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ABSTRACT: For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships.
This is a prospective study of adolescents (N=1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes.
Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents' self-report of illegal activity or trouble controlling behavior at follow-up.
At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.
Drug and alcohol dependence 02/2012; 124(3):250-8. · 3.60 Impact Factor
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ABSTRACT: This study examined client and program factors predicting initiation and engagement for 2,191 adolescents at 28 outpatient substance abuse treatment sites implementing evidence-based treatments. Using Washington Circle criteria for treatment initiation and engagement, 76% of the sample initiated, with 59% engaging in treatment. Analyses used a 2-stage Heckman probit regression, accounting for within-site clustering, to identify factors predictive of initiation and engagement. Adolescents treated in a pay-for-performance (P4P) group were more likely to initiate, whereas adolescents in the race/ethnicity category labeled other (Native American, Asian, Pacific Islander, Native Alaskan, Native Hawaiian, mixed race/ethnicity), or who reported high truancy, were less likely to initiate. Race/ethnicity groups other than Latinos were equally likely to engage. Among White adolescents, each additional day from first treatment to next treatment reduced likelihood of engagement. Although relatively high initiation and engagement rates were achieved, the results suggest that attention to program and client factors may further improve compliance with these performance indicators.
Journal of substance abuse treatment 10/2011; 42(4):346-55. · 2.90 Impact Factor
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ABSTRACT: Information about treatment services can be ascertained in several ways. We examine the level of agreement among data on substance user treatment services collected via multiple methods and respondents in the nationally representative Alcohol and Drug Services Study (ADSS, 1996-1999), and potential reasons for discrepancies. Data were obtained separately from facility director reports, treatment record abstracts, and client interviews. Concordance was generally acceptable across methods and respondents. Although any of these methods should be adequate, additional information is gleaned from multiple sources.
Substance Use & Misuse 11/2010; 46(5):620-32. · 1.10 Impact Factor
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ABSTRACT: The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.
Health Affairs 02/2009; 28(2):w251-61. · 4.31 Impact Factor
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ABSTRACT: In 2002 buprenorphine (Suboxone or Subutex) was approved by the U.S. Food and Drug Administration for office-based treatment of opioid addiction. The goal of office-based pharmacotherapy is to bring more opiate-dependent people into treatment and to have more physicians address this problem. This study examined prescribing practices for buprenorphine, including facilitators and barriers, and the organizational settings that facilitate its being incorporated into treatment.
Addiction specialists and other psychiatrists in four market areas were surveyed by mail and Internet in fall 2005 to examine prescribing practices for buprenorphine. Respondents included 271 addiction specialists (72% response rate) and 224 psychiatrists who were not listed as addiction specialists but who had patients with addictions in their practice (57% response rate).
Three years after approval of buprenorphine for office-based addiction treatment, nearly 90% of addiction specialists had been approved to prescribe it and two-thirds treated patients with buprenorphine. However, fewer than 10% of non-addiction specialist psychiatrists prescribed it. Regression-adjusted factors predicting prescribing of buprenorphine included support of training and use of buprenorphine by the physician's main affiliated organization, less time in general psychiatry compared with addictions treatment, more time in group practice rather than solo, ten or more opiate-dependent patients, belief that drugs play a large role in addiction treatment, and patient demand.
Office-based pharmacotherapy offers a promising path to improved access to addictions treatment, but prescribing has expanded little beyond the addiction specialist community.
Psychiatric services (Washington, D.C.) 09/2008; 59(8):909-16. · 2.81 Impact Factor
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ABSTRACT: Health plans in the United States are struggling to contain rapid growth in their spending on medications. They have responded by implementing multi-tiered formularies, which label certain brand medications 'non-preferred' and require higher patient copayments for those medications. This multi-tier policy relies on patients' willingness to switch medications in response to copayment differentials. The antidepressant class has certain characteristics that may pose problems for implementation of three-tier formularies, such as differences in which medication works for which patient, and high rates of medication discontinuation.
To measure the effect of a three-tier formulary on antidepressant utilization and spending, including decomposing spending allocations between patient and plan.
We use claims and eligibility files for a large, mature nonprofit managed care organization that started introducing its three-tier formulary on January 1, 2000, with a staggered implementation across employer groups. The sample includes 109,686 individuals who were continuously enrolled members during the study period. We use a pretest-posttest quasi-experimental design that includes a comparison group, comprising members whose employer had not adopted three-tier as of March 1, 2000. This permits some control for potentially confounding changes that could have coincided with three-tier implementation.
For the antidepressants that became nonpreferred, prescriptions per enrollee decreased 11% in the three-tier group and increased 5% in the comparison group. The own-copay elasticity of demand for nonpreferred drugs can be approximated as -0.11. Difference-in-differences regression finds that the three-tier formulary slowed the growth in the probability of using antidepressants in the post-period, which was 0.3 percentage points lower than it would have been without three-tier. The three-tier formulary also increased out-of-pocket payments while reducing plan payments and total spending.
The results indicate that the plan enrollees were somewhat responsive to the changed incentives, shifting away from the drugs that became nonpreferred. However, the intervention also resulted in cost-shifting from plan to enrollees, indicating some price-inelasticity. The reduction in the proportion of enrollees filling any prescriptions contrasts with results of prior studies for non-psychotropic drug classes. Limitations include the possibility of confounding changes coinciding with three-tier implementation (if they affected the two groups differentially); restriction to continuous enrollees; and lack of data on rebates the plan paid to drug manufacturers. Implications for Health Care Provision and Use: The results of this study suggest that the impact of the three-tier formulary approach may be somewhat different for antidepressants than for some other classes.
