WEBVTT 00:00:00.610 --> 00:00:07.260 position:50% align:middle - [Moderator] Mr. Smiley has worked as a statistician in the Research Department at NCSBN for 19 years. 00:00:07.260 --> 00:00:12.503 position:50% align:middle During his time at NCSBN, he has co-authored studies on the use of simulation 00:00:12.503 --> 00:00:17.730 position:50% align:middle in nursing education, on data from the National Nursing Workforce Survey, 00:00:17.730 --> 00:00:22.700 position:50% align:middle and on best practices for substance use disorder monitoring programs. 00:00:22.700 --> 00:00:27.124 position:50% align:middle He has undergraduate degrees in Mathematics and Computer Science 00:00:27.124 --> 00:00:30.920 position:50% align:middle and graduate degrees in Statistics and Demography. 00:00:30.920 --> 00:00:36.956 position:50% align:middle He is the past president of the Chicago Chapter of the American Statistical Association. 00:00:43.385 --> 00:00:44.420 position:50% align:middle - [Richard] Greetings. 00:00:44.420 --> 00:00:53.832 position:50% align:middle Today, I will be presenting results from NCSBN study of substance use disorder, SUD, monitoring programs. 00:00:53.832 --> 00:00:59.346 position:50% align:middle During the presentation, you are welcome to submit questions in the Q&A box. 00:00:59.346 --> 00:01:04.465 position:50% align:middle I will answer questions live after the presentation has ended. 00:01:05.148 --> 00:01:07.607 position:50% align:middle Here is the outline for this session. 00:01:07.607 --> 00:01:12.989 position:50% align:middle I will introduce the study, provide some background on previous research, 00:01:12.989 --> 00:01:19.332 position:50% align:middle go through the methods used, discuss the results, and share some conclusions 00:01:19.332 --> 00:01:22.084 position:50% align:middle regarding next steps to be taken. 00:01:22.546 --> 00:01:31.382 position:50% align:middle Research by NCSBN has shown that substance use disorder is the most common reason that disciplinary actions 00:01:31.382 --> 00:01:33.367 position:50% align:middle are taken against a nurse. 00:01:34.290 --> 00:01:41.170 position:50% align:middle SUD programs are engaged by over 40 boards of nursing to encourage successful treatment of the nurse's 00:01:41.170 --> 00:01:46.441 position:50% align:middle condition and to return the nurse to safe and competent practice. 00:01:47.330 --> 00:01:52.940 position:50% align:middle SUD programs typically require regular check-ins, random drug testing, 00:01:52.940 --> 00:01:58.837 position:50% align:middle attendance at structured peer group support meetings, attendance at mutual support meetings 00:01:58.837 --> 00:02:06.916 position:50% align:middle such as Alcoholics Anonymous, and worksite monitoring, but program-specific requirements vary across states. 00:02:06.916 --> 00:02:13.546 position:50% align:middle SUD programs for physicians are known as Physician Health Programs, PHP. 00:02:13.546 --> 00:02:20.706 position:50% align:middle These programs are affiliated with the medical licensing board and are standardized in most states. 00:02:20.706 --> 00:02:28.370 position:50% align:middle PHPs refer patients to abstinence-oriented residential treatment followed by outpatient treatment 00:02:28.370 --> 00:02:32.236 position:50% align:middle and substance monitoring for five years or more. 00:02:32.236 --> 00:02:39.970 position:50% align:middle A longitudinal study of 16 PHP programs showed that over 90% of the physicians who have successfully 00:02:39.970 --> 00:02:43.333 position:50% align:middle completed the program return to practice. 00:02:43.333 --> 00:02:51.476 position:50% align:middle While studies using PHP data have sufficiently established the effectiveness of PHP programs, 00:02:51.476 --> 00:02:56.246 position:50% align:middle comparable evidence does not exist for nursing SUD programs. 00:02:56.246 --> 00:03:03.558 position:50% align:middle Because nursing SUD programs can vary vastly from state to state, determining the effectiveness 00:03:03.558 --> 00:03:07.334 position:50% align:middle of specific components of SUD programs has been difficult. 00:03:07.334 --> 00:03:15.517 position:50% align:middle No one has previously studied what program elements yield the best outcomes for the nurses enrolled. 