Performance Measurement in Addictions Treatment Programs

1
Performance Measurement in Addictions Treatment
Programs

• A series of briefings offered to state
  legislatures through a collaborative effort of
  the State Associations of Addiction Services,
  National Conference of State Legislatures, and
  the Treatment Research Institute. Funded by the
  Substance Abuse and Mental Health Services
  Association (SAMHSA) under the Partners for
  Recovery Initiative through a contract with Abt
  Associates Incorporated.
• 
  
  

2
Whats Wrong With Addiction Treatment
What Could Help?
3
Part I Is Treatment Necessary?
Lessons from a Kaiser Permanente study Weisner
et al. (2003) Addiction
4
Weisner et al., 2003

• Evaluation of 482 alcohol dependent adults
• 371 received treatment
• 111 recruited from general pop.
• Follow-up at 12 months
• 84 contact rate (78 tx 93 com)
• Outcomes
• 30-day Abstinence
• 12-month Non-problem alcohol use

5
Baseline Comparisons

• Data Treat. Com
• Male 64 68
• Age 42 36
• Married 33 30
• Poverty 62 38

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Alcohol abstinent at 12 months
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Non-problem use _at_ 12 months
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What predicts abstinence?

• Likelihood of abstinence was increased by
• Being in treatment
• Better if treatment gt 90 days
• Fewer abusers in social network
• Lower psychiatric problems

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Part II
What "Works" ?

• FDA standards of effectiveness
• Do substance abuse treatments meet those
  standards?

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An FDA Perspective
A Drug is Approved for An Indication 2
-Randomized Clinical Trials Often ask for
separate investigators Placebo Control
Movement to test vs approved medication
Treatment Research Institute
11
FDA-Level Evidence

• Therapies
• Cognitive Behavioral Therapy
• Motivational Enhancement Therapy
• Community Reinforcement and Family Training
• Behavioral Couples Therapy
• Multi Systemic Family Therapy
• 12-Step Facilitation
• Individual Drug Counseling

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FDA-Level Evidence

• Medications
• Alcohol (Disulfiram, Naltrexone, Accamprosate)
• Opiates (Naltrexone, Methadone, Buprenorphine)
• Cocaine (Disulfiram, Topiramate, Vaccine?)
• Marijuana (Rimanoban)
• Methamphetamine Nothing Yet

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Part III

• The Specialty Care System A Customer
  Perspective
• Patient Survey
• Care Provided
• Infrastructure

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Addiction Specialty Care

• 13,200 specialty programs in US
• 31 treat less than 200 patients per year
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• Sources NSSATS, 2002 DAunno, 2004

15
Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

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Substance Use Pyramid
In Spec Treatment 2,100,000
?
Abuse/Dependent 23,000,000
Harmful Users ??,000,000
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Why Dont Patients Want Treatment?
Sources 4 Review Articles Rapp et al. JSAT
2005 Stanton JMFT 2004 Appel et al. AJDA
2004 Tsogia et al. JMH 2001
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Top Patient Reasons

• 1) No Problem/Can Handle 58
• 2) No Confidence in Trt 51
• 3) Bad Trt Experience 36
• 4) Abstinence-Only Goal 31

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Part IV

• Why Wont Programs Deliver Quality Care?
• The Infrastructure
• Acute Care Treatment Model
• The Evaluation Model

CANT
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Program Infrastructure

• Phone Interviews With National Sample of 175
  Programs regarding personnel, management,
  information
• McL, Carise Kleber JSAT, 2003

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The Treatment System

• Modality 1975 1990 2005

Residential 64 39 9
Outpatient 27 59 79
Methadone 9 10 12
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Program Changes In 16 Months

• 12 had closed
• 13 had changed service operation RESULT 25
  FEWER PROGRAMS
• 31 of the rest had been taken over, usually by
  MH agencies RESULT STAFF CONFUSION

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STAFF TURNOVER!

