Relapse prevention in alcohol aftercare: effects on drinking outcome, change process, and aftercare attendance.
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Adult↗
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Nutritional supplementation for hip fracture aftercare in the elderly.
BACKGROUND: Fractures of the hip are an important cause of later ill health and mortality in elderly people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. OBJECTIVES: This review assesses the effects of nutritional interventions in elderly people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, the Cochrane Controlled Trials Register, Medline, Nutrition Abstracts and Reviews, Embase, Biosis, Cinahl, Healthstar and reference lists. We contacted investigators, and hand searched Proceedings of the Nutrition Society, Clinical Nutrition and The Journal of Parenteral and Enteral Nutrition. Date of the most recent search: June 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials of nutritional interventions of mainly older patients (aged over 65 years) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories, was by consensus. Both reviewers independently extracted data and assessed trial quality. Additional information was sought from all trialists. Pooling of data for primary outcomes and select exploratory analyses were undertaken. MAIN RESULTS: Fifteen randomised trials involving 943 participants were included. Overall the quality of trials was poor; specifically in terms of allocation concealment, assessor blinding and intention to treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Oral multinutrient feeds (providing non-protein energy, protein, some vitamins and minerals), evaluated by six trials, may reduce unfavourable outcome (death or complications) (14/66 versus 26/73; Peto odds ratio 0.28, 95% confidence interval 0.11 to 0.67), but did not demonstrate an effect on mortality (12/91 versus 14/97; Peto odds ratio 0.82, 95% confidence interval 0.34 to 1.96). Four trials, examining nasogastric multinutrient feeding, showed no evidence for an effect on mortality (Peto odds ratio 0.98, 95% confidence interval 0.44 to 2.17), but the studies were heterogeneous regarding case-mix. Insufficient information was provided to evaluate unfavourable outcome. The effect of protein in an oral feed, tested in two trials, showed no evidence for an effect on mortality (Peto odds ratio 0.93, 95% confidence interval 0.31 to 2.79), but may have reduced days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of benefit for either vitamin supplement. REVIEWER'S CONCLUSIONS: The strongest evidence for the effectiveness of nutritional supplementation exists for oral protein and energy feeds, but the evidence is still very weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.
Aged↗
[Results of functional aftercare following surgically treated ruptures of the outer ligaments. A comparative study of aftercare by a lower leg walking cast or the Dr. Spring special shoe].
There is no doubt that primary suturing of the ruptured ankle ligament gives the best results regarding joint stability. However, there are differing views concerning the follow-up treatment. In particular, there are controversial opinions about the value of a special shoe by Dr. Spring during the rehabilitation phase. During the period April 1984 to July 1985 100 patients with rupture of the fibular ligament were treated operatively, 50 of whom were treated post-operatively with 14-day lying plaster of Paris followed by a further 14 days with the special shoe from Dr. Spring and 50 with a lower leg walking plaster of Paris. The results were compared over a period of 8 weeks, using objective criteria. The subjective impressions followed after at least 6 months. After 8 weeks the mobility of the joint in dorsalflexion and pronation is similar in both groups; in plantar flexion and supination better mobility was seen after the plaster of Paris treatment. There was no significant difference in the duration of unfitness for work. Subjectively, there was a reduced tendency to swelling after the plaster of Paris treatment.
Adolescent↗
Increasing participation in substance abuse aftercare treatment.
Increasing the length of participation in alcohol and drug treatment is associated with improved outcomes (1). The present study was designed to increase substance abuse aftercare participation following completion of inpatient treatment. We compared the effect of a 20-minute aftercare orientation session to a minimal treatment condition on aftercare group therapy participation. The orientation session was conducted by an aftercare group therapist, who met with the participant to encourage him to attend aftercare, to explain why aftercare is helpful, and to have him sign an aftercare participation contract. Participants in the minimal treatment condition watched a videotape on motivation to reach goals. Participants were 40 males in an inpatient substance abuse treatment program at a Veterans Affairs Medical Center (VAMC). Ninety percent were alcohol dependent; 35% were cocaine dependent; 10% were marijuana dependent; and 10% were polysubstance dependent. Participants who received the aftercare orientation were more likely to attend aftercare (70%) than those who received the minimal treatment (40%). Additionally, the former group attended more sessions (x = 3.0) than those who were not oriented to aftercare (x = 1.4). The utility and limitations of a brief orientation session on aftercare adherence are discussed.
