Utilization and cost impact of integrating substance abuse treatment and primary care.
TL;DR: The findings for the full sample suggest that integrating substance abuse treatment with primary care, may not be necessary or appropriate for all patients, but it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine.
Abstract: Objective. To examine the impact of integrating medical and substance abuse treatment on health care utilization and cost.Research Design. Randomized clinical trial assigning patients to one of two treatment modalities: an Integrated Care model where primary health care is provided along with substa
Citations
More filters
01 Nov 2008
TL;DR: There is a reasonably strong body of evidence to encourage integrated care, at least for depression, and there is no discernible effect of integration level, processes of care, or combination on patient outcomes for mental health services in primary care settings.
Abstract: Objectives To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data sources MEDLINE, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review methods Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernible effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or a systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.
420 citations
Cites background from "Utilization and cost impact of inte..."
...Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial JAMA 2006 May 10; 295(18):2148-57....
[...]
...Effect of Improving Depression Care on Pain and Functional Outcomes Among Older Adults With Arthritis: A Randomized Controlled Trial JAMA: Journal of the American Medical Association 2003 Nov; 290(18):2428-34....
[...]
...Medical Journal of Australia 1976 May 1; 1(18):666-9....
[...]
TL;DR: Significant progress has been made in adapting addiction treatment to respond more fully to the chronic nature of most patients’ problems, and the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease is addressed.
Abstract: This article reviews progress in adapting addiction treatment to respond more fully to the chronic nature of most patients' problems. After reviewing evidence that the natural history of addiction involves recurrent cycles of relapse and recovery, we discuss emerging approaches to recovery management, including techniques for improving the continuity of care, monitoring during periods of abstinence, and early reintervention; recent developments in the field related to self-management, mutual aid, and other recovery supports; and system-level interventions. We also address the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease.
327 citations
Cites background from "Utilization and cost impact of inte..."
...Godley and colleagues (2002, 2004, 2007) developed a protocol called assertive continuing care (ACC) and showed that it improved participation and recovery indicators....
[...]
TL;DR: Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups.
Abstract: s into the 14 special population groups shown in Table 14-1. Catalogued materials include research studies, books, newsletter articles, case studies, program descriptions, journal articles, monographs, communications, and so forth. Table 14-1 shows the frequency distribution of materials in each of the specified areas for three distinct time periods: 1973-1982, 1983-1985, and 1986-1987. The table also contains a summary for the total 15-year period, 1973-1987. THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 350 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. TABLE 14-1 Total Number of Resource Materials on Special Population Groups Included in the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Data Base Special Population Group 1973-1982 1983-1985 1986-1987 Total 1973-1987 Youth 722 1,120 511 2,353 College/university students 8 119 134 261 Elderly 205 186 49 440 Alcoholic females 425 347 208 980 Homosexuals 16 14 22 52 Economically disadvantaged 39 66 47 152 Racial and ethnic groups (general) 301 338 165 804 Blacks 103 131 69 303 Hispanics 48 54 42 144 Asians and Pacific Islanders 54 60 30 144 American Indians 117 85 35 237 Religious groups 79 113 51 243 Public inebriates 2 33 46 81 Handicapped/disabled 0 22 23 45 SOURCE: Committee analysis of data from the National Clearinghouse for Alcohol and Drug Abuse Information data base. Over the 15 year period the emphasis in catalogued material has been predominantly on youth, women, and racial and ethnic groups. The increase in abstracted materials for all the special populations in the last five years deserves notice; youth and women are the categories for which the most materials are recorded. There is also a marked increase in attention paid to college students, whereas there seems to be a slight tapering off in attention paid to elderly, youth, and American Indians. It is possible to characterize the literature abstracted in the NCADI data base as containing only a very few controlled trials in which the effectiveness of generic treatment is compared with treatment specifically tailored to the characteristics of the special population under consideration. There is a paucity of adequate studies on treatment outcome for any of the groups identified (Gilbert and Cervantes, 1988; Vannicelli, 1988; Westermeyer, 1988). The comment on treatment outcome made by Braiker (1982) continues to have current general applicability to all special population groups: A review of the general literature on alcoholism treatment effectiveness reveals that most studies either fail to distinguish between outcome rates for men and women alcoholics or exclude the latter group from the study samples altogether. Among those studies that distinguish outcome rate by sex, varying and often conflicting results are reported. (p. 127) Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups. These were surveys of alcoholism treatment services provided by all known public and private alcoholism and drug abuse facilities and units in the United States (NIAAA, 1983; Reed and Sanchez, 1986; NIDA/NIAAA 1989) (see Chapter 4 and Chapter 7). Table 14-2 presents data on the number of specialized programs offered by alcoholism treatment units by the year THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 351 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of the survey. Youth, women, the elderly, Hispanics, public inebriates, and blacks were the only special population groups included in all three of these surveys; American Indians/Alaskan natives were included in the last two surveys. TABLE 14-2 Specialized Programs Offered by Alcoholism Treatment Units by Survey Yeara Percentage of Total Units Reporting Specialized Program 1982b 1984c 1987d Youth 21 27 31 Elderly 9 9 8 Women 23 22 28 Hispanics 9 9 11 Blacks 8 7 6 American Indians/Alaskan natives —e 5 5 Public inebriates 13 9 7 Other 13 9 15 None 51 46 41 Total units reporting 4,233 6,963 5,791 a Includes both alcoholism-only units and combined alcoholism and drug abuse units. b Data from the 1982 National Drug and Alcoholism Treatment Utilization Survey (NIAAA, 1983). c Data from the 1984 National Alcoholism and Drug Abuse Program Inventory (Reed and Sanchez, 1986). d Data from the 1987 National Drug and Alcoholism Treatment Unit Survey (NIDA/NIAAA, 1989). e Not included in the 1982 survey. The inventory asked respondents to identify whether they offered one or more specialized programs to certain population groups. Judging on the basis of the treatment units reporting, it appears that an increasing percentage of units are offering one or more specialized programs. In 1987 the largest number of specialized programs offered in treatment units were for youth (31 percent), followed closely by those for women (28 percent), with a sharp drop to programs for Hispanics (11 percent) and the elderly (8 percent). Changes in the total number of units reporting and in the number of specialized programs must be interpreted cautiously because there was a more thorough outreach effort in 1984 to locate all units that were either not identified in 1982 or that did not respond; this effort may simply have uncovered existing units that had not responded earlier rather than identifying new units that had only recently been established (cf. Reed and Sanchez, 1986:2). An examination of these two sources—the NCADI database and the NIAAA surveys of treatment units— shows that women and youth are the special population groups that have received the most attention since the early 1970s. What they do not reveal are the most effective ways to meet the needs of individual problem drinkers or how to identify factors germane to a special population that might affect treatment. The overviews are also unable to provide guidance on when treatment should emphasize an individual's special population membership to facilitate a successful outcome. Indeed, if these overviews tell us anything, it is that women and youth appear to be the special population groups that people are most concerned about. Given the historical dilemmas, variations, and inconsistencies in defining which groups should be considered as special populations in the planning, funding and evaluation THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 352 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of alcohol problems treatment, Lex (1985:90) has suggested that a special population be defined as any subgroup that is “special in terms of their uniformity on some dimension and their differences from more typical societal patterns and problems.” The committee agrees with this definition. However, the definition does not fully capture the problems encountered in attempting to review existing knowledge on the value of special population programming. This review of the history of attention to special population groups suggests that their definition is often not only in terms of the unique biological and sociocultural characteristics that define a group with similar risk factors and drinking practices but also in terms of the momentary concern regarding access to appropriate services. Interest in each group has waxed and waned. There has been no systematic follow up to determine whether access has been improved or treatment outcome positively affected by these periods of attention. What is challenging, for both researchers and clinicians, is to determine where and how the emphasis on special population membership can best facilitate effective treatment for alcohol problems. Given this background, for the purposes of this report, a special population will be viewed as any subgroup that has been identified by the field as needing a specifically tailored “culturally sensitive” treatment program. The committee has chosen to look at developments and issues for only a few of the commonly identified special population groups and the evolution and effectiveness of treatment programs designed for them as portrayed in the research and clinical literature. It is important to note that these groups are by no means inclusive of all special population groups; rather, they have been selected as representatives of special populations as a whole. Chapter 15 considers these groups on the basis of structural characteristics (i.e., demographic characteristics); Chapter 16, adapts the perspectives of functional characteristics (i.e., circumstantial concerns) as a definitional framework. Chapter 17 presents the committee's conclusions and recommendations on the issue of treatment for alcohol problems among special populations.