00:03:15.517 --> 00:03:22.595 position:50% align:middle The purpose of this study is to address that deficit by assessing the completion rates of nursing 00:03:22.595 --> 00:03:30.226 position:50% align:middle SUD programs and identifying the most important program characteristics associated with program completion. 00:03:31.033 --> 00:03:38.320 position:50% align:middle In order to accomplish this, a retrospective longitudinal cohort study of nurses 00:03:38.320 --> 00:03:45.941 position:50% align:middle participating in SUD programs between the years 2007 to 2015 was conducted. 00:03:45.941 --> 00:03:53.290 position:50% align:middle Data collected from programs in 13 states monitored by Affinity eHealth produced an analysis file 00:03:53.290 --> 00:03:56.103 position:50% align:middle containing over 7,000 nurses. 00:03:56.600 --> 00:04:01.536 position:50% align:middle To the best of our abilities, the study replicated the reporting and classification methods 00:04:01.536 --> 00:04:04.347 position:50% align:middle used in the PHP studies. 00:04:04.915 --> 00:04:12.985 position:50% align:middle It is especially important to note that the study assumes that program completion is in and of itself 00:04:12.985 --> 00:04:20.796 position:50% align:middle a good outcome that is highly correlated with the successful return to practice by nurses. 00:04:20.796 --> 00:04:29.688 position:50% align:middle Among the program factors considered for analysis were length of stay in program, drug testing frequency, 00:04:29.688 --> 00:04:36.271 position:50% align:middle non-compliance history, relapse history, meeting attendance, check-in history, 00:04:36.271 --> 00:04:38.762 position:50% align:middle and drug test history. 00:04:38.762 --> 00:04:45.205 position:50% align:middle Overall, across all programs, the successful completion rate was 61.5%. 00:04:45.205 --> 00:04:50.970 position:50% align:middle For programs in the sample with at least 50 nurses, the successful completion rates varied 00:04:50.970 --> 00:04:55.603 position:50% align:middle from 51.9% to 69.1%. 00:04:55.603 --> 00:05:03.373 position:50% align:middle In the study, the 61.5% rate served as a baseline for determining if and to what degree 00:05:03.373 --> 00:05:08.426 position:50% align:middle a program factor was helpful or harmful to program completion. 00:05:09.731 --> 00:05:16.373 position:50% align:middle The table shown here demonstrates that those who had a relapse were much less likely to complete the program. 00:05:17.849 --> 00:05:23.468 position:50% align:middle There was a large drop off in the program completion rate from those who had no relapses 00:05:23.468 --> 00:05:30.555 position:50% align:middle to those who had one relapse and a steady drop off thereafter as the number of relapses increased. 00:05:30.555 --> 00:05:37.046 position:50% align:middle This figure shows that the percent of nurses successfully completing a program moderately 00:05:37.046 --> 00:05:42.281 position:50% align:middle correlates with the number of times a nurse attends a structured support group meeting. 00:05:43.284 --> 00:05:49.893 position:50% align:middle It shows that after 20 to 25 meetings per year, roughly twice a month, there is not much of an increase 00:05:49.893 --> 00:05:53.372 position:50% align:middle in the percent of those who successfully completed the program. 00:05:53.372 --> 00:06:00.352 position:50% align:middle This suggests that establishing twice a month attendance at structured support group meetings 00:06:00.352 --> 00:06:03.319 position:50% align:middle as a program standard would be effective. 00:06:03.319 --> 00:06:08.918 position:50% align:middle This figure shows that the percent of nurses successfully completing a program correlates with 00:06:08.918 --> 00:06:15.039 position:50% align:middle the number of times a nurse attends a mutual support group meeting like Alcoholics Anonymous. 00:06:15.039 --> 00:06:22.168 position:50% align:middle After 50 to 60 meetings per year once a week, there does not seem to be much of an increase 00:06:22.168 --> 00:06:26.046 position:50% align:middle in the percent of those who successfully completed the program. 