Volume 13, Number 