Evaluation of an inpatient alcohol rehabilitation programme

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<ul><li><p>Drug and Alcohol Dependewe, ll(1963) 333452 Elsevier Scientific Publishers Ireland Ltd. </p><p>EVALUATION OF AN INPATIENT REHABILITATION PROGRAMME </p><p>D. IAN SMITH </p><p>333 </p><p>ALCOHOL </p><p>Western Australian Akohol and Drug Authority, Salvatori House, 35 Outmm Stwet, West Perth, 6005 (Australia) </p><p>(Received December 29th, 1982) </p><p>SUMMARY </p><p>A retrospective matching procedure was used to form a control group of 145 men who underwent detoxification, but unlike the treatment group did not enter the Quo Vadis Hospital rehabilitation programme. On a wide range of variables for which data was obtained at follow-up interview, respondents in the two groups were very similar. By contrast, official records data showed that the treatment group had significantly more re- admissions to the detoxification hospital during the follow-up period than the control group. A number of methodological issues are briefly discussed. </p><p>Key words: Treatment-Alcohol -Detoxification -Outcome </p><p>INTRODUCTION </p><p>In the field of alcohol treatment there is an urgent need for evaluative studies. In a number of literature reviews [1,23 it has been shown that many rehabilitation programmes do not achieve their objectives and may even be worse than ineffective [3]. As a result, health and welfare workers have become increasingly aware of the need to scientifically evaluate the effectiveness of such programmes. </p><p>The purpose of this paper is to summarise the principal findings of a study* which evaluated the effectiveness of the Western Australian Alcohol and Drug Authoritys Quo Vadis Hospital rehabilitation programme by </p><p>*D.I. Smith, unpubliahed report, Western Australian Alcohol and Drug Authority, 1981 and unpublished supplementary report, 1982. </p><p>@ 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland </p></li><li><p>334 </p><p>comparing a group of persons who entered the programme during 1978 and 1979 with a similar group of persons who did not enter the programme. </p><p>The Quo Vadis Hospital programme The Hospital could accommodate 35 patients and had 30 full-time and </p><p>eleven part-time ataB comprising Nurses, Welfare officers, Rehabilitation Assistants and support ataB. Medical OfEcers and an AA Counsellor regularly visited the Hospital. </p><p>In the work rehabilitation programme patients were encouraged to undergo re-training in work skills and develop regular working habits so that when a person left the Hospital he would be ready to obtain employ- ment. In a weekly talk by a Medical Oflicer the adverse physiological effects of alcohol were stressed. The nursing staff reinforced the material presented by the Medical Oflicer and encouraged patients to have a high standard of nutrition, hygiene and physical health. Some emphasis was placed on the development of leisure time activities. Patients regularly participated in crafts and hobbies sessions. A range of sporting facilities were available for use by the patients at the Hospital and regular weekend outings were arranged to places with non-drinking facilities. </p><p>Participation in AA was a vital programme constituent. The patients attended one outside evening meeting and conducted their own Quo Vadis Hospital meeting one night a week. In view of the AA component, not surprisingly the programme had an abstinence goal. Patients were not permitted to consume alcohol and patients returning from leave were required to submit to a breathalyzer test. On admission patients were advised that a positive test result would lead to their discharge. </p><p>While patients of both sexes, who may be either alcohol- or drug-depen- dent were admitted, the majority were male non-aboriginal alcohol-depen- dent persons. Approximately three-quarters of the patients were admitted following their discharge from Aston Hospital, the Authoritys medical detoxification unit in West Perth. Most of the remaining patients came from Carrellis Centre, the Authoritys assessment centre, with the balance being referred from hospitals and other health centres in the metropolitan area. Patients were encouraged to stay for approximately 12 weeks, but some left much sooner while others stayed for as long as 6 months. </p><p>Type of experimental design The need to include an appropriate control group in studies evaluating </p><p>alcohol treatment programmes has been stressed 131. Otherwise it would not be possible to determine the extent to which clients changed as a result of the treatment as distinct from the natural tendency of alcohol dependent persons to improve with time [2,41. </p><p>A retrospective matching procedure similar to that of Annis and Liban [5] was used to form the control group. In the terminology of Campbell and Stanley 161, the experimental design was quasi-experimental and in parti- </p></li><li><p>335 </p><p>cular it was a non-equivalent control group design in which the patients were self-selected, that is, the researcher did not control whether a person entered the treatment or control group. Especially