272 citations
TL;DR: A small but growing body of research suggests that a range of models may hold potential for improving patients' health and health care, at a relatively modest cost.
195 citations
TL;DR: A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement.
Abstract: The health care system in the United States, plagued by spiraling costs, unequal access, and uneven quality, can find its best chance of improving the health of the population through the improvement of behavioral health services. It is in this area that the largest potential payoff in reduction of morbidity and mortality and increased cost-effectiveness of care can be found. A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement. The evidence supports many but not all behavioral health services when delivered in settings in which people will accept these services under particular administrative and fiscal structures.
169 citations
References
More filters
TL;DR: Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups.
Abstract: s into the 14 special population groups shown in Table 14-1. Catalogued materials include research studies, books, newsletter articles, case studies, program descriptions, journal articles, monographs, communications, and so forth. Table 14-1 shows the frequency distribution of materials in each of the specified areas for three distinct time periods: 1973-1982, 1983-1985, and 1986-1987. The table also contains a summary for the total 15-year period, 1973-1987. THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 350 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. TABLE 14-1 Total Number of Resource Materials on Special Population Groups Included in the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Data Base Special Population Group 1973-1982 1983-1985 1986-1987 Total 1973-1987 Youth 722 1,120 511 2,353 College/university students 8 119 134 261 Elderly 205 186 49 440 Alcoholic females 425 347 208 980 Homosexuals 16 14 22 52 Economically disadvantaged 39 66 47 152 Racial and ethnic groups (general) 301 338 165 804 Blacks 103 131 69 303 Hispanics 48 54 42 144 Asians and Pacific Islanders 54 60 30 144 American Indians 117 85 35 237 Religious groups 79 113 51 243 Public inebriates 2 33 46 81 Handicapped/disabled 0 22 23 45 SOURCE: Committee analysis of data from the National Clearinghouse for Alcohol and Drug Abuse Information data base. Over the 15 year period the emphasis in catalogued material has been predominantly on youth, women, and racial and ethnic groups. The increase in abstracted materials for all the special populations in the last five years deserves notice; youth and women are the categories for which the most materials are recorded. There is also a marked increase in attention paid to college students, whereas there seems to be a slight tapering off in attention paid to elderly, youth, and American Indians. It is possible to characterize the literature abstracted in the NCADI data base as containing only a very few controlled trials in which the effectiveness of generic treatment is compared with treatment specifically tailored to the characteristics of the special population under consideration. There is a paucity of adequate studies on treatment outcome for any of the groups identified (Gilbert and Cervantes, 1988; Vannicelli, 1988; Westermeyer, 1988). The comment on treatment outcome made by Braiker (1982) continues to have current general applicability to all special population groups: A review of the general literature on alcoholism treatment effectiveness reveals that most studies either fail to distinguish between outcome rates for men and women alcoholics or exclude the latter group from the study samples altogether. Among those studies that distinguish outcome rate by sex, varying and often conflicting results are reported. (p. 127) Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups. These were surveys of alcoholism treatment services provided by all known public and private alcoholism and drug abuse facilities and units in the United States (NIAAA, 1983; Reed and Sanchez, 1986; NIDA/NIAAA 1989) (see Chapter 4 and Chapter 7). Table 14-2 presents data on the number of specialized programs offered by alcoholism treatment units by the year THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 351 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of the survey. Youth, women, the elderly, Hispanics, public inebriates, and blacks were the only special population groups included in all three of these surveys; American Indians/Alaskan natives were included in the last two surveys. TABLE 14-2 Specialized Programs Offered by Alcoholism Treatment Units by Survey Yeara Percentage of Total Units Reporting Specialized Program 1982b 1984c 1987d Youth 21 27 31 Elderly 9 9 8 Women 23 22 