Adult↗
The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment.
This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression. Patients living farther from their source of outpatient mental health care were less likely to obtain aftercare following inpatient substance abuse treatment. Patients who traveled 10 miles or less were 2.6 times more likely to obtain aftercare than those who traveled more than 50 miles. Only 40% of patients who lived more than 25 miles from the nearest aftercare facility obtained any aftercare services. Patients who received aftercare services had fewer visits if they lived farther from their source of aftercare. Lack of geographic access (distance) is a barrier to outpatient mental health care following inpatient substance abuse treatment, and influences the volume of care received once the decision to obtain aftercare is made. Aftercare services must be geographically accessible to ensure satisfactory utilization.
Adult↗
Matching substance abuse aftercare treatments to client characteristics.
This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.
Adult↗
Length of stay, referral to aftercare, and rehospitalization among psychiatric inpatients.
OBJECTIVE: This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients. METHODS: Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support. RESULTS: Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission. CONCLUSIONS: The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.
Adult↗
Predictors of participation in aftercare sessions and self-help groups following completion of intensive outpatient treatment for substance abuse.
OBJECTIVE: The goals of this study were to identify predictors of greater participation in aftercare treatment sessions and self-help groups during the first 3 months following completion of a 4-week intensive outpatient rehabilitation (IOP) program. METHOD: The subjects were 138 male veterans who met DSM-III-R criteria for lifetime diagnoses of both alcohol and cocaine dependence (n = 67), alcohol dependence only (n = 48) or cocaine dependence only (n = 23); completed an IOP program; and expressed a desire to enter a formal aftercare program. Analyses examined relationships between predictor variables from five different domains and number of aftercare sessions and self-help groups attended in the last week of each month of the follow-up period. RESULTS: Of the many potential predictor variables that were examined, only remission from cocaine and alcohol dependence during IOP and higher AIDS risk behavior scores in the prior 6 months contributed independently to the prediction of greater participation in aftercare. Further analyses identified several variables that were differential predictors of participation in individualized relapse prevention aftercare versus standard 12-step focused group aftercare. More years of cocaine use, greater current legal problems and a lack of current alcohol dependence predicted greater self-help participation at the level of a trend. CONCLUSIONS: The achievement of remission from substance use dependence during IOP may be an important criterion for moving to the next level of care. However, the results of the present study also point to the need for an increased focus on factors present during the course of aftercare in future studies of retention in aftercare following outpatient rehabilitation.
Acquired Immunodeficiency Syndrome↗
Do burn patients need burn specific multidisciplinary outpatient aftercare: research results.
In a cross-sectional study of patients 12-24 months after a burn injury, the need for a multidisciplinary burn specific outpatient clinic was examined in relation to aftercare consumption, physical and psychological problems. Four hundred and twenty nine patients were assessed by means of three self-report questionnaires: IES, SCL(PTSD-SL) and BSHS-SV-S. Results indicated that the current aftercare providers are almost exclusively medical doctors and that a quarter of the patients are dissatisfied with received aftercare. However, dissatisfaction about current aftercare was not the only criterion to determine whether patients wanted burn-specific aftercare. The severity of psychological and physical problems predicted interest in a multi-disciplinary outpatient clinic. Self-reported psychological and physical problems were found to be related to one another. Univariate logistic regression outcomes suggested that patients with serious psychological and physical problems are more likely to express interest in a burn-specific outpatient clinic, but that, in a multivariate regression analysis, physical problems and psychological problems measured on the SCL(PTSD-SLEEP) do not contribute to the prediction of the interest in a burn-specific outpatient clinic anymore once symptoms of PTSD are taken care of. Results suggest that psychological aftercare for burn patients needs to be improved. Possible steps to improve aftercare to meet patients' needs are discussed.
Adaptation, Psychological↗
Social reinforcement of substance abuse aftercare group therapy attendance.
Although adherence to aftercare therapy in substance abuse treatment is associated with improved treatment outcome, relatively little research has explored methods of improving aftercare adherence. To improve on established methods of promoting aftercare adherence, 43 graduates of the 28-day intensive substance abuse treatment program at the Salem Veteran's Affairs Medical Center who received standard aftercare orientation are compared to 38 graduates who received the standard intervention plus social reinforcement of aftercare group therapy attendance. Clients who received social reinforcement attended more aftercare group sessions than did clients who received the standard treatment during the 8-week intervention (68.8% vs. 49.4% of sessions attended), and during the 4-week follow-up period (41.5% vs. 31.4% of sessions). These findings are noteworthy since the standard treatment had been shown to be effective in increasing aftercare adherence in prior studies (Lash, 1998; Lash & Blosser, 1999). Areas for future research are discussed.
Adult↗
Effectiveness of a stand-alone aftercare program for drug-involved offenders.
A study was made of the effectiveness of an aftercare program operating in conjunction with area outpatient drug free treatment programs while organizationally independent of those programs. Parolees and probationers mandated to treatment were assigned to aftercare on the basis of residence in the catchment areas in which aftercare facilities were located (n = 32) and randomly to aftercare (n = 62) and control (n = 51) when not a resident in a catchment area. No outcome differences were found between aftercare groups based on proximity to facility. At 6 months postbaseline the combined aftercare group showed significantly lower levels of criminal activity and frequent drug use as compared to controls. At 12 months postbaseline there was an attenuation of group differences with only tendencies toward significance obtained for lower levels of frequent drug use by the aftercare group. The findings are discussed in terms of the relevance of community variables for programming and for understanding long-term treatment outcomes.
Adult↗
Increasing adherence to substance abuse aftercare group therapy.
Adherence to aftercare therapy in substance abuse treatment is associated with improved outcomes. Although previous research has established that adherence contracts and orientation to aftercare are an effective method of increasing aftercare attendance, participation levels are often low. We examined whether feedback and prompts are an effective means of further increasing adherence to substance abuse aftercare group therapy beyond that found when orientation and adherence contracts are completed. We randomly assigned 41 substance dependent individuals completing inpatient or intensive outpatient treatment to receive either attendance feedback and prompts to attend aftercare, or no feedback and no prompts. participants who received the feedback and prompts were more likely to begin aftercare, and to attended more weekly aftercare groups, and they were less likely to be readmitted to the hospital. The clinical utility of prompts and feedback are discussed.
Adult↗
Perceived self-efficacy as a predictor of aftercare treatment entry by the detoxification patient.
63 urban, male, polysubstance abusers enrolled in an inpatient, hospital detoxification program with plans for aftercare were administered a set of 27 items describing behaviors that staff members nominated as necessary to make a transition from detoxification to aftercare. Patients were asked to rate each item twice, estimating (1) the importance of the described behavior to the achievement of aftercare and (2) their perceived ability to execute it. These ratings produced two highly saturated univariate tests, the Importance to Aftercare Scale (alpha = .89) of 17 items that did not predict aftercare entry and the Perceived Efficacy to Aftercare Entry Scale (alpha = .90) of 20 items which did correlate (.28) with entering aftercare.
Adolescent↗
The effects of travel barriers and age on the utilization of alcoholism treatment aftercare.
OBJECTIVE: The objective of this research was to ascertain whether geographical accessibility (in conjunction with other patient characteristics) reduced the probability of participating in alcoholism aftercare treatment. METHODS: A sample of 4,621 United States male veterans discharged with an outpatient appointment from one of 33 Department of Veterans Affairs inpatient Alcohol Dependency Treatment Programs was identified. The outpatient records of each patient were obtained to determine whether aftercare services were utilized following discharge. Binary choice analysis was used to model the decision to enter aftercare treatment as a function of travel distance, age, marital status, ethnicity, severity of illness, and urbanization. RESULTS: Travel barriers significantly reduced aftercare participation, especially for elderly and rural veterans. Both younger and older veterans were less likely to keep their aftercare appointment than middle-aged veterans. Married patients were more likely to utilize outpatient services than unmarried patients. Ethnic status, severity of illness, and urban size all negatively affected the likelihood of appointment attendance. CONCLUSIONS: The results obtained from this analysis can be effectively used to identify which patients are not likely to enter aftercare alcoholism treatment. The discharge plans of patients at risk for appointment noncompliance should be given special attention since aftercare has been shown to improve treatment outcome. Moreover, because alcoholism treatment reduces the utilization of other medical services, promoting continuity of care should help lower the overall costs of providing health care to alcoholic patients.
Adult↗
Do aftercare services reduce inpatient psychiatric readmissions?