00:06:26.046 --> 00:06:33.190 position:50% align:middle This suggests that establishing once-a-week attendance at mutual support group meetings as a program standard 00:06:33.190 --> 00:06:34.816 position:50% align:middle would be effective. 00:06:36.083 --> 00:06:41.533 position:50% align:middle This figure shows that the percent of nurses successfully completing a program highly correlates 00:06:41.533 --> 00:06:48.120 position:50% align:middle with the number of times a nurse checks in with the monitoring program to find out if he or she has been 00:06:48.120 --> 00:06:50.182 position:50% align:middle selected for drug testing. 00:06:50.182 --> 00:06:56.523 position:50% align:middle The steady increase throughout the graph shows that the highest percent of nurses successfully completing 00:06:56.523 --> 00:07:01.337 position:50% align:middle a program is at around 360 check-ins per year. 00:07:01.337 --> 00:07:08.144 position:50% align:middle This suggests that establishing daily check-ins, including weekends and holidays, as a program standard 00:07:08.144 --> 00:07:10.421 position:50% align:middle would be highly effective. 00:07:10.421 --> 00:07:16.317 position:50% align:middle This figure shows that the percent of nurses successfully completing a program correlates with 00:07:16.317 --> 00:07:18.966 position:50% align:middle the number of years in the program. 00:07:18.966 --> 00:07:24.660 position:50% align:middle It shows a steady increase throughout the graph and suggests that the highest percent of nurses 00:07:24.660 --> 00:07:29.008 position:50% align:middle successfully completing a program is at around the five-year mark. 00:07:29.008 --> 00:07:36.947 position:50% align:middle A receiver operating characteristic curve, ROC, analysis was conducted on these data. 00:07:36.947 --> 00:07:42.845 position:50% align:middle The figure shows two distributions of data with one placed on top of the other. 00:07:42.845 --> 00:07:50.340 position:50% align:middle The distribution on the top represents the length of stay in the program for those who were not successful 00:07:50.340 --> 00:07:51.843 position:50% align:middle at completing it. 00:07:51.843 --> 00:07:58.645 position:50% align:middle The distribution on the bottom shows the length of stay in the program for those who were successful 00:07:58.645 --> 00:08:00.245 position:50% align:middle at completing it. 00:08:00.400 --> 00:08:10.830 position:50% align:middle The ROC analysis identified a cut point at 715 days, about two years, at which the bulk of those who did not 00:08:10.830 --> 00:08:18.366 position:50% align:middle complete the program was below that number of days, while the bulk of those who completed the program 00:08:18.366 --> 00:08:20.923 position:50% align:middle was above that number of days. 00:08:21.590 --> 00:08:28.611 position:50% align:middle At that two-year cut point, the percent correctly identified non-completers was 55%. 00:08:28.611 --> 00:08:34.345 position:50% align:middle By raising the cut point to three years, the percent of correctly identified non-completers 00:08:34.345 --> 00:08:36.700 position:50% align:middle was raised to 71%. 00:08:36.700 --> 00:08:44.328 position:50% align:middle In other words, most program failures occurred within the first three years of participation in the program. 00:08:45.578 --> 00:08:52.030 position:50% align:middle This figure shows that the percent of nurses successfully completing a program distinctly correlates 00:08:52.030 --> 00:08:57.123 position:50% align:middle with the number of times she or he is selected for a drug test. 00:08:57.123 --> 00:09:02.642 position:50% align:middle It also shows that after 26 tests per year, roughly twice a month, 00:09:02.642 --> 00:09:08.406 position:50% align:middle there does not seem to be much of an increase in the percent who successfully completed the program. 00:09:08.406 --> 00:09:15.849 position:50% align:middle This suggests that establishing a twice a month random selection for drug testing as a program standard 00:09:15.849 --> 00:09:18.914 position:50% align:middle would be highly effective. 00:09:18.914 --> 00:09:25.120 position:50% align:middle The length of stay in the program and the number of times selected for drug testing program factors 00:09:25.120 --> 00:09:27.360 position:50% align:middle were jointly analyzed. 