gonna want to do what they think is in

the best interest of the client. ... if the client comes in and says, I had a horrible thing happen and I really want to spend the session today talking about that, and it says in the manual, well, you have to do blah blah blah ... people who do treatment aren't gonna do it. But … the manuals could provide ... good techniques. And that, I think, does get integrated.

Clinical Supervisor

• ... if [a counselor] heard about an interesting conference, ... and it was ... how to do motivational interviewing... she would be interested in that. She would think back - "yeah, I know a little bit about MET, and… it seemed really interesting when it worked with people." ... And I'm interested in doing more... But see, nobody cares about that.

Clinical Supervisor

• I tried to use [MET] in the groups. And it worked really well... the clients ... gave better responses to questions ... when I repeated back what they had said. Like, ... if I said, well, how long has it been since you last used? Well, I used maybe a week ago... Oh, okay. Only about a week ago. Do you think you could do a little bit better the next time? Do you think maybe you can go another week or something? ... Why don't you see if you can go for two weeks…

Counselor

Adoption (Organizational Level)

SITE MI/MET

Adoption

Site 1 Yes

Site 2 Partial Adoption

Site 3 Counselor Adoption

Site 4 No

Site 5 No

Adoption in Clinical Trials

Three similar studies:Fals-Stewart (2004): 1 out 5 clinics adopted BCTGuydish (2005): 1 out of 6 clinics adopted MatrixGuydish (2009): 2 out of 5 clinics adopted MI/MET

Together, 4 of 16 clinics (25%) adopted after participating in clinical trial

Quantitative Methods to study adoption in clinical trials

Does the presence of smoking cessation clinical trial affect staff practices related to smoking?

2 experimental clinics vs. 3 control clinics

Knowledge, attitudes and practicesBaseline, 18 month FU

Survey staff Administrative and clinical All paid staff (full/part time) Reimbursed $25 for participation

Source: Chun, Jongserl, Guydish , Joseph & Delucchi , Kevin (2009). Does the presence of smoking cessation clinical trial affect staff practices related to smoking? Journal of Drug Issues, 39, 385-400.

KAP sample scale items

Knowledge – Hazards of smoking have been clearly demonstrated– Smoking increases risk of heart attack

Barriers– Lack of reimbursement– Lack of impact on patients

Self-efficacy– My patients follow my advice about behavior change– If counseled patients who smoke what percentage would you think would quit

smoking? Beliefs

– Smoking personal decision which does not concern counselor– If in recovery less than 6 months quitting smoking would threaten sobriety

Practices– How often advise patients who smoke to quit– Encourage patients to use NRT

Source: Delucchi, Kevin, Tajima , Barbara & Guydish, Joseph (2009). Development of the smoking knowledge, attitudes and practices (S-KAP) instrument. Journal of Drug Issues, 39, 347-364.

Knowledge, Attitudes, Practices Experimental vs. Control

ExperimentalN=57

ControlN=62

Baseline 18 months Baseline 18 months

Knowledge 4.36 4.40 4.25 4.34

Beliefs 4.07 4.05 3.89 3.83

Barriers* 1.78 1.68 1.92 1.96

Self-Efficacy 3.40 3.45 3.25 3.20

Practice 3.28 3.15 2.70 2.82

Source: Chun, J., Guydish, J. & Delucchi, K. (2009. Does the Presence of Smoking Cessation Clinical Trial Affect Staff Practices related to Smoking? Journal of Drug Issues, 39, 385-400.

Summary

Changes in clinical practice can occur at the individual counselor level.

The presence of a research study testing new interventions in clinical settings has limited effect on changing practices.

Can we change clinic practices at the organizational level?

Does an organizational change intervention affect staff practices related to smoking?

Developed by Hoffman and Slade (1993) to address tobacco use in tx programs in New Jersey

12-step approach to implementation

6-month manualized intervention

Core strategies Formation of tobacco leadership group On-site consultation Formation of workgroup to address 12-step

approach

Aims

Change organizational practices related to smoking using the ATTOC intervention:

– Changes in staff knowledge, attitudes and practices (KAP)

– Changes in client knowledge, attitudes and services (KAS)

Methods3 residential treatment programs

Data Collection (pre, post, follow-up) Staff surveyed (knowledge, attitudes, practices)

Administrative and clinical staff Clients interviewed (pre, post, follow-up)

Convenience sample of N=50 at each time point Minimum 10 days in treatment

Nicotine Replacement Therapy Offered to staff and clients Nicotine patch and gum

Study Design

CTP 2

CTP 1

CTP 3

O1 O3O2X

O2 O3O1 O4X

O2 O3 O4 O5X

ATTOC Staff KAP

3.5

4

4.5

Pre Post

Knowledge

1.5

2

2.5

Pre Post

Barriers

3

3.5

4

Pre Post

Beliefs*(S,T)

2.5

3

3.5

Pre Post

Efficacy*(S,T)

2

2.5

3

Pre Post

Practice*(S,T)

Site 3

Site 2

Site 1

(S) = significant site effect(T) = significant time effect

Smokers at Pre and PostAll three sites combined

McNemar’s, p=0.002

GEE, p=0.001

ATTOC Client KAS

3.5

4

4.5

Pre Post

Knowledge*(S)

3

3.5

4

Pre Post

Attitudes*(S,T)

1

2

3

Pre Post

Services*(T, SxT)

Site 3

Site 2

Site 1

(S) = significant site effect(T) = significant time effect(S x T) = significant site x time interaction

ATTOC SummaryPre to Post Pre to F.U.

Staff:

Knowledge

Barriers

Self-efficacy

Beliefs

Practices

Client:

Knowledge

Attitudes

Services

SummaryIndividual practice change can occur, but this

reaches only small client groups.

Organizational practice change can reach all clients served in a clinic, but reach only a small number of clinics.

What about practice change at the system level?

The New York State Systems Change Intervention: Tobacco Dependence

The New York Office of Alcohol and Substance Abuse Services (OASAS) Regulates and licenses 1550 treatment and prevention programs In 2003, initiated a 4 year plan leading to tobacco dependence policy Regulation completed in July 2007

– smoke free grounds– no-evidence (of smoking) policies for staff– tobacco dependence intervention for all clients who request – $4 million, one year contract to deliver smoking-related training to programs and staff – $4 million to provide Nicotine Replacement Therapy to all programs

Regulation implemented in July 2008

New York Tobacco Policy Study*22 late surveys have not been scanned into dataset

Clinic Staff N

Completion rate ClientN

Residential #1 28 100% 46

Residential #2 29 93% 35

Residential #3 39 92% 48

Residential #4 27 93%* 50

Residential #5 43 79%* 50

Outpatient #1 22 95% 50

Outpatient #2 12 92% 25

Outpatient #3 31 94% 50

Outpatient #4 7 86% 30

Outpatient #5 16 100% 25

TOTAL 254 91% (232) 409

Client Smoking

AllN=406

ResidentialN=227

OutpatientN=179

Current Smoker 70% 61% 81%

Quit < 6 months ago

22% 33% 8%

KAP: New York vs. Comparison Group

KAP: New York vs. Comparison Group

Conclusions

• Current strategies for changing drug abuse treatment practices focus on the individual counselor

• Funding and regulatory agencies want changes at the program and system level

• These require integrated change strategies, which involve counselor training, organizational support and system incentives