Assertive Community Treatment for Alcohol Misuse Disorder Patients Who Are High Utilizers of Emergency Department Services: - A Prospective, Multi-centre, Before-and-After Cohort Study
Trial Snapshot
- Phase
- Not Applicable
- Status
- Not yet recruiting
- Sponsor
- Khoo Teck Puat Hospital
- Enrollment
- 300
- Primary Endpoint
- Emergency Department (ED) attendance
Study Overview
Brief Summary
Background Frequent attenders (FAs) at emergency department (ED) in Singapore hospitals have been increasing over the years. More than half of the FAs are reported to be alcohol-related frequent attenders (ARFA) and they were found to be using EDs unnecessarily. We aim to assess if there will be a difference in patient outcomes in terms of ED usage and cost-effectiveness by implementing an assertive community treatment (ACT) program to manage AFRAs.
Methods This is a prospective, multi-centre, before-and-after, superiority and cohort study to assess the impact of ACT from 4 study sites. 200-300 patients will be recruited and followed up for 12 months. The primary objective of the study is to investigate whether there will be a reduction in AFRA ED attendances. The secondary objective is to estimate the change in total cost utilization.
Conclusion/Significance All patients who are on ACT programme will be enrolled in this study. The study intervention will be used as a new mode of care at participating hospitals. We expect to see reduced alcohol addiction level, reduced isolation level, improved motivation and better overall health. With reduced alcohol-related hospital visits, we would also expect to see improved healthcare utilization by ARFAs which will lead to increased cost savings to the healthcare systems and decreased social costs.
Detailed Description
BACKGROUND Singapore has seen a steady growth in the use of emergency department (ED) services. ED visits increased from 752,122 in 2007 to 1,006,800 in 2013. Despite efforts to redirect low acuity ED patients to primary care, EDs continue to be busy and with long waits for patients. Data suggest that frequent attenders to ED take up a disproportionate share of the resources. Based on a set of pre-determined criteria, frequent attenders were found to be more likely to make inappropriate and unwarranted visits to ED. These ED visits would be better served by a different part of the healthcare system.
Patients with alcohol misuse problems are known to make up a significant proportion of frequent attenders. Such patients are referred to as Alcohol-Related Frequent Attenders (ARFAs).This population of patients exist in the community and tend to cycle through the healthcare system through emergency departments.
ARFA's are characterized by poor physical and mental health and a high level of unmet social needs, contributing to markedly poor engagement with appropriate services. They belong to the segment of patients with severe alcohol misuse disorders that have low motivation for change.
It is known that traditional clinic-based alcohol services have difficulty engaging ARFAs. Traditional treatment focuses on abstinence-based therapies. Its emphasis has been on patients who are ready to change their drinking and can organize their time sufficiently for on-site clinic treatment. Traditional treatment excludes ARFAs who are the most severe alcohol misuse patients. Such an approach has been supported by the argument that it is therapeutically appropriate to concentrate on patients that want to change while others are allowed to reach their personal rock bottom.
The traditional approach has been ineffective in treating the ARFA population. The majority of ARFAs do not present for treatments to reduce their drinking. Amongst alcohol misuse patients that present for treatment, the drop-out rate is high. Local data from the National Addictions' Management Service (NAMS) Specialist Outpatient Clinic shows that up to 75% of such patients drop-out of follow-up with a counsellor in just 3 months. Patients who engage poorly with addictions treatment tend to present instead to emergency services and have unplanned hospital admissions for alcohol-related consequences.
Study Design
- Study Type
- Observational
- Observational Model
- Cohort
- Time Perspective
- Prospective
Eligibility Criteria
- Ages
- 21 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- Yes
Inclusion Criteria
- •• Patients who are not on active follow-up at the National Addictions Management Service at the Institute of Mental Health (IMH).
- •Patients who speak English or Mandarin.
- •Patients who are 21 years of age or older.
- •≧2 SNOMED alcohol-related ED visits in last 12 months AND ≧5 Emergency Department visits (All-cause)
- •Patients who are cognitively intact and able to understand and appreciate the contents of the consent.
Exclusion Criteria
- •• Patients who are on active follow-up at the NAMS at the Institute of Mental Health (IMH).
- •Patients who are uncontactable by phone AND through opportunistic recruitment.
- •Patients who do not give consent.
- •Patients who do not speak English or Mandarin.
- •Patients who are under 21 years of age.
Outcomes
Primary Outcomes
Emergency Department (ED) attendance
Time Frame: 2 years
The primary outcome will be the rate of ED visits when comparing the pre-intervention period (12 months) with the post-intervention period (12 months). We anticipate a 25% reduction because of the ACT intervention.
Secondary Outcomes
- Level of Alcohol Dependence by Christo Inventory of Substance-misuse services (CISS score)(6 months (Baseline and 6 months post-intervention))
- Emergency Medical Services (EMS) 995 calls(2 years (12 months pre-intervention, 12 months post-intervention))
- Police Arrests(2 years (12 months pre-intervention, 12 months post-intervention))
- Sustained reduction in ED attendance and EMS calls(3 years (12 months pre-intervention, 24 months post-intervention))
- Police Offences(2 years (12 months pre-intervention, 12 months post-intervention))
- Center for Epidemiologic Studies Depression Scale Revised (CESD-R-10)(5 months (Baseline and 5 months post-intervention)
- UCLA 3-point Loneliness Scale(6 months (Baseline and 6 months post-intervention))
- Overall cost savings per patient(2 years (12 months pre-intervention, 12 months post-intervention))