00:09:27.360 --> 00:09:32.382 position:50% align:middle An ROC analysis was conducted on the subset of nurses who were selected for drug tests 00:09:32.382 --> 00:09:34.366 position:50% align:middle at least 24 times a year. 00:09:34.366 --> 00:09:40.741 position:50% align:middle This analysis identified a cut point at 726 days, again about two years, 00:09:40.741 --> 00:09:46.609 position:50% align:middle at which the bulk of those who did not complete the program was below that number of days, 00:09:46.609 --> 00:09:51.060 position:50% align:middle while the bulk of those who completed was above that number of days. 00:09:51.060 --> 00:09:56.843 position:50% align:middle At that cut point, the percent of correctly identified non-completers was 72%. 00:09:57.733 --> 00:10:03.564 position:50% align:middle Raising that cut point to three years raised the negative predictive probability to 88%. 00:10:04.264 --> 00:10:09.747 position:50% align:middle In other words, for those who are selected for drug tests at least 24 times a year, 00:10:09.747 --> 00:10:15.608 position:50% align:middle almost all program failures occurred within the first three years of participation in the program. 00:10:15.608 --> 00:10:21.950 position:50% align:middle This suggests that establishing three years of participation in the program as a program standard 00:10:21.950 --> 00:10:23.463 position:50% align:middle would be effective. 00:10:23.463 --> 00:10:29.130 position:50% align:middle The impact of frequent drug testing can be seen further in this table. 00:10:29.735 --> 00:10:36.600 position:50% align:middle For those nurses who were in a program at least two years, all program completion rates were extremely high 00:10:36.600 --> 00:10:39.671 position:50% align:middle for those who tested at least 24 times a year. 00:10:39.671 --> 00:10:46.840 position:50% align:middle A regression analysis of the data confirm that the positive factor most associated with program completion 00:10:46.840 --> 00:10:51.613 position:50% align:middle was the number of times per year that a nurse was selected for a drug test. 00:10:51.613 --> 00:10:56.530 position:50% align:middle The impact of frequent drug testing is further seen in this table. 00:11:02.437 --> 00:11:02.500 position:50% align:middle For those nurses who were in a program at least two years, and who suffered at least one relapse, 00:11:02.500 --> 00:11:08.052 position:50% align:middle all program completion rates were still high for those who tested at least 24 times a year, 00:11:08.052 --> 00:11:14.788 position:50% align:middle and extremely high for those who tested at least 24 times a year and in the program at least five years. 00:11:15.874 --> 00:11:20.940 position:50% align:middle For those nurses who were tested frequently, their likelihood of successful completion 00:11:20.940 --> 00:11:22.550 position:50% align:middle was much greater. 00:11:22.550 --> 00:11:27.590 position:50% align:middle The median number of test selections for those who completed the program was 40. 00:11:27.590 --> 00:11:34.204 position:50% align:middle The median number of test selections for those who did not complete the program was nine. 00:11:34.204 --> 00:11:38.755 position:50% align:middle But not too many nurses were tested that frequently. 00:11:38.755 --> 00:11:45.101 position:50% align:middle Only 7% of the nurses in the analysis file were selected for 24 drug tests a year or more. 00:11:45.101 --> 00:11:50.209 position:50% align:middle In summary, the overall completion rate was 61.5%. 00:11:51.597 --> 00:11:56.822 position:50% align:middle The positive factor most associated with program completion was the number of times per year 00:11:56.822 --> 00:11:59.517 position:50% align:middle a nurse was selected for a drug test. 00:11:59.517 --> 00:12:05.190 position:50% align:middle Other factors positively associated with program completion were number of check-ins, 00:12:05.190 --> 00:12:09.030 position:50% align:middle number of days in the program, attending structured support group meetings, 00:12:09.030 --> 00:12:11.845 position:50% align:middle and attending mutual support group meetings. 