Health Services Research

23 Pages 5845 Words

ong the 405 self-selected subjects, DH was related to abstinence (OR = 2.1; 95% CI = 1.3, 3.5).Conclusions. Although significant benefits of the DH program were not found in the randomized study, DH treatment was associated with better outcomes in the self-selected group. However, for subjects with mid-level psychiatric severity in both the randomized and self-selected samples, the DH program produced higher rates of abstention and was more cost-effective. Self-selection in studies that randomize patients to services requiring very different levels of commitment may be important in interpreting findings for clinical practice.Key Words. Substance abuse, HMO, outcome, cost-effectiveness, generalizabilityStudies of alcohol and drug treatment employing random assignment to inpatient and outpatient modalities suggest comparable effectiveness, despite the difference in costs (Alterman, O'Brien, McLellan, et al. 1994; Finney and Monahan 1996; McLellan, Belding, McKay, et al. 1997). Outpatient care is now the predominant treatment setting (Schmidt and Weisner 1993), but questions remain regarding the level of intensity necessary for cost effective outcomes. The two most common models are day hospital (DH), comparable to inpatient settings in intensity, and traditional outpatient (OF) treatment, in which patients meet for two to eight hours per week. Based on evidence that higher abstinence rates are associated with more intensive treatment (Monahan and Finney 1996), we hypothesized that abstinence rates at six months would be higher among people treated in a DH program, and we conducted a randomized study of these two options in a large health maintenance organization (HMO).
A wide range of psychiatric problems and severity are found among addiction treatment populations, with the effectiveness of treatment varying by severity (Mattson and Allen 1991; McLellan, Belding, McKay, et al. 1997; Ross, Glasser, and Germanson 1988); this suggests that...