• Counselor turnover 50 per year
• 50 of directors have been there Less Than 1
  year

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Other Staff

• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse (part of full time)
• lt 25 Had a SW or a Psychologist
• Major professional group - Counselors

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Information Systems

• Modest Computer Availability
• Mostly For Administrative Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

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The Acute Care Model

• The Acute Care Model
• Treatment Models for Other Illnesses

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A Nice Simple Rehab Model
Substance Abusing Patient
Medications, Therapies, JCAHO, CARF, WC Ev. Based
Prac.
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
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ASSUMPTIONS

• Some fixed amount or duration of treatment will
  resolve the problem
• Outcomes Determined After Discharge
• Clinical efforts put toward matching treatment
  and getting patients to complete treatment
• Evaluation of effectiveness following completion
• Poor outcome means failure

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How Do Other Treatments Work? Chronic Illness
Continuing Care
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A Continuing Care Model
Substance Abusing Patient
Detox
Duration Determined by Performance Criteria
Rehab
Duration Determined by Performance Criteria
Continuing Care Recovering Patient
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ASSUMPTIONS

• Patient will continue in treatment
• There are agreed upon clinical targets at each
  stage of treatment
• Achieving the clinical targets will prepare you
  for the next (reduced intensity) stage
• There will be no discharge just reduced
  intensity of care

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But Addiction Isnt Like Other Diseases .Is
it?
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A Comparison With Three Chronic Medical Illnesses

• Hypertension
• Diabetes
• Asthma

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Why These?

• No Doubt They Are Illnesses
• All Chronic Conditions
• Influenced by Genetic, Metabolic and
  Behavioral Factors
• No Cures - But Effective Treatments Are
  Available

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Heritability Estimates Twin Studies
Eye Color 1.00
ASTHMA (adult only) .35 - .70 DIABETES (insulin
dep) .70 - .95 (males) HYPERTENSION .25 - .50
(males)
ALCOHOL (dependence) .55 - .65 (males) OPIATE
(dependence) .35 - .50 (males)
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HYPERTENSION
Adherence to medication regime lt
60 Adherence to diet and exercise lt 30
Retreated in 12 months 50 - 60 (by
Physician, ER, or Hospital)
Treatment Research Institute
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DIABETES (Adult Onset)
Adherence to medication regime lt
50 Adherence to diet and exercise lt 30
Retreated in 12 months 30 - 50 (by
Physician, ER, or Hospital)
Treatment Research Institute
38
ASTHMA
Adherence to medication lt 30
Retreated in 12 months 60 - 80 (by
Physician, ER, or Hospital)
Treatment Research Institute
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RELAPSE
Predictive Factors - All 3 Illnesses
1 - Lack of Adherence to diet, medications, or
behavior change 2 - Low Socioeconomic status 3
- Low Family Supports 4 - Psychiatric
Co-Morbidity
Sources Natl Ctr Health Stats Harrison, 13th
Ed. 30 studies
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Part V Evaluating Treatment
I

• Implications of How We Evaluate
• Differences in Outcome Expectations

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• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

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Comparing Treatments Testing Three Treatments
in an Acute Care Model
Treatment Research Institute
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Project MATCH Testing Three Versions of the
Rehabilitation Model in Alcohol Dependence
Treatment Research Institute
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Project MATCH

• RCT - 3 Research-Derived Therapies
• 27 Million Dollar NIAAA Study
• Different Mechanisms of Action
• Fixed Interventions No Changes
• Goal Achieve Lasting Abstinence or Improved
  Drinking Post Completion

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MATCH Results

• Equal Significant Improvements
• Equal Outcomes at all points
• No Significant Matches Confirmed
• Outpatient Arm Did Best

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Project Match Fixed Time - Fixed Content Rehab
Oriented
Post Treatment Evaluations
Treatment Type
6 12 18 24
30 39
X X X
X X X
X X X
X X X
X X X
X X X
MET
CBT
12-Step
47

Project Match Fixed Time - Fixed Content Rehab
Oriented
Treatment Type
Post Treatment Evaluations
6 12 18 24
30 39
45
38
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MET
CBT
12-Step
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Improvement in Project MATCH
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Comparing Treatments Testing Three Treatments
in a Continuing Care Model
Treatment Research Institute
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ALLHAT The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack
Treatment Research Institute
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ALLHAT

• Purpose reduce BP among hypertensive adults
  with 1 risks for heart attack
• Real World Effectiveness Study
• 623 practice sites
• 33,357 patients - followed for 4-8 years
• Age 67, 47 Women, 54 Minority
• 41 Million NHLBI Study

Treatment Research Institute
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ALLHAT

• Design RCT, double blind, intent-to-treat
• Criterion-driven stages
• Pre-Specified Indicator
• BP lt 140/90
• No Placebo ethical and value issues
• Evaluated During Treatment 5 years

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ALLHAT

• Groups Explicitly Different Mechanisms of
  Action and Cost
• Diuretic - 0.10 /pill
• Calcium Channel Blocker - 1.50 /pill
• ACE Inhibitor - 4.00 /pill
• Goal to Reach Pre-Specified Criterion DURING
  TREATMENT

