Performance measures and racial/ethnic disparities in the treatment of substance use disorders.

OBJECTIVE: A limited literature on racial/ethnic disparities in the treatment of substance use disorders suggests that quality of treatment may differ based on client's race/ethnicity. This study examined whether (a) disparities exist in the probability of treatment engagement, a performance measure for substance use disorders, and (b) treatment engagement is associated with similar reductions in likelihood of arrest for Whites, Blacks, Latinos, and American Indians. METHOD: Adult clients who began an outpatient treatment episode in 2008 in public sector specialty treatment facilities in Connecticut, New York, Oklahoma, and Washington made up the sample (N = 108,654). Administrative treatment data were linked to criminal justice data. The criminal justice outcome was defined as an arrest within a year after beginning treatment. Engagement is defined as receiving a treatment service within 14 days of beginning a new outpatient treatment episode and at least two additional services within the next 30 days. Two-step Heckman probit models and hierarchical time-to-event models were used in the analyses. RESULTS: Black clients in New York and American Indian clients in Washington had significantly lower likelihood of engagement than White clients. As moderators of engagement, race/ethnicity had inconsistent effects across states on the hazard of arrest. CONCLUSIONS: Racial/ethnic minority groups may benefit from additional treatment support to reduce criminal justice involvement. States should examine whether disparities exist within their treatment system and incorporate disparities reduction in their quality improvement initiatives.

A performance measure for continuity of care after detoxification: relationship with outcomes.

Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.

Engagement in outpatient substance abuse treatment and employment outcomes.

This study, a collaboration between an academic research center and Washington State's health, employment, and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly funded treatment. The first stage predicted employment in the year following the first treatment visit, and three separate second-stage models predicted the number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.

Criminal justice outcomes after engagement in outpatient substance abuse treatment.

The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14 days of beginning a new episode of specialty treatment and at least two additional services within the next 30 days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of "hazard ratios," which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement.

Randomized trial of enhanced profiling in substance abuse treatment.

A randomized trial of substance abuse treatment programs tested whether "enhanced profiles," consisting of feedback and coaching about performance indicators, improved the performance of residential, methadone, and detoxification programs. These enhanced profiles were reviewed during quarterly on-site visits between October 2005 and July 2007. The performance indicators were the percentage of clients completing referrals to a lower level of care, and the percentage of clients admitted to a higher level of care within 30 days of discharge. Control programs received only "basic profiles," consisting of emailed quarterly printouts of these performance indicators. Effectiveness was evaluated using hierarchical linear models with client-level information nested within agencies and regions of the state. Treatment programs receiving enhanced profiles (n = 74) did not perform significantly differently from those receiving only basic profiles (n = 29) on either performance measure. To improve performance, interventions with greater scope and incentives may be needed.