Commentary on Gustafson et al. (2013)
Commentary on Gustafson et al. (2013): Can we know that addiction treatment has been improved without evidence of better patient outcomes?
Article first published online: 10 MAY 2013
© 2013 Society for the Study of Addiction
Volume 108, Issue 6, pages 1158–1159, June 2013
How to Cite
Humphreys, K. (2013), Commentary on Gustafson et al. (2013): Can we know that addiction treatment has been improved without evidence of better patient outcomes?. Addiction, 108: 1158–1159. doi: 10.1111/add.12144
- Issue published online: 10 MAY 2013
- Article first published online: 10 MAY 2013
- US Department of Veterans Affairs
- National Institute of Alcohol Abuse and Alcoholism
- Clinical practice;
- organizational change;
- quality improvement;
Gustafson and colleagues  are to be highly complimented for conducting what is probably the largest ever randomized trial of addiction treatment improvement methods. Both their negative and positive results are informative. Group discussions of treatment improvement opportunities, whether in person or over the telephone, do not produce sufficient organizational change to justify their cost. Perhaps 'twas ever thus: the old joke holds that 20 minutes into any meeting, half the attendees have drifted off into active sexual fantasy; but the problem may have become worse now that the other half are answering text messages or updating their Facebook pages. In contrast, focused work under the guidance of a coach can enhance treatment processes at a sustainable cost. So far, so good, in terms of changing treatment, but what about the patients?
What this impressive study does not establish is whether ‘improved’ treatment actually increases the likelihood that patients benefit from care. This lacuna is normative in the study of addiction treatment improvement . Many studies assume without evidence that reasonable-sounding changes in treatment process (e.g. increased retention) necessarily translate into better patient outcomes. However, some large, well-funded, skillfully conducted initiatives  have changed clinical practices within substance use disorder treatment programs but have seen little or no resulting improvement in patient outcomes (having been involved in several of such efforts, I acknowledge this with no small amount of disappointment) .
It could be granted that, because of the complexities of aggregating data across levels of analysis, improvement in the care and outcomes of individual patients will not necessarily be evident when researchers examine treatment program-level indicators of effectiveness [5, 6]; granted, further, that improving a job environment for the human beings who occupy it (e.g. improving morale, reducing interpersonal conflict) is a worthy goal. Such changes in the experience of addiction program staff may spill over into the treatment environment to the benefit of patients [7, 8] but, even if they do not, clinicians are people too and certainly worthy of salubrious work environments.
That said, it would certainly energize the addiction treatment improvement enterprise if researchers could demonstrate convincingly that making treatment better consistently produced significantly better outcomes. Otherwise, the treatment field founders on the contradiction of being a ‘vastly improved’ restaurant, where the food tastes the same as it always did and the patrons are no more satisfied with their meal. As they acknowledge, Gustafson and colleagues  did not have patient outcome data and therefore cannot conclude that expanding treatment improvement collaborations would necessarily improve the health of addicted people, yet encouraging signs are present in their results. Reduced waiting-times could plausibly benefit patients by lessening their likelihood of dropping out and not allowing motivation to dissipate prior to treatment . From a public health viewpoint, an increase in the number of new patients, such as the collaborative produced, could be of health benefit by giving more of the population in need at least some care, rather than limiting treatment to only a small population of desperately ill individuals . These speculated links between treatment process and health outcomes sound plausible, but because other equally plausible-sounding speculations have not been supported in many research studies, they must be demonstrated empirically before we can assume that the treatment improvements generated by Gustafson and colleagues actually result in better outcomes for anyone with addiction.
Declaration of interests
John Finney made insightful comments on a draft of this paper. Preparation of this paper was supported by grants from the US Department of Veterans Affairs and National Institute of Alcohol Abuse and Alcoholism. This paper does not necessarily reflect the official position of any government agency.
- 5Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy. Am J Public Health 2011; 101: 1635–1642., , ,
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