28 Hispanics 9 9 11 Blacks 8 7 6 American Indians/Alaskan natives —e 5 5 Public inebriates 13 9 7 Other 13 9 15 None 51 46 41 Total units reporting 4,233 6,963 5,791 a Includes both alcoholism-only units and combined alcoholism and drug abuse units. b Data from the 1982 National Drug and Alcoholism Treatment Utilization Survey (NIAAA, 1983). c Data from the 1984 National Alcoholism and Drug Abuse Program Inventory (Reed and Sanchez, 1986). d Data from the 1987 National Drug and Alcoholism Treatment Unit Survey (NIDA/NIAAA, 1989). e Not included in the 1982 survey. The inventory asked respondents to identify whether they offered one or more specialized programs to certain population groups. Judging on the basis of the treatment units reporting, it appears that an increasing percentage of units are offering one or more specialized programs. In 1987 the largest number of specialized programs offered in treatment units were for youth (31 percent), followed closely by those for women (28 percent), with a sharp drop to programs for Hispanics (11 percent) and the elderly (8 percent). Changes in the total number of units reporting and in the number of specialized programs must be interpreted cautiously because there was a more thorough outreach effort in 1984 to locate all units that were either not identified in 1982 or that did not respond; this effort may simply have uncovered existing units that had not responded earlier rather than identifying new units that had only recently been established (cf. Reed and Sanchez, 1986:2). An examination of these two sources—the NCADI database and the NIAAA surveys of treatment units— shows that women and youth are the special population groups that have received the most attention since the early 1970s. What they do not reveal are the most effective ways to meet the needs of individual problem drinkers or how to identify factors germane to a special population that might affect treatment. The overviews are also unable to provide guidance on when treatment should emphasize an individual's special population membership to facilitate a successful outcome. Indeed, if these overviews tell us anything, it is that women and youth appear to be the special population groups that people are most concerned about. Given the historical dilemmas, variations, and inconsistencies in defining which groups should be considered as special populations in the planning, funding and evaluation THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 352 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of alcohol problems treatment, Lex (1985:90) has suggested that a special population be defined as any subgroup that is “special in terms of their uniformity on some dimension and their differences from more typical societal patterns and problems.” The committee agrees with this definition. However, the definition does not fully capture the problems encountered in attempting to review existing knowledge on the value of special population programming. This review of the history of attention to special population groups suggests that their definition is often not only in terms of the unique biological and sociocultural characteristics that define a group with similar risk factors and drinking practices but also in terms of the momentary concern regarding access to appropriate services. Interest in each group has waxed and waned. There has been no systematic follow up to determine whether access has been improved or treatment outcome positively affected by these periods of attention. What is challenging, for both researchers and clinicians, is to determine where and how the emphasis on special population membership can best facilitate effective treatment for alcohol problems. Given this background, for the purposes of this report, a special population will be viewed as any subgroup that has been identified by the field as needing a specifically tailored “culturally sensitive” treatment program. The committee has chosen to look at developments and issues for only a few of the commonly identified special population groups and the evolution and effectiveness of treatment programs designed for them as portrayed in the research and clinical literature. It is important to note that these groups are by no means inclusive of all special population groups; rather, they have been selected as representatives of special populations as a whole. Chapter 15 considers these groups on the basis of structural characteristics (i.e., demographic characteristics); Chapter 16, adapts the perspectives of functional characteristics (i.e., circumstantial concerns) as a definitional framework. Chapter 17 presents the committee's conclusions and recommendations on the issue of treatment for alcohol problems among special populations.