Policymakers should monitor the effects of three-tier programs on utilization in psychotropic medication classes.
Future studies should seek to understand the reasons for patients' limited response to the change in incentives, perhaps using physician and/or patient surveys. Studies should also examine the effects of three-tier programs on patient adherence, quality of care, and clinical and economic outcomes.
The Journal of Mental Health Policy and Economics 07/2008; 11(2):67-77. · 0.97 Impact Factor
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ABSTRACT: This study examines the association between adherence to during-treatment process measures of quality (defined as initiation and engagement in treatment as developed by the Washington Circle) and outcome measures (defined as arrests and incarcerations) in the following year. The data come from the Oklahoma Department of Mental Health and Substance Abuse Services administrative data system linked to data from state criminal justice agencies. Clients who initiated a new episode of outpatient treatment and who engaged in treatment were significantly less likely to be arrested or incarcerated in the following year. Initiation of substance abuse treatment alone, without engagement in treatment, was not significantly associated with arrests or incarcerations. These findings validate the clinical importance of the Washington Circle performance measures of initiation and engagement. Applying the "process-of-care" measures can make a difference when they are used as a target for quality improvement in treatment facilities.
Journal of Substance Abuse Treatment 01/2008; 33(4):341-52. · 3.14 Impact Factor
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ABSTRACT: The nationally representative Alcohol and Drug Services Study (ADSS, 1996--1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N=988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.
Substance Use & Misuse 02/2004; 39(13-14):2391-424. · 1.10 Impact Factor
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ABSTRACT: In the US, the spiraling costs of substance abuse and mental health treatment caused many state Medicaid agencies to adopt managed behavioral health care (MBHC) plans during the 1990s. Although research suggests that these plans have successfully reduced public sector spending, their impact on the quality of substance abuse treatment has not been established.
The Massachusetts Medicaid program started a risk-sharing contract with MHMA, a private, for-profit specialty managed behavioral health care (MBHC) carve-out vendor on July 1, 1992. This paper evaluates the carve-out s impact on spending per inpatient episode and three proxy measures of quality: (i) access to inpatient treatment (ii) 30-day re-admissions and (iii) continuity of care.
Medicaid claims for inpatient treatment were collapsed into episodes. Clients were tracked across the five-year period and an interrupted time series design was used to compare the three quality outcomes and spending in the year prior to (FY1992) and the four years during MHMA (FY1993-FY1996). Logistic and linear regression models were used to control for race, disability status, age, gender and primary diagnosis.
Despite a 99% reduction in the use of hospital-based settings, access to 24-hour services overall increased by 38%, largely due to an expansion in the use of freestanding detoxification and acute residential services. Continuity improved by 73%. Nevertheless, rates of 7-day (58%) and 30-day (24%) readmission increased significantly, even after controlling for increases in disability status. Per episode spending decreased by 76% ($2,773), characterized by a dramatic spending reduction in FY1993 that was maintained but not augmented in subsequent years.
The carve-out had mixed effects on the quality of substance abuse treatment. While one of the three measures (readmission rates) deteriorated, two improved (access and continuity).
Rapid re-admissions were strongly associated with shorter lengths of stay, suggesting that strengthening discharge planning may preserve the benefits of MBHC while avoiding its risks.
Since reductions in Medicaid spending were impressive but finite, MBHC may not be the permanent solution to inflation in behavioral health care. MBHC firms should implement quality-monitoring programs to ensure that aggressive utilization management strategies do not compromise quality of care.
The impact of managed behavioral health care should ideally be evaluated in randomized controlled studies. In addition, research is needed to establish that the quality measures employed in this evaluation - improved access, enhanced continuity and fewer rapid re-admissions actually correspond to reductions in drug or alcohol use and other favorable outcomes obtained through client self-report or urinalysis.
The Journal of Mental Health Policy and Economics 01/2003; 5(4):163-74. · 0.97 Impact Factor
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ABSTRACT: Examination of organizational and financial characteristics of the specialty substance abuse treatment system allows an understanding
of how to meet the needs of clients in the system. Further, this assessment may afford insights into how the specialty sector
may adapt in the changing environment of managed care. Data from Phase I of the Alcohol and Drug Services Study (ADSS) describe
the specialty substance abuse treatment system in terms of type of care, setting, level of affiliation, licen-sure/accreditation,
ownership, revenue sources, client referral sources, client’s primary substance of abuse, and managed care. Although the system
is largely outpatient and remains substantially two tiered in terms of public/private funding mix, it varies along a number
of organizational and financial dimensions which have implications for system structure and facility viability in the changing
environment of substance abuse treatment service delivery.
12/2000: pages 9-26;
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ABSTRACT: In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment
and support services that substance abuse clients have access to during treatment. Trends in services over recent years are
described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting
access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and
Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in
service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence
on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different
types of facilities are likely to have access to certain types of services.
12/2000: pages 137-156;
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ABSTRACT: We examined 2001 prescription drug claims for a range of employer-based retiree plans administered by a national pharmacy benefit management firm, to understand how use and spending differ with various cost-sharing approaches and other drug use management techniques among the elderly. In these plans, most of which had generous benefits and substantial use of mail order, more aggressive cost-sharing requirements combined with other management strategies were associated with greater member cost sharing, a shift to less costly medications (generic and mail order), and lower total prescription drug spending. Although we did not find lower rates of use in plans with aggressive cost sharing, this may be attributable in part to their higher drug use associated with mail-order incentives.
Health Affairs Suppl Web Exclusives:W408-19. · 4.31 Impact Factor
