emcdda ha… · presentation to national focal points, emcdda, 24 th-26 th june 2013. background to...
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Trutz Haase
Jonathan Pratschke
Feline Engling
EMCDDA
Methodological Toolkit for the Estimation of the Number of People in Drug Treatment
Presentation to National Focal Points, EMCDDA, 24th -26th June 2013
Trutz Haase
Jonathan Pratschke
Feline Engling
![Page 2: EMCDDA Ha… · Presentation to National Focal Points, EMCDDA, 24 th-26 th June 2013. BACKGROUND TO THE STUDY ... There is limited scope for “borrowing strength” across countries,](https://reader033.vdocuments.us/reader033/viewer/2022051808/6008bfbde7dfa525562e0115/html5/thumbnails/2.jpg)
BACKGROUND TO THE STUDY
Phase 1 of the Study:
� Development of a Generic Mapping System
� Workshop in January 2012 – 8 Focal Points participating
� Final Report in July 2012
Phase 2 of the Study:
� Development of a Methodological Toolkit
� to assist national Focal Points in dealing with double counting
� to improve national estimates along the lines of the Generic Mapping System
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A SAMPLE MAP OF A COUNTRY’S TREATMENT SYSTEM
Outpatient Network
Specialised Treatment Centres
Low Threshold Agencies
PrisonsOpioid
Substitution Treatment
General Practitioners
Day Care Centres
Country
Inpatient Network
Hospital: Detoxification/
Emergency
Hospital: Rehabilitation/
Psychiatric
Prisons
Residential Communities
Therapeutic Communities
Total Drug Treatment
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A GENERIC MAPOF SERVICE PROVISION AND TREATMENT DATA
Sub-total: Outpatient Network
Specialised Drug Treatment Centres
Low-threshold Agencies
Treatment Units in Prisons
Opioid Substitution Treatment
Other Outpatient Treatment
General Practitioners
General Health Care Centres
Country
Outpatient Network
Sub-total: Inpatient Network
Medical Detoxification Treatment
Hospital-based Residential Drug Treatment Units
Treatment Units in Prisons
Other Inpatient Treatment (1)
Other Inpatient Treatment (2)
Therapeutic Communities
Residential Drug Treatment Centres
Total Drug Treatment
Inpatient Network
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A SAMPLE MAPOF SERVICES PROVISION AND TREATMENT DATA
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WHICH INFORMATION? THE BASIC “BOX”
repNR Unit Count M rep NR Patient Count M
calcTDI Unit Count L calc TDI Patient Count LL
Units Patients
Comment Comment
Generic Category Country-specific Category
Source Indicator
calc calculated
rep reported
est Estimated
nnn Source
?? Check
Evaluation Flag
HH Very high
H High
M Medium
L Low
LL Very low
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ADVANTAGES OF GENERIC MAPPING SYSTEM
� Same map/format for each country
� You understand your own map/data, you understand everyone else’s
� Parallel use of generic and country-specific terms of classification
� Clear distinction between where information is missing (ni) and valid zeros (0)
� Thus drawing attention to missing information (with positive knock-on effects)
� Data can be aggregated to country level sub-totals and totals
� Data can be aggregated across groups of countries and EMCDDA-wide
� All data can be instantly shown on a per 1,000 capita basis
� Cross-country per capita calculations can be used for evaluation of counts
� Data can be easily updated
� Standardised reports can be easily produced
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TASKS FOR PHASE 2 OF THE PROJECT
� The challenge ahead is to derive appropriate algorithms for estimating missing
data and to optimise country-specific estimates.
� Particular attention needs to be paid to the sensitivity of the Generic Mapping
System to double counting.
� Hence the Focus of Phase 2 is on developing a “Methodological Toolkit for the
Estimation of the Number of People in Drug Treatment”
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSPDU PREVALENCE ESTIMATES (1)
� Definition of PDU
� Most countries have adopted EMCDDA definition, though some continue to use alternative (historically-motivated) definitions.
