System for Monitoring Substance Abuse Patients' Outcomes and Care
John W. Finney PhD
VA Palo Alto Health Care System (152MPD)
Palo Alto, CA
Funding Period: July 2000 - June 2005

BACKGROUND/RATIONALE:
Substance use disorders (SUDs) are exceedingly prevalent and costly among VA patients. In Fiscal Year 2000 (FY00), 21 percent of the 353,200 unique VA inpatients had a primary or secondary substance abuse or dependence diagnosis. These patients accounted for 1.2 million days of inpatient care. In addition, 9 percent of the 3.64 million VA outpatients had an alcohol or drug diagnosis in FY00. In all, 124,300 patients received specialized outpatient substance abuse care in FY00. As a result of its prevalence, SUDs were one of eight medical/psychiatric conditions initially targeted in the VA’s Quality Enhancement Research Initiative (QUERI).

OBJECTIVE(S):
To monitor VA SUD patients’ outcomes and care, the VA, until recently, required that all new patients in specialized treatment programs receive an assessment based on the Addiction Severity Index (ASI) at intake. Patients were supposed to be followed up by program staff with another 45-60-minute ASI interview six months later. This system was burdensome for program staff and yielded low (e.g., 20%) follow-up rates and unrepresentative outcome data. The current project evaluates a more efficient outcomes monitoring system (OMS) for assessing VA SUD patients' outcomes and linking them to the care patients have received.

METHODS:
The OMS is testing a more efficient system for monitoring VA SUD patients’ outcomes and care. Using a quasi-experimental, pretest-posttest design in which patients are assessed at treatment intake and at a six-month follow up, treatment type and program comparisons will be made after controlling for patient casemix differences. Building on the previous mandated ASI interview-based system, a self-report instrument made up of ASI "composite score" items was used to gather information on patients’ symptoms and functioning at intake and follow up. Intake data were obtained annually from representative samples of patients in each of a representative sample of 50-55 specialized SUD treatment programs. For annual Cohorts 1-3, intake data were obtained for 1,968, 1,718, and 2,021 patients, respectively. Patient follow ups were conducted by OMS staff primarily via mailed surveys, with some telephone interviews, as needed. Casemix adjustment and additional patient data, as well as information on guideline-concordant treatment practices and costs, are being obtained from national VA databases. Additional data on guideline-concordant treatment practices have been gathered from annual surveys of the directors of the selected SUD programs. Costs of conducting follow-ups using this system will be estimated.

FINDINGS/RESULTS:
The follow-up rate for all three cohorts was 65% or higher, substantially superior to the 20% rate achieved by program staff under the mandated monitoring system. Preliminary findings indicate that VA SUD patients exhibit significant improvement alcohol and substance use and related problems. In addition, preliminary analyses have found that more employment services in SUD programs are linked to better employment outcomes for patients in inpatient/residential SUD programs, whereas higher levels of psychological services are related to reduced rates of drug use and problem drinking for patients with greater baseline psychological problems, but only in outpatient SUD programs. VA SUD treatments also appear effective for suicidal SUD patients, and these patients were particularly responsive to treatment in inpatient settings.

IMPACT:
This project is testing a practical, efficient system for monitoring the outcomes and care for VA patients treated for substance use disorders. Project findings to date support the feasibility of the methods used. If the system were adopted systemwide, it would allow the VA determine the impact of quality improvement efforts in the VA SUD treatment system. Project data will be used to estimate the effectiveness and cost-effectiveness of different forms of VA SUD care, identify types of treatment settings that are optimal for different types of patients, and determine the relationship between process (e.g., continuing care) and outcome indicators of program performance.

PUBLICATIONS:

Journal Articles

1. Tiet QQ, Ilgen MA, Byrnes HF, Harris AH, Finney JW. Treatment setting and baseline substance use severity interact to predict patients' outcomes. Addiction. 2007; 102(3): 432-40.
2. Tiet QQ, Byrnes HF, Barnett P, Finney JW. A practical system for monitoring the outcomes of substance use disorder patients. Journal of Substance Abuse Treatment. 2006; 30(4): 337-47.
3. Petrakis IL, Leslie D, Finney JW, Rosenheck R. Atypical antipsychotic medication and substance use-related outcomes in the treatment of schizophrenia. The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions. 2006; 15(1): 44-9.
4. Ilgen MA, Tiet Q, Finney JW, Harris AH. Recent suicide attempt and the effectiveness of inpatient and outpatient substance use disorder treatment. Alcoholism, Clinical and Experimental Research. 2005; 29(9): 1664-71.
5. Johnson JE, Finney JW, Moos RH. Predictors of 5-year mortality following inpatient/residential group treatment for substance use disorders. Addictive Behaviors. 2005; 30(7): 1300-16.
6. Kelly JF, Finney JW, Moos R. Substance use disorder patients who are mandated to treatment: characteristics, treatment process, and 1- and 5-year outcomes. Journal of Substance Abuse Treatment. 2005; 28(3): 213-23.

DRA: Health Services and Systems, Mental Illness, Substance Abuse, Addictive Disorders
DRE: Communication and Decision Making, Quality of Care, Technology Development and Assessment
Keywords: Clinical practice guidelines, Patient outcomes, Quality assurance, improvement, Research method, Screening
MeSH Terms: none