00:12:12.962 --> 00:12:18.022 position:50% align:middle Going forward, the analysis leads to the following recommendations regarding setting up 00:12:18.022 --> 00:12:20.698 position:50% align:middle an SUD monitoring program. 00:12:21.384 --> 00:12:27.056 position:50% align:middle Three years without a relapse is a sufficient link for a program. 00:12:27.056 --> 00:12:32.591 position:50% align:middle If a relapse does occur, the three-year clock should be reset to zero. 00:12:33.504 --> 00:12:39.450 position:50% align:middle Check-ins for possible drug test selection should be conducted daily, if possible, 00:12:39.450 --> 00:12:45.817 position:50% align:middle with the nurse always facing the possibility of being tested on a weekend or a holiday. 00:12:45.817 --> 00:12:52.712 position:50% align:middle Drug tests should be conducted at least twice a month with the tests being random in time and type, 00:12:52.712 --> 00:12:55.751 position:50% align:middle such as urine, hair collection. 00:12:55.751 --> 00:13:01.637 position:50% align:middle Nurses should attend at least two structured peer group support meetings per month. 00:13:02.881 --> 00:13:08.906 position:50% align:middle Nurses should attend at least one mutual support group meeting per week, like AA. 00:13:08.906 --> 00:13:15.295 position:50% align:middle Results of the study appeared in the July 2020 issue of the Journal of Nursing Regulation 00:13:15.295 --> 00:13:21.728 position:50% align:middle in an article entitled "Outcomes of Substance Use Disorder (SUD) Monitoring Programs" 00:13:21.728 --> 00:13:24.450 position:50% align:middle by Richard Smiley and Kyrani Reneau. 00:13:24.450 --> 00:13:28.164 position:50% align:middle We will now go live for questions. 00:13:46.311 --> 00:13:46.863 position:50% align:middle Hi. 00:13:49.400 --> 00:13:52.580 position:50% align:middle Thank you very much for listening to the presentation. 00:13:52.580 --> 00:14:00.475 position:50% align:middle I invite you to put any questions you have into the Q&A box and we will get to them. 00:14:01.724 --> 00:14:09.287 position:50% align:middle And, I think I see a first question appear from Ruby Jason. 00:14:09.287 --> 00:14:16.400 position:50% align:middle Was there a review of completion of an alternative discipline program resulted in greater completion 00:14:16.400 --> 00:14:22.998 position:50% align:middle than the same characteristics of monitoring but a public discipline and that... 00:14:22.998 --> 00:14:32.710 position:50% align:middle Okay, I see what you're saying. 00:14:32.710 --> 00:14:42.000 position:50% align:middle In other words, was there a difference between a discipline that was alternative to discipline 00:14:42.000 --> 00:14:44.875 position:50% align:middle versus public discipline? 00:14:44.875 --> 00:14:54.500 position:50% align:middle Unfortunately, we didn't quite have that information as far as what the contract was that the nurses were on. 00:14:54.500 --> 00:15:04.720 position:50% align:middle I think, while most of them may have been participating in an ATD setting, we were aware that some nurses were 00:15:04.720 --> 00:15:07.710 position:50% align:middle participating who had been disciplined anyway. 00:15:07.710 --> 00:15:12.274 position:50% align:middle And, we couldn't distinguish which were which so we couldn't tell. 00:15:14.026 --> 00:15:18.725 position:50% align:middle What about nurses with limited work hours and no night shift? 00:15:18.725 --> 00:15:28.170 position:50% align:middle I'm sorry, we did not have that level of detail or information on the nurses that we had. 00:15:28.170 --> 00:15:32.189 position:50% align:middle We were limited by what we had in the data set. 00:15:33.662 --> 00:15:37.895 position:50% align:middle And let's see. 00:15:42.063 --> 00:15:54.522 position:50% align:middle As I mentioned in the presentation, the primary bit of the data set that was useful to us 00:15:54.522 --> 00:16:04.861 position:50% align:middle was the raw data coming from the monitoring programs that told us whether or not 00:16:04.861 --> 00:16:08.485 position:50% align:middle a person had been tested or not. 00:16:08.485 --> 00:16:12.497 position:50% align:middle And, it was primarily that raw data that we were getting the most power from. 00:16:12.497 --> 00:16:18.227 position:50% align:middle I mean, some of these other breakdowns for demographics and that, we just didn't have 00:16:18.227 --> 00:16:24.450 position:50% align:middle as much about the nurses as we may have liked to have had to break out the studies in those way. 00:16:24.450 --> 00:16:32.190 position:50% align:middle And what we're going to be doing is moving forward proactively with a study and we're hoping 00:16:32.190 --> 00:16:35.013 position:50% align:middle we'll be able to get some more of that information. 