SIF Presentation_Final
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This document summarizes a research project on supervised injection facilities. It examines how such facilities can reduce overdose deaths, increase service provision, and decrease neighborhood crime reports based on evidence from 27 academic papers. The methodology includes a literature review to identify relationships between these variables and develop a causal loop diagram. Key findings are that supervised injection facilities can eliminate overdose deaths by allowing staff interventions and increase supportive service referrals. They may also reduce public injection and discarded needles while not increasing drug dealing in the vicinity. Limitations include the small paper sample and inconsistencies between facility outcomes.
SIF Presentation_Final
- 1. Supervised Injection Facility: A causal loop design and analysis. Research Project University of Victoria By Antonio J. Marante Supervisory Committee Dr. Abdul Roudsari, Supervisor Dr. Scott Macdonald, Co-Supervisor Dr. Alex Kuo, Chair
- 2. Agenda • Objective • Research question • Methodology • Literature review • System dynamics • Results • Discussion. Designing a policy decision • Conclusions and recommendations
- 3. Objective • This study focuses on supervised injection facility (SIF) operations, providing and analyzing services for clients, crime reports, workflow, metrics, e-health applications, and managing overdose events to reduce overdose deaths. • Acronyms • Drug Consumption Room (DCRs) in Europe • Medical Supervised Injection Center (MSIC) in Australia • Supervised Injection Facility (SIF) in Canada • This study does not intend to discuss government approval.
- 4. Research Question: • How does the supervised injection facility affect (a) the reduction or elimination of mortalities due to overdose, (b) services provision, and (c) the reduction in neighborhood crime reports? • Why is this important? The value of this project provides data . • The outcomes of the research project support regional health authorities in implementing a supervised injection facility in Victoria.
- 5. Positive outcomes SIF Vancouver • The SIF in Vancouver reported 1,114 overdose incidents from 2004 to 2010 with zero deaths, demonstrating that staff are able to intervene each time (Vancouver Coastal Health Authority, 2016). • Overdose deaths in Vancouver occurred outside the facility. Additionally, Vancouver Coastal Health Authority reported a 35% decrease in overdoses at the InSite program and 9% over the city.
- 6. Overdose deaths in BC period 2007-2016
- 7. Methodology. Literature review. • Process 1. Inclusion and exclusion criteria . • Algorithm developed to search papers • The strategy used in PUBMED and Web of Science was looking for MeshTerm = Supervised injection service; OR MeshTerm =Safer injection facility; OR MeshTerm =Supervised injecting center; OR MeshTerm =Drug consumption room; OR MeshTerm =Drug consumption facility; OR MeshTerm =Injection drug user. (N=1,895) • After filters, total 27 papers. Australia N=2, 7%) Canada (N=12, 45%) Germany (N= 1, 4%) Multi-Country (N=9, 33%) United Kingdom (N=2, 7%) Luxembourg,… By source By year By country
- 8. Methodology. Literature review (cont.) Process 2: Deconstructing all papers in specific fields • Extracting data from literature: author, year of publication, title, research approach used. • Major Point, Topics, Ideas, (Include inconsistencies, similarities, questions, concerns, and possible omissions); summary and conclusions. Process 3: Domain of knowledge: integration analysis. Variable relationships • Elaborate domains of knowledge 1. Overdose deaths 2. Services provision 3. Crime reports 4. e-Health applications used/designed 5. Workflow 6. Ethics 7. Metrics 8. Budget
- 9. Domain Analysis All papers were coded in an Excel spreadsheet, identifying the domain of knowledge per paper. Table 5 describes the domains by papers. Each domain is a binary variable: number 1 means the domain explains some information, and 0 means the opposite.
- 10. Methodology. Process 3: Variable relationships Integration • In simpler terms, this process can be compared to a student using major bullet points to explain what a paper discusses. Hence, one paper can have more than one domain of knowledge. Variables relationships • Builds a relation describing how one event influences other events (Forrester, 2009) with the goal to construct a causal relationship model. Looking for words as increment, decrement in papers text: identifying control variables: cause and effect. •Deconstructing •Terms •Source • Structural question consolidates domains and terms. •Causal model representation
- 11. Examples of variable relationships: Overdose Terms Source Structural question Causal diagram representation INSITE staff have successfully intervened in over 336 overdose events since 2006 and no overdose deaths have occurred at the service. Mathematical modelling (see caution about validity below) suggests that INSITE saves about one life a year as a result of intervening in overdose events. Health Canada (2016) What are the results of SIF about overdose fatalities? As staff intervene in overdose events in the SIF, mortality rates decrease Staff interventions at SIF Mortality rates -
- 12. Examples of variable relationships: Service provision Terms Source Structural question Causal diagram representation 54.2% of users interviewed reported that a contact to another helping institution was arranged for them by the consumption room at least once. In 90.6% of these cases, the arranged contact actually took place. Further supportive services mentioned the most frequently were detoxification and therapy institution as well as public authorities. Environmental and Social Research Universitätsstr (2003) What are the results of further supportive services outside the institution (e.g. referrals?) As users are contacted for supportive services in the SIF, the number of referrals increases (up to 90.6%). Users contacted For supportive services at SIF Referral rates+
- 13. Examples of variable relationships: Crime reports Terms Source Structural question Causal diagram representation The opening of Insite resulted in a reduction of public injection, discarded syringes and drug-related litter, and no observed increase in the number of suspected drug dealers in the vicinity of the facility Drug-related crimes have not increased and even a small reduction in vehicle break-ins and thefts Center of Addictions Research, UVIC, 2006 What are the results of implementing SIF regards on public order? As SIF operates, there is a reduction of public injection, discarded syringes and drug-related litter, and no observed increase in the number of suspected drug dealers in the vicinity of the facility. Patients increases At SIF Public injection, Discarded syringes, and drug-related litter -