� Estimation Basis: Large variations in data used, including:
a) police reports related to opioids and/or other illicit drug use
b) drug-related deaths
c) substitution registry and/or other OST related-data
d) drug treatment data from inpatient, out-patient and other drug treatment facilities
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSPDU PREVALENCE ESTIMATES (2)
� Multiplier Construction
� General population surveys unsuitable, hence employment of either capture re-capture (CRC) or respondent-driven sampling (RDS) methods
� Accuracy depends on both the accuracy of the base indicator and the nature of the survey used to calculate weights/multipliers
� Surveys tend to be infrequent and limited in size (both institutionally and geographically)
� Resulting PDU estimates tend to have large confidence intervals
� There is limited scope for “borrowing strength” across countries, as each multiplier is specific to the dataset used
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSPDU PREVALENCE ESTIMATES (3)
� Implications for EMCDDA
� Differences in the methodologies adopted to estimate PDU are a problem when making comparisons between countries, or when estimating PDU across the EMCDDA 30 countries
� They are less problematic when monitoring changes over time within individual countries, as long as the methodology remains the same
� There exists a potential trade-off between adopting a common methodology across the EMCDDA 30, and the discontinuity that such a change may entail for a particular country
� There is limited scope to “borrow strength” across multiple countries, as each multiplier is highly specific to the base dataset being used
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSTREATMENT DATA (1)
� Centralisation
� Does not necessarily entail existence of a single integrated system of individual client records
� Most countries operate a single national reporting system in which pre-aggregated data are drawn together from different sub-systems
� The organisational structures of such sub-systems tend to reflect either organisational/institutional distinctions, or geographical region
� In the most basic approach, double-counting is eliminated at the level of individual treatment facilities
� More advanced systems eliminate double counting at the level of sub-systems
� Few countries have developed a process of client identification applied across the entire national system
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSTREATMENT DATA (2)
� Integration
� To date, most national reporting systems follow the reporting structure of TDI, but exclude GPs and low-threshold agencies from core datasets
� Not all treatment centres are included in counts and data collection may focus on larger treatment units only
� This can be corrected for by extrapolating to all facilities, taking account of their relative size
� This process of extrapolation might be improved upon using the facility surveys that are planned in EMCDDA countries
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OBSERVATIONS FROM THE 2011 NATIONAL REPORTSTREATMENT DATA (3)
� Overcoming Double-Counting
� The most effective way to eliminate double-counting is to use client IDs
� Client IDs are widely applied within individual treatment facilities, and double-counting as a result of multiple treatment episodes within a given centre is largely eliminated from reported TDI data
� The introduction of client IDs across multiple facilities – generally using pseudonyms – remain the exception rather than rule
� Where studies exist on the overlap between sub-systems, these tend to relate to the broad TDI categories
� Overlaps between facility types as specified in the Generic Mapping System have not yet been reported
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TOWARDS A METHODOLOGICAL TOOLKIT (1)
� Double Counting as a Result of Multiple Service Use
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TOWARDS A METHODOLOGICAL TOOLKIT (2)
� Overcoming Double Counting
� The most accurate and flexible way of tackling the methodological challenge of multiple service use involves the use of personal identifiers
� The anonymity of service users has to be protected by using special identification codes that can only be linked with individuals by a “trusted third party”
� The additional information provided by personal identifiers can, at least in theory, be used to identify overlaps between services and to count the number of interventions received by an individual
� Whilst technically possible, “pseudonomisation” is IT intensive, technically demanding and can generate additional difficulties in terms of data access and analysis, particularly if these are not planned from the outset
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TOWARDS A METHODOLOGICAL TOOLKIT (3)
� Implementing the Use of Client IDs
� Decision at the aggregate level (EMCDDA countries)
� Decision at national level
� Achieving agreement/participation of treatment providers
� Tendering and commissioning of “Trusted Third Party” (TTP)
� Development and distribution of client software
� Implementation at level of treatment facility
� Collation of data and data aggregation
� Statistical analysis of data records at national level
� Reporting back to EMCDDA (using TDI/Generic Mapping System)
� EMCDDA 30 overall comparative analysis
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TOWARDS A METHODOLOGICAL TOOLKIT (4)
� The Alternative: A Survey of Service Users
� A census of treatment providers could be used as sampling frame
� A stratified sample of treatment providers would be extracted
� A sample of service users would then be carried out
� Survey instruments would inquire about use of services and treatments received over previous year
� Results could be generalised to the total population of people in treatment
� The survey would provide reliable estimates of overlaps – multiple episodes and multiple services use
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TOWARDS A METHODOLOGICAL TOOLKIT (4)
� A Synthesis: Mixed Methods Approach
� The calculation of overlaps requires either system-wide client IDs or a survey of service users
� Either approach would be adequate and it is not necessary for all EMCDDA countries to apply the same method
� Results can be used even if a minority of countries provide data on overlaps between facility types specified in the Generic Mapping System
� Results from individual countries may be extrapolated to “similar” countries or adapted using additional assumptions or models
� This “agenda” has the potential to yield considerable improvements in EMCDDA-wide estimates of the number of people in drug treatment
� Other benefits include policy-relevant insights into similarities/differences across countries and regions and over time
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