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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. 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 Jun 1; 30(4):337-47. [view]
2. Blonigen DM, Timko C, Finney JW, Moos BS, Moos RH. Alcoholics Anonymous attendance, decreases in impulsivity and drinking and psychosocial outcomes over 16 years: moderated-mediation from a developmental perspective. Addiction (Abingdon, England). 2011 Dec 1; 106(12):2167-77. [view]
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 Jan 1; 15(1):44-9. [view]
4. Walker AS, Eyre DW, Wyllie DH, Dingle KE, Harding RM, O'Connor L, Griffiths D, Vaughan A, Finney J, Wilcox MH, Crook DW, Peto TE. Characterisation of Clostridium difficile hospital ward-based transmission using extensive epidemiological data and molecular typing. PLoS Medicine. 2012 Feb 7; 9(2):e1001172. [view]
5. Harris AH, Kivlahan DR, Bowe T, Finney JW, Humphreys K. Developing and validating process measures of health care quality: an application to alcohol use disorder treatment. Medical care. 2009 Dec 1; 47(12):1244-50. [view]
6. Harris AH, Humphreys K, Bowe T, Tiet Q, Finney JW. Does meeting the HEDIS substance abuse treatment engagement criterion predict patient outcomes? The journal of behavioral health services & research. 2010 Jan 1; 37(1):25-39. [view]
7. Gifford EV, Tavakoli S, Weingardt KR, Finney JW, Pierson HM, Rosen CS, Hagedorn HJ, Cook JM, Curran GM. How do components of evidence-based psychological treatment cluster in practice? A survey and cluster analysis. Journal of substance abuse treatment. 2012 Jan 1; 42(1):45-55. [view]
8. Harris AH, Kivlahan D, Barnett PG, Finney JW. Longer length of stay is not associated with better outcomes in VHA's substance abuse residential rehabilitation treatment programs. The journal of behavioral health services & research. 2012 Jan 1; 39(1):68-79. [view]
9. Harris AH, Humphreys K, Bowe T, Kivlahan DR, Finney JW. Measuring the quality of substance use disorder treatment: evaluating the validity of the Department of Veterans Affairs continuity of care performance measure. Journal of substance abuse treatment. 2009 Apr 1; 36(3):294-305. [view]
10. Johnson JE, Finney JW, Moos RH. Predictors of 5-year mortality following inpatient/residential group treatment for substance use disorders. Addictive Behaviors. 2005 Aug 1; 30(7):1300-16. [view]
11. 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 Sep 1; 29(9):1664-71. [view]
12. 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 Apr 1; 28(3):213-23. [view]
13. Tiet QQ, Ilgen MA, Byrnes HF, Harris AH, Finney JW. Treatment setting and baseline substance use severity interact to predict patients' outcomes. Addiction. 2007 Mar 1; 102(3):432-40. [view]
14. Harris AH, Humphreys K, Finney JW. Veterans Affairs facility performance on Washington Circle indicators and casemix-adjusted effectiveness. Journal of substance abuse treatment. 2007 Dec 1; 33(4):333-9. [view]
15. Finney JW, Humphreys K, Kivlahan DR, Harris AH. Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy. American journal of public health. 2011 Sep 1; 101(9):1635-42. [view]

Journal Other

1. Finney JW, Humphreys K, Harris AH. Cross-level bias and variations in care. [Letter to the Editor]. JAMA : the journal of the American Medical Association. 2011 Nov 16; 306(19):2096-7; author reply 2097. [view]

VA Cyberseminars

1. Finney JW. Are misinterpreted, hospital-level relationships between process performance measures and outcomes undermining evidence-based patient care? [Cyberseminar]. 2013 May 22. [view]

Conference Presentations

1. Finney JW, Humphreys KN, Kivlahan DR, Harris AH. Differences between patient-and facility-level performance measure-outcome relationships: Implications for health care quality management and research. Paper presented at: Kaiser Permanente Division of Research Annual Meeting; 2010 Jan 5; Oakland, CA. [view]
2. Finney JW, Humphreys KN, Kivlahan DR, Harris AH. Differences between patient-level and facility-level performance measure-outcome relationships: Implications for quality measurement and management. Poster session presented at: Treatment of Addictive Behaviors Annual International Conference; 2010 Feb 9; Santa Fe, NM. [view]
3. Tiet Q, Finney J, Byrnes H, Tregor G, Liu L, Kuang S, Strumolo A. Evaluation of a new monitoring system and SUD patients' outcomes. Paper presented at: American Psychological Association Annual Convention; 2004 Jul 2; Honolulu, HI. [view]
4. Finney JW, Humphreys KN, Kivlahan DR, Harris AH. Incongruence between patient-level and facility-level performance measure-outcome relationships: Implications for quality management and research. Poster session presented at: Addiction Health Services Research Conference; 2009 Oct 29; San Francisco, CA. [view]
5. Harris AH, Finney JW. Multi-level modeling (and thinking) in the development and validation of health care quality measures. Paper presented at: Health Policy Statistics Annual International Conference; 2010 Jan 1; Washington, DC. [view]
6. Byrnes H, Finney J, Tiet Q, Tregor G, Liu L, Kuang S, Strumolo A. Needs-service matching in substance use disorder treatment programs. Paper presented at: Research Society on Alcoholism Annual Scientific Meeting; 2004 Jun 2; Vancouver, Canada. [view]
7. Tiet Q, Brynes H, Finney J, Tregor G, Gillo S, Hix R, Liu L. Outcomes of substance use patients. Paper presented at: American Psychological Association Annual Convention; 2003 Aug 1; Toronto, Canada. [view]
8. Tiet Q, Finney J, Byrnes H, Tregor G, Liu L, Kuang S, Strumolo A. Patient-treatment setting interaction effects on substance use disorder patients' outcomes. Paper presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]
9. Finney JW. Relationships between health care process performance measures and outcomes outcomes for patients and hospitals: Understanding the ecological fallacy. Presented at: Centers for Medicare & Medicaid Services Quality Measurement and Health Assessment Group Measures Forum; 2012 Sep 20; Bethesda, MD. [view]
10. Barnett PG, Gage M, Tiet QQ, Finney JW. The cost of substance use rehabilitation across the continuum of settings. Paper presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]
11. Ilgen MA, Tiet Q, McKellar J, Barnett P, Luna Y, Finney JW. Treatment intensity and symptom severity in patients with substance use disorders. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
12. Tiet Q, Finney J, Byrnes H, Tregor G, Liu L, Kuang S, Strumolo A. Treatment Setting/Psychiatric Symptom Interaction Effects on Alcohol Outcomes. Paper presented at: American Psychological Association Annual Convention; 2004 Jul 2; Honolulu, HI. [view]
13. Harris AHS, Humphreys KN, Finney JW. Veterans Affairs facility performance on Washington circle indicators and casemix-adjusted effectiveness. Poster session presented at: American Psychological Association Annual Convention; 2007 Aug 19; San Francisco, CA. [view]

DRA: Substance Use Disorders, Health Systems Science, Mental, Cognitive and Behavioral Disorders
DRE: none
Keywords: Clinical practice guidelines, Patient outcomes, Quality assurance, improvement, Research method, Screening
MeSH Terms: none