Which elements of improvement collaboratives are most effective? A cluster‐randomized trial

Abstract

Aims Improvement collaboratives consisting of various components are used throughout healthcare to improve quality, but no study has identified which components work best. This study tested the effectiveness of different components in addiction treatment services, hypothesizing that a combination of all components would be most effective. Design An unblinded cluster-randomized trial assigned clinics to one of four groups: interest circle calls (group teleconferences), clinic-level coaching, learning sessions (large face-to-face meetings), and a combination of all three. Interest circle calls functioned as a minimal intervention comparison group. Setting Outpatient addiction treatment clinics in the U.S. Participants 201 clinics in 5 states. Measurements Clinic data managers submitted data on three primary outcomes: waiting time (mean days between first contact and first treatment), retention (percent of patients retained from first to fourth treatment session), and annual number of new patients. State and group costs were collected for a cost-effectiveness analysis. Findings Waiting time declined significantly for 3 groups: coaching (an average of −4.6 days/clinic, P=0.001), learning sessions (−3.5 days/clinic, P=0.012), and the combination (−4.7 days/clinic, P=0.001). The coaching and combination groups significantly increased the number of new patients (19.5%, P=0.028; 8.9%, P=0.029; respectively). Interest circle calls showed no significant effects on outcomes. None of the groups significantly improved retention. The estimated cost/clinic was $2,878 for coaching versus $7,930 for the combination. Coaching and the combination of collaborative components were about equally effective in achieving study aims, but coaching was substantially more cost effective. Conclusions When trying to improve the effectiveness of addiction treatment services, clinic-level coaching appears to help improve waiting time and number of new patients while other components of improvement collaboratives (interest circles calls and learning sessions) do not seem to add further value.

The Costs of Implementing Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care

“…Specifically, we sought to understand how much time and money a large FQHC might expect to spend on external facilitation and internal staff resources (e.g., physicians attending meetings) to create organizational readiness and to deliver OAUD services using collaborative care. There is some previous literature examining the cost of continuous quality improvement programs, including a study on depressive care in primary care clinics within the Veterans Affairs system (Liu et al, 2009), diabetes care in diabetes clinics (Sathe et al, 2016), Network for the Improvement of Addiction Treatment interventions (Gustafson et al, 2013), and a range of quality improvement activities in substance abuse treatment centers (Hunt, Hunter, and Levan, 2017). This report builds off previous literature by documenting some of the costs of SUMMIT in a primary clinic setting.…”

Influence networks among substance abuse treatment clinics: implications for the dissemination of innovations

“…After identifying clinics with the highest and lowest influence scores, we created indicator variables for three categories-influential, non-influential, and bridging (clinics that are poorly linked except to one or two influential clinics)-and performed a series of regression analyses using SAS 9.2 to identify whether being influential or being a bridging organization was associated with a difference in pace of joining the study or in the two outcome measures. For the first two linear regression analyses, the dependent variables were the two outcome measures, improvement in waiting time and an increase in annual program admissions [25,26]. Because the parent study had data from 18 months, we assumed better outcomes related to earlier or fuller adoption of the innovation.…”

“…Data for this study come from a parent study called NIATx 200, which was a cluster-randomized trial funded by the National Institute on Drug Abuse [25,26]. NIATx stands for the Network for the Improvement of Addiction Treatment (NIATx), which is a program within the Center for Health Enhancement S y s t e m S t u d i e s a t t h e U n i v e r s i t y o f Wisconsin-Madison.…”

Commentary on Gustafson et al. (2013): Can we know that addiction treatment has been improved without evidence of better patient 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 [1] 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 [9].…”

“…Gustafson and colleagues [1] 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.…”