麻豆传媒

A personalized, hands-on care strategy for patients struggling with addiction was effective at reducing hospital readmission, a randomized trial found.

In a comparison of hospitalized adults with substance use disorder involving opioids, cocaine, or alcohol, those who received care saw far better outcomes than those who simply received treatment as usual, according to Jan Gryczynski, PhD, of the Friends Research Institute in Baltimore, and colleagues.

Patients who received this elevated care saw 26% lower rates of inpatient admissions during a 12-month observation period (HR 0.74, 95% CI 0.58-0.96, P=0.020), the group wrote in the.

This equated to 6.05 inpatient admissions per 1,000 person-days for those who had NavSTAR care versus 8.13 admissions per 1,000 person-days for the treatment-as-usual group.

This personalized care program also significantly reduced emergency department (ED) visits. Patients with substance use disorders saw a 44% reduced risk for an ED visit in the year after receiving NavSTAR care (HR 0.66, 95% CI 0.49-0.89, P=0.006). This equated to an event rate of 17.66 versus 27.85 ED visits per 1,000 person-days for the NavSTAR versus usual care patients, respectively.

And following this, patients who received NavSTAR care were half as likely to have an inpatient readmission within 30 days (15.5% vs 30.0%, P<0.001).

These patients were also far more likely to enter a community substance use disorder treatment program within the 3 months following hospital discharge (50.3% vs 35.3%, P=0.014). This outcome was quite important, as Gryczynski's group underscored that this is likely one of the main reasons why hospital readmission and ED visits were so much lower for this group.

"This is a highly refractory patient population characterized by significant morbidity, social vulnerabilities, and high levels of acute care use, often fragmented across multiple hospitals," the researchers wrote. "As such, these findings have important implications for patient care and service organization in hospitals concerned with reducing readmissions."

Reducing hospital readmissions for people struggling with substance use disorders also presents "a particularly vexing challenge," the group noted.

"They can affect hospital use in various ways, spanning direct consequences (such as overdose, soft tissue infections, and intoxication-related injury), longer-term sequelae (such as cirrhosis), and undermining treatment adherence and self-care," they added.

In total, the parallel trial included 400 adults at the University of Maryland Medical Center in Baltimore who were recruited through the addiction consultation service. All patients met the DSM-5 criteria for opioid, cocaine, or alcohol use disorder. Overall, 43% of the cohort were women, and 56% were Black. Of note, 43% were homeless.

The most common substances used were opioids (78.5%), followed by cocaine (53.5%) and alcohol (35.3%).

The NavSTAR program layered treatment as usual with motivational intervention delivered by a social worker, which was aimed at breaking down internal and external barriers to self-care. This included addressing the patient's own ambivalence towards overcoming addiction, as well as encouraging behavioral changes. Delivered bedside, the personalized care strategy also involved care coordination for the patient, including linking the patient to outside resources upon discharge, such as meeting basic needs like food, housing, clothing, and transportation. The social workers engaged with the patients on a weekly basis after discharge for the initial 4 weeks and then biweekly thereafter.

Treatment as usual involved in-hospital services from a multidisciplinary substance use disorder consultation liaison team.

During the year-long follow-up, 48 participants died: 10.5% in the NavSTAR group and 13.5% in the treatment-as-usual group.

Although the positive effect of the NavSTAR program likely also reduced healthcare costs, Gryczynski's group explained it wasn't directly measured in this analysis, but will be part of their future research.

Another limitation to this study was that urine tests to determine substances used didn't include fentanyl, which was on the rise in Baltimore at the time of the study, the researchers pointed out.

Comment