Treatment Research Institute
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ALLHAT Results

• Equal Significant Improvements
• No Significant Predictors of Match
• Most Patients Required Combined Treatments

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Improvement in ALLHAT

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ALLHAT Pre-Specified Criteria Adjustment
Oriented
DURING Treatment Evaluations
Start 27 Control
Step 1 Step 2 Step 3
63
40
54
Diuretic
66
56
42
CCB
64
44
54
ACE
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Improvement Comparison
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• Lessons from Chronic Illness
• Medications relieve symptoms but. behavioral
  change is necessary for sustained benefit

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• Lessons from Chronic Illness
• Treatment effects usually dont last very long
  after treatment stops.

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Maybe this is why
61

• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

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Part VI OK, But What Can We Do ?

• A New Treatment Model
• New Purchasing Methods

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A New Treatment Model ?
Lessons from Physician Health Plans
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Physician Health Plans

• 49 PHPs
• All authorized by state licensing boards
• Most treat many types of health professionals
• Do NOT provide treatment
• Assess, Intervene, Evaluate, Refer, Monitor,
  Report and Advocate
• All under authority of Board

DuPont et al., 2008, (in review).
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Evaluation and Contracting

• Phase 1 - Evaluation (1 2 mos.)
• Evaluate referred physician
• Explain PHP and Contract
• Full diagnostic evaluation often with family
• Intervention where appropriate
• Result is signed contract
• 3 5 years in duration
• Protection from immediate adverse actions
• Monitoring with report to Board 4 yrs

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Formal Treatment

• Phase 2 1 yr
• Selected residential treatment 30 90 days
• Referral to IOP or OP 6 months
• Return to practice month 3
• Aftercare program 3-6 months

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Monitoring Support

• Phase 3 3 - 4 yrs
• AA attendance - usually mandatory
• Caduceus Society meetings - mandatory
• Personal Therapist
• Family Therapy
• Worksite visits
• Urine Drug Screenings
• Weekly - monthly (random during weekdays)
• 20 panel testing

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Results During Contract

904 Physicians Consecutively Enrolled into 16
state Physician Health Programs
Continuers 132 - Still being monitored 132
(15)
Completed 448 - No Longer Being
Monitored 67 - Completed but monitored
voluntarily 515 (57)
Non-Completers 85 Voluntarily stopped /
Retired 48 Failed, License Revoked 22
- Died (6 suicides) 102 Transferred/Moved 257
(28)
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Urine Testing Over 4 years
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Results at 5-7 Years
Practicing Medicine Completers 92 Continuers
73 Non-Completers 28
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Results at 5-7 Years
Revoked License Completers
2 Continuers 11 Non-Completers 32
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PHP vs Drug Court

• Component PHP Drug Court

Eval Dx Contract Treatment AA Involvement Case
Mgmt Monitoring Length
Yes W/ Consequence 60 Res / 90 Opt/
Meds Mandatory Fam, Emp, Prof. Yes Urine
visit 3 - 5 yrs
Yes Yes Opt 90 Mandatory Courts Usually Urine
1 Year
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Relapse Rates _at_ 1 Year
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New Purchasing Methods
Performance Contracting In Delaware
McLellan et al., Health Policy, 2008
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Addiction Specialty Care

• 13,200 programs in US
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• 31 treat less than 200 patients per year
• Sources NSSATS, 2002 DAunno, 2004

76
Delaware Situation 2002

• 11 Outpatient Providers
• Limited Budget
• No success with outcome evaluation
• Providers wont/cant use EBPs

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Delawares Performance Based Contracting

• 2002 Budget 90 of 2001 Budget
• Opportunity to Make 106
• Two Criteria 80 Utilization/Occupancy
  Active Participation
• Audit for accuracy and access

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Delawares ResultsYears 1 2

• One program lost contract
• Two new providers entered, did well
• Mental Health and Employment Programs
• Programs worked together
• First, common sense business practices
• Second, incentives for teams or counselors
• 5 programs learned MI and MET

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Utilization
80
Attending
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CONCLUSIONS

• Specialty care system is in trouble
• Customers Do Not Want the Product
• Ruled by Gov, Not Market Forces
• System Change is Necessary
• Public Health Value thru Patient Value
• Treatment Programs MUST Change
• Meet Customer Needs Offer New Options

Purchasers CAN
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- The End -