- 14. Examples of variable relationships: Budget Terms Source Structural question Causal diagram representation The SIF may have reduced needle sharing and increased condom use; these behavioural changes could translate to about $6 million in annual healthcare cost savings. Peer-reviewed research demonstrates other health benefits that InSite has provided for the larger community. BC Center for Disease Control (2014) What are the results of declining overdose deaths in regards healthcare cost savings? As SIF operates, there is a reduction in needle sharing and increased condom use, and there is a decrease in budget up to $6 million Patients increases At SIF Needle sharing, and Budget- Condom use+
- 15. Examples of variable relationships: Metrics Terms Source Structural question Causal diagram representation Ambulance administered naloxone events in BC peaked in 2011 (the year that overdose deaths due to increased heroin potency were also noted see chapter 5) with 2,242 events, and decreased subsequently reaching 2,011 in 2013. Based on ambulance attendances, the reduction in opioid-related overdoses was much more substantial in the immediate vicinity of the MSIC than in other neighbouring areas and in New South Wales in general. This finding suggests that the Sydney MSIC provided an environment where injecting drug users at risk of overdose were able to receive early intervention and thereby avoid the need for ambulance services. BC Center for Disease Control (2014) NSW Department of Health, Australia What are the results of ambulances services? As SIF operates, the number of ambulance phone calls decrease. Patients increases At SIF Number of ambulance phone calls.-
- 16. Methodology. Literature review (Cont.) • Process 4. Quantitative analysis • Transform Table of Domain of Knowledge into the Table of truth. What papers cover each domain. • a Fuzzi-Set / Qualitative comparative analysis (fsQCA) software, developed by the University of Arizona (2008). • Elaboration the excel spreadsheet with 2k cases, being k=number of domains. • 256 rows in excel, which then translate to fsQCA. • solution coverage: 0.800781 • solution consistency: 1.000000 • The combinations of all domains have coverage solution equals to 0.8 indicating they are a subset of the outcome (SIF effectiveness); and these variables have a solution consistency equal to 1.0 reflecting that they explain by themselves the effectiveness of the supervised injecting facility.
- 17. Table of truth
- 18. Methodology. Variable relationships summary • Overdose deaths (11) • Service provision (18) • Crime report (23) • Budget (3) • Metrics (4) • Workflow (5) is embedded in the service provision. • E-health (8), and ethics (17) domain of knowledge have different relationships and are not graphed in the causal loop diagram • These domains are the nodes constructing a causal model network (Anderson & Aydin, 2005; Brailsford, 2008; Erdil & Emerson, 2009), making the evidence found from the literature review visible.
- 19. Methodology. System Dynamics: Designing the causal loop diagram • System Dynamic • System behavior • Influence relationships • Reinforce and balance loops • Strategic scope • Control variables • Members with similar behaviors, • Multiple connections • DCRs, MSICs, or SIFs are suitable for this definition • Interactions • Perceptions. • In this paper, SIF uses research based evidence
- 20. Results
- 21. Discussion • Answering the research question. • Identifying loops, the changes in SIF variables and multiple stakeholders’ decisions, understanding SIF fragments and entire knowledge, and pointing out the consequences of proposed actions. • SIF improves patients’ health • Patients grow exponentially in all reinforce loops • Drug cessation is located in the balance loop. • Limited e-Health applications used at SIFs.
- 22. How does the supervised injection facility affect: a. The reduction or elimination of mortalities due to overdose. Zero deaths. b. Service provision. i. Primary care services. ii. Supportive services. c. The reduction in neighborhood crime reports. Vancouver has multiple sources of documentations of public order/disorder, showing the positive effects before and after opening the facility.
- 23. ( c ) The reduction in neighborhood crime reports Average (daily mean) Before After Source IDUs injecting in public 4.3 (3.5-5.4) 2.4 (1.9–3.0) Publicly discarded syringes 11.5 (10.0–13.2) 5.4 (4.7–6.3) Injection-related litter 601 (590–613) 310 (305–317) Public Injection: this population noted the following public injection pattern: Residents (p<0.01) 33% 19% Business Operators (p<0.03) 38% 28% less syringes dropped (p<0.01) Residents 67% 40% Business Operators 72% 57% Complaints about PWID nuisances, but nochange in the number of drug deals Residents (p<0.8) 28% 26% Business Operators (p<0.26) 33% 28% Predicted daily mean no. (and 95% CI) Wood et al (2004c). (Before 6 weeks opening SIF; After 12 weeks opening SIF Portier et al. (2014). (Not specify time before and after SIG opened).
- 24. Limitations • Based on limited 27 academic and government papers. • It does not include specific outcomes from Denmark, Luxembourg, Spain, and Norway. • There is inconsistency in providing outcomes for all SIF studied. • The outcomes reported by Australia, Canada, and Germany are not standards. • System dynamic is developed under the mental model. • Researchers can find new relationships from the literature review designing a new causal loop diagram.
- 25. Conclusions and recommendations • The influential causal loop diagram is a mirror of the researcher's perception of what is documented from LR in all variables relations. • Potier et al. (2014) developed the first study connecting the SIF to injecting drug cessation which is represented as a balance loop, self –regulatory process. • In the reinforcing loops, resources increase exponentially (consumers, services, budget). At some point, the system collapses. • The literature review methodology can be replicated by following the steps described in this research project. • It is recommended to continue the research moving to the quantitative analysis. • Two extra outcomes • Project Webpage design http://antonio.ezonlinestrategies.com • Register in the poster competition for ITCH 2017 Building Capacity for Health Informatics in the Future.