272 citations
TL;DR: The study provides considerable evidence that alcoholism treatment can reduce overall medical costs in a heterogeneous alcoholic population (white collar/blue collar; fee-for-service/HMO).
Abstract: This study utilized two separate research designs to examine whether the initiation of alcoholism treatment is associated with a change in overall medical care cost in a population of alcoholics enrolled under a health plan sponsored by a large midwestern manufacturing corporation. In the longest longitudinal study of alcoholism treatment costs to date, a review of claims filed from 1974 to 1987 identified 3,729 alcoholics (3,068 of whom received treatment and 661 of whom did not). In one design, a time-series analysis found that following treatment initiation the total health care costs of treated alcoholics--including the cost of alcoholism treatment--declined by 23% to 55% from their highest pretreatment levels. Costs for identified but untreated alcoholics rose following identification. In a second design, analysis of variance was used to control for group differences including pretreatment health status and age. This analysis indicated that the posttreatment costs of treated alcoholics were 24% lower...
221 citations
"Utilization and cost impact of inte..." refers background in this paper
...Four cost measures were examined: (1) inpatient cost, (2) ER cost, (3) primary care cost, and (4) total medical cost (including inpatient, ER, and nonemergent outpatient visit cost)....
[...]
01 Jan 1999
TL;DR: ILSI Europe has gathered together leading sceintists to address the relationship between alcohol consumption and hypertension, stroke, coronary heart disease, digestive tract cancers, liver diseases, breast cancer, pregnancy, weight gain and genetics.
Abstract: Although alcohol has been one of the most studied and researched substances consumed by man, there are few sources one can consult for an objective review of the current state of scientific knowledge in this broad area. In this book, ILSI Europe has gathered together leading sceintists (including epidemiologists, clinicians, toxicologists and other biomedical researchers) to address the relationship between alcohol consumption and hypertension, stroke, coronary heart disease, digestive tract cancers, liver diseases, breast cancer, pregnancy, weight gain and genetics. This book will be a valuable reference for all those involved in addressing the health effects of excessive, moderate and light consumption of alcohol.
208 citations
TL;DR: This article describes databases that are currently found in or used by older health maintenance organizations (HMOs) and offers examples of the research that can be conducted by linking these databases and describes the potential for capturing the complete health care experience of large, representative populations in readily retrievable databases.
Abstract: Spurred by demands for data from employer-purchasers and accreditation agencies and the adoption of strategies for disease management and outcome-based quality assurance, managed care organizations have recognized the need for rapid, convenient access to clinical information. Large investments in administrative and clinical data systems have also produced unprecedented opportunities for research on health care and epidemiology in large, defined populations. There is a long history of contributions to research by investigators who are based in the older nonprofit group and staff models of health maintenance organizations (HMOs). Many of these organizations maintain research units that are primarily funded by outside sources. Research includes descriptive and etiologic studies of epidemiology, randomized and observational studies of the effectiveness of treatment regimens, studies of disease costs and estimation of cost-effectiveness, investigations of risk predictions in populations, of risk and changes in organizational behavior, and evaluations of interventions to alter physician and patient behavior. The work is often conducted in collaboration with academic researchers. The HMO Research Network has recently been established to foster a scientific exchange among HMO-based researchers. As managed care organizations come to provide health care coverage to most U.S. citizens, research conducted by these organizations increasingly overlaps with public health research. Collaboration between HMO-based research centers and researchers from academia and government will undoubtedly continue to increase.
170 citations