OBJECTIVE: To determine whether aftercare services reduce the likelihood that children and adolescents will be readmitted to inpatient psychiatric facilities. DATA SOURCES/STUDY SETTING: Analyses of data from the Fort Bragg Demonstration. Data were based on 204 sample individuals (children and adolescents), all of whom were discharged from inpatient facilities during the study period. STUDY DESIGN: These analyses use hazard modeling to examine the impact of aftercare services on the likelihood of readmission. Comparisons of individuals for whom the timing of aftercare services differ are adjusted for a wide range of individual characteristics, including client demographics, diagnosis, symptomatology, and psychosocial functioning. DATA COLLECTION/EXTRACTION METHODS: Detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. This information was taken from structured diagnostic interviews and behavior checklists, including the Child Behavior Checklist and Diagnostic Interview Schedule for Children, completed by the child and his or her caretaker. Information on the use of mental health services was taken from insurance claims and a management information system, and was used to identify the period from discharge to readmission and to describe the client's use of outpatient therapy, case management, intermediate (or stepdown) services, and residential treatment centers during this period. PRINCIPAL FINDINGS/CONCLUSIONS: Using Cox models that allow for censoring and that include the use of aftercare services as time-varying covariates, we find that aftercare services generally do not influence the likelihood of inpatient readmission. For the lower middle class families included in this study, the estimated effect of aftercare is not statistically significant and has limited practical significance. When we look at specific forms of aftercare, we find that outpatient therapy has the largest effect and that stepdown services in intermediate settings have the smallest. We also identify family and individual characteristics that influence the likelihood of readmission.
Adolescent↗
Community psychiatric nurse aftercare for alcoholics: a five-year follow-up study.
The aim of this study was to determine if community psychiatric nurse (CPN) aftercare for 1 year improved the 5-year outcome in patients following inpatient treatment for alcohol dependence. A 5-year follow-up study, observer blind, with non-random allocation of subjects to aftercare by CPN for 1 year or standard outpatient care, was used. Subjects had all received inpatient treatment for 6 weeks in a rural alcohol treatment unit. Subjects were traced and assessed in the community 5 years after the index admission. The participants consisted of 127 white male alcoholics. All were first admissions, who had been selected for inpatient treatment and who completed a 6-week inpatient stay. Seventy-three subjects received intensive aftercare by CPN for 1 year, 54 subjects received standard outpatient appointments not due to random allocation but because no CPN was available. Data were collected by semi-structured interview at entry to the trial, namely background epidemiological information, details of drinking history, previous hospital admission, educational, employment and criminal information. At 5-year follow-up, data on drinking status, use of other drugs, hospital admissions, criminal behaviour and gambling, attendance at self-help groups, relationships and employment were collected. Thirty-six per cent of the CPN aftercare group was completely abstinent during the 5 years after treatment compared to 6% of the standard aftercare group (p < 0.001). Subjects receiving CPN aftercare were less likely to report blackouts (p < 0.05) or gambling (p < 0.05). They were more likely to attend hospital meetings (p < 0.0001). CPN aftercare is an effective way of maximizing the effects of inpatient treatment. The effects endured for 5 years after treatment.
Adolescent↗
Posttreatment follow-up, aftercare, and worksite reentry of the recovering alcoholic employee.
A review of literature on the effects of aftercare in the treatment of alcoholism reveals mixed results, with some studies showing positive effects and some showing no effects. However, few studies controlled for bias in the process of selection into aftercare, and many of the studies reveal significant difficulties in engaging patients into aftercare. The relapse prevention model is reviewed as a potentially powerful tool for use in aftercare. The literature on worksite reentry of alcoholics shows a generally positive correlation between employment and recovery, but does not produce unambiguous findings regarding the direction of the relationship. A nontraditional, proactive approach to aftercare is proposed, based on studies of other types of health problems that show improved results with this approach. It is argued that the worksite is the most appropriate place to locate aftercare services for employed alcoholics, particularly worksites with employee assistance programs. However, further research is needed to guide the development of these services.
Aftercare↗
An analysis of distance variables that affect aftercare attendance.
Recent reserach has examined variables related to attendance of aftercare services because of the correlation between aftercare and posthospitalization treatment success. The present study, which examined aftercare attendance for 40 randomyl selected subjects following discharge from an inpatient alcohol treatment program, extends the list of variables found to influence attendance. A multiple-regression analysis of subject demographic variables and variables of a more programmatic nature found that distance variables (e.g., number of miles to an aftercare agency) significantly influenced aftercare attendance. The results are discussed with respect to aftercare program decisions.
Adult↗