if the two groups are well matched, such a study design can provide the necessary information to rule out the hypothesis that an intervention is having an effect. </p><p>The use of a retrospective matching procedure had a number of ad- vantages over random assignment to treatment and control groups in a prospective study. Firstly, the ethical question of denying patients the opportunity to enter treatment when facilities were available was avoided. Secondly, patient selection was not restricted to persons willing to parti- cipate in an experiment. This can be an important source of bias 141. Thirdly, as staff and patients did not know that the evaluative study was to be conducted, threats to external validity arising from special efforts by the staff or patients or from a Hawthorne effect did not occur. Fourthly, it ensured that a significant result in favour of the treatment group could not be attributed to an aversive state in the control group patients arising from their disappointment at their assignment to a control rather than experi- mental condition. Emrick 121 summarised five studies and showed that the results suggested that elements in the treatment environment harm alcohol dependent persons by eliciting thoughts and feelings of disappointment, abuse, neglect or rejection when the patients are not selected for treatment after volunteering. This aversive state can function as an antecedent to further drinking, resulting in fewer patients improving. In the often cited study of Sobell and Sobell 171, no less than 40% of the clients in the non-behaviour therapy group felt permanently rejected at a 2-year follow-up interview. A further 20% initially experienced rejection, but then felt bet- ter. Only 13% felt good or okay about not being selected for the experi- mental treatment. </p><p>The questioning of the value of random assignment has not been confined to the alcohol treatment field. Black [8], for instance, argued that where there are many factors which can influence the outcome and the factors are both multiple and unpredictable, effective randomisation becomes im- possibly complex. In a leading article the British Medical Journal 191 stated that the controlled trial has been placed on too high a pedestal and needs to be brought back to earth. After showing that random assignment can be inferior to the use of retrospective controls, Cranberg 1101 concluded that ho one method is best in every case, and the choice of the method rests on consideration of the options and their consequences. Those designing a trial should not succumb to fashion in experimental design and assume that a strictly controlled clinical trial is necessarily a trial that uses concurrent controls. Due to the artificiality of random assignment, it is clear that evaluative studies of alcohol treatment programmes which include random assignment to treatment and control conditions will not necessarily give more accurate results than studies including retrospective matching. </p><p>In a thought-provoking paper Athey and Coyne 1111 argued that evaluative studies which involve the imposition of special treatment (or no </p></li><li><p>treatment) conditions by randomisation are unlikely to be of much, or perhaps any benefit. To overcome these important methodological problems, Cottheil [12] advocated that evaluators should follow matched groups of alcohol dependent persons exposed to different treatments or no treatment. This was the approach adopted for the Quo Vadis Hospital evaluation study. </p><p>METHOD </p><p>Treatment and control groups The treatment group comprised 145 male non-aboriginal alcohol </p><p>dependent persons who were first admitted to Quo Vadis Hospital in the period from January 1, 1978 to December 31, 1979, within 7 days of being discharged from Aston Hospital following detoxification. The one-week cut- off point was selected as patients sometimes like to spend a weekend at home between being discharged from Aston Hospital and being admitted to Quo Vadis Hospital. Aboriginal, female and drug dependent persons were excluded from the study due to the small number of such persons admitted to Quo Vadis Hospital. Patients admitted to Quo Vadis Hospital for rest and recuperation reasons before entering the Authoritys Ord Stree t Hospital probramme were also excluded. (The Ord Street Hospital has an eight week inpatient programme for persons with less physical damage and more verbal ability than those admitted to Quo Vadis Hospital). From the viewpoint of an evaluative study, 145 matched persons per group was a very satisfactory number, especially when it is realised that some major studies in the alcoholism treatment field have only had 50 or less persons per group </p><p>171. For each person included in the treatment group a similar person was </p><p>selected from the Aston Hospital records to form the control group. The criteria for matching were: (i) male; (ii) alcohol dependent; (iii) non- aboriginal; (iv) never admitted to Quo Vadis Hospital; (v) approximately the same age; (vi) similar marital statu$; (vii) similar usual occupation as denoted by the categories in Congaltons [13] scale; (viii) similar employment status of unemployed or employed when entered the study; (ix) similar place of birth; (x) admitted to Aston Hospital at approximately the same time as the treatment group person in order to elinate any confounding due to seasonal changes; (xi) approximately the same duration of hospitalisation in Aston Hospital prior to entering the study; (xii) approximately the same number of prior admissions to Aston Hospital in order that the two groups would be approximately equivalent in past treatment experiences, the importance of which was stressed by Schuckit and Cahalan [3]. </p><p>*Data was analysed with the Statistical Package for the Social Sciences 1141. Where an F test indicated at a 0.05 level of probability that homogeneity of variance could not be assumed for a t-test comparison, a separate variance formula was used. All t-tests were two-tailed. For x2 </p><p>tests with only one degree of freedom, Yates correction for continuity was used. </p></li><li><p>337 </p><p>In addition to comparing the treatment and control groups on the variables used for matching, the two groups were compared *.** on a further 37 variables taken from the Authoritys records. Some significant differences between the two groups were found (Table I), but with the exception of the control group having had significantly more prior admissions to Ord Street Hospital the differences were apparently of no prognostic value in the sense improved patients in both groups. Although the difference was not significant, the control group had 9% more prior admissions to Aston Hospital. During the period from Hospital often used a short form to assist in determining whether a patient should be encouraged to go to Quo Vadis Hospital following detoxification. Some 44 of the treatment group patients, by only 14 control group patients were selected for assessment. Treatment group patients were rated as having significantly better physical helath and in total as being significantly more suible for admission to Quo Vadis Hospital. Even if the physical health sub-scale was omitted from the total the difference was still significant. It appears that the selection procedure produced a control group of patients who were very similar to the treatment group on a number of variables which have been demonstrated in previous research to be predictive of treatment outcome [1,3,41. However, it should be stressed that the two groups could have been different on variables for which no information was recorded. In particular, the possibility of the treatment group being more motivated to overcome their alcohol dependency should not be overlooked 1151. Thus the success rate of the control group was to be viewed as a minimum statement of the extent to which the treatment group could have been expected to improve without the benefit of the Quo Vadis Hospital programme. </p><p>Further evidence of the equivalence of the two groups is to be found in the following four factors which apparently acted to determine whether an Aston Hospital patient went to Quo Vadis Hospital Firstly, some suitable patients could not have gone due to a shortage of accommodation at Quo Vadis Hospital on some occasions. Secondly, at follow-up interview nine control group respondents reported that they had wanted to go to Quo Vadis Hospital, but Aston Hospital staff would not let them go. Thirdly, as a </p><p>**In the interests of brevity many tables in the original and supplementary reports (footnote p. </p><p>000) have been omitted from the paper and deposited with the National Auxiliary Publications </p><p>Service. They include further comparisons of treatment and control groups, comparison of </p><p>patients interviewed and not not interviewed in both groups, additional comparisons of the two groups on official records follow-up and interview data, comparisons of the short and long stay </p><p>sub-groups of the treatment group, comparisons of the men who did or did not improve in each group, comparison of 55 patients excluded from the treatment group with the treatment and control groups, assessment of the methodology according to the Sobells criteria, product </p><p>moment correlation matrices, factor analyses and discriminant function analyses. To obtain these, order NAPS Document No. 04094 from ASIWNAPS, Microfiche Publications, P.O. Box 3513, Grand Central Station, New York, N.Y. 10163. Remit with order $4 for microfiche or $26.05 for full-size photocopy. </p></li><li><p>338 </p><p>TABLE I </p><p>OUTCOME OF MATCHING PROCEDURE </p><p>Figures in brackets next to the means are SD. *P &lt; 0.05; **P -c 0.01; ***P -=z 0.001. </p><p>Treatment Control </p><p>Age Under 35 years 36-44 years 45 - 49 years 56+ years </p><p>41 43 43 46 31 26 30 26 </p><p>Marital status when entered the study Single 64 65 Married or de-facto 16 16 Separated, divorced or widowed 65 64 </p><p>Usual occupation Professional, managerial, oflice and sales workers Skilled workers Semi-skilled workers Unskilled workers Invalid pensioner Not known </p><p>Employed when entered the study YeS No </p><p>Place of birth W...</p></li></ul>

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