00:16:36.198 --> 00:16:42.404 position:50% align:middle From Suzanne, was the testing you refer to only urine? 00:16:42.404 --> 00:16:46.918 position:50% align:middle Or did it include hair and/or pet? 00:16:49.466 --> 00:16:54.930 position:50% align:middle Let's see, I think it was primarily urine. 00:16:54.930 --> 00:16:56.425 position:50% align:middle But, we did have... 00:16:57.830 --> 00:17:04.427 position:50% align:middle Suzanne, I would have to look into that specifically to see what... 00:17:04.427 --> 00:17:13.844 position:50% align:middle if we actually had the details on what the methods of testing were as far as that type of detail. 00:17:13.844 --> 00:17:19.656 position:50% align:middle Because if we had that information, we certainly would have checked that out. 00:17:19.656 --> 00:17:22.698 position:50% align:middle And so, that wasn't something we could use as a variable. 00:17:22.698 --> 00:17:30.258 position:50% align:middle But, were the nurses practicing while in the SUD and monitoring program? 00:17:31.639 --> 00:17:34.077 position:50% align:middle Some of them were. 00:17:34.077 --> 00:17:40.657 position:50% align:middle We did not have detail about when they were granted returned to practice 00:17:40.657 --> 00:17:45.217 position:50% align:middle because our information about the nurses was anonymous. 00:17:45.217 --> 00:17:54.356 position:50% align:middle To respect privacy, we did not have specific information about the names of the nurses 00:17:54.356 --> 00:17:55.417 position:50% align:middle and who they were. 00:17:55.417 --> 00:18:01.048 position:50% align:middle So, that detail about whether or not they returned to practice, we really did not have. 00:18:01.048 --> 00:18:08.760 position:50% align:middle And, I think I mentioned right at the start of the study that we kind of assumed that even completion 00:18:08.760 --> 00:18:17.109 position:50% align:middle of the program, says they completed, that was a good event in and of itself, 00:18:17.109 --> 00:18:25.106 position:50% align:middle that most people who have studied this think program completion is linked to successful return to practice. 00:18:25.106 --> 00:18:29.690 position:50% align:middle But, that closing the loop part is something we did not have, 00:18:29.690 --> 00:18:38.530 position:50% align:middle and, once again, is a feature that we intend to incorporate into our next go around with the study. 00:18:38.530 --> 00:18:47.620 position:50% align:middle We will be piloting some of these guidelines that we have come up with. 00:18:47.620 --> 00:18:53.889 position:50% align:middle We're going to be trying to pilot this at some programs and see what happens prospectively going forward. 00:18:53.889 --> 00:19:03.498 position:50% align:middle So, that would be the type of information we'd be definitely trying to collect in terms of what happens 00:19:03.498 --> 00:19:09.899 position:50% align:middle with the program and do the nurses successfully return to practice. 00:19:11.084 --> 00:19:12.918 position:50% align:middle Let's see, from... 00:19:12.918 --> 00:19:17.334 position:50% align:middle Comparison to public versus non-public outcomes would be interesting. 00:19:17.334 --> 00:19:18.216 position:50% align:middle I agree. 00:19:18.490 --> 00:19:20.345 position:50% align:middle That would be good. 00:19:20.345 --> 00:19:27.854 position:50% align:middle And, I'm not seeing any other questions here. 00:19:29.626 --> 00:19:36.413 position:50% align:middle Let's see, did missed check-ins...? 00:19:38.061 --> 00:19:39.953 position:50% align:middle Refresh, okay, so you're saying... 00:19:39.953 --> 00:19:41.770 position:50% align:middle I just saw one here. 00:19:41.770 --> 00:19:43.208 position:50% align:middle Did missed...? 00:19:43.632 --> 00:19:44.977 position:50% align:middle Okay. 00:19:55.948 --> 00:20:05.701 position:50% align:middle Did missed check-ins to test factor into data for those that did not complete? 00:20:06.864 --> 00:20:13.316 position:50% align:middle In other words, if they missed check-ins was that a reason for non-completion? 00:20:13.938 --> 00:20:24.680 position:50% align:middle Like, if they missed too many check-ins, did that cause them to not complete a program? 00:20:24.680 --> 00:20:29.860 position:50% align:middle I'm not sure of that. 00:20:29.860 --> 00:20:30.994 position:50% align:middle I don't want to say yes. 00:20:30.994 --> 00:20:32.162 position:50% align:middle I don't think so. 00:20:36.930 --> 00:20:41.720 position:50% align:middle Once again, that would be...missed check-ins are also non-compliances. 00:20:41.720 --> 00:20:43.669 position:50% align:middle So, at some point, that adds up. 00:20:43.669 --> 00:20:53.021 position:50% align:middle But, I don't know if specifically... and programs treat that differently. 00:20:53.021 --> 00:21:01.352 position:50% align:middle So, there may be some programs where that could be seen as a much bigger infraction than in other programs. 00:21:01.352 --> 00:21:02.659 position:50% align:middle So, I don't know. 00:21:02.659 --> 00:21:05.885 position:50% align:middle I can't definitely say yes or no on that question. 00:21:06.523 --> 00:21:12.523 position:50% align:middle And, let's see. 00:21:13.952 --> 00:21:17.348 position:50% align:middle And, once again, that's the final question I'm seeing in this. 00:21:17.348 --> 00:21:24.709 position:50% align:middle So, was there a correlation of missed tests to failure? 00:21:25.976 --> 00:21:28.275 position:50% align:middle Yes, I mean there was. 00:21:28.275 --> 00:21:35.410 position:50% align:middle The more missed tests does correspond to lower program completion. 00:21:35.410 --> 00:21:37.150 position:50% align:middle It's covered elsewhere. 00:21:37.150 --> 00:21:43.739 position:50% align:middle There's stronger variables so we didn't really include that in the final presentation. 00:21:43.739 --> 00:21:52.059 position:50% align:middle But, yes, there is a link between more missed check-ins and likelihood of not completing the program. 00:21:57.154 --> 00:22:00.164 position:50% align:middle Let's see if there's anything else here. 00:22:09.800 --> 00:22:10.700 position:50% align:middle Okay. 00:22:19.620 --> 00:22:20.371 position:50% align:middle Okay. 00:22:22.999 --> 00:22:28.996 position:50% align:middle To my mind I have answered all the questions I see but, let's see. 00:22:36.947 --> 00:22:38.036 position:50% align:middle Let's see. 00:22:52.000 --> 00:22:52.817 position:50% align:middle Okay. 00:23:03.672 --> 00:23:11.486 position:50% align:middle And so, I'm being told I'm missing a question that basically says, did... 00:23:12.910 --> 00:23:14.200 position:50% align:middle Say it again. 00:23:15.160 --> 00:23:21.138 position:50% align:middle Was financial...that nurses could be missing? 00:23:21.200 --> 00:23:22.488 position:50% align:middle Yes, that... 00:23:23.240 --> 00:23:33.560 position:50% align:middle In our study, you do see evidence for even participating, even opting to join the SUD program 00:23:33.560 --> 00:23:41.838 position:50% align:middle or in actions taken, finances are always seemingly an issue. 00:23:41.838 --> 00:23:51.645 position:50% align:middle That one of the issues, that these drug tests have a cost 00:23:51.645 --> 00:24:02.677 position:50% align:middle and so financial reasons could be the reason that maybe people may opt not to go. 00:24:02.677 --> 00:24:04.820 position:50% align:middle So, it could be a factor. 00:24:04.820 --> 00:24:07.310 position:50% align:middle Finances are always an issue with this. 00:24:10.955 --> 00:24:12.800 position:50% align:middle Otherwise, that's it. 00:24:12.800 --> 00:24:14.308 position:50% align:middle That's all I'm seeing. 00:24:16.200 --> 00:24:25.282 position:50% align:middle So, thank you very much for your questions, and thanks for listening to the presentation. 00:24:25.282 --> 00:24:27.916 position:50% align:middle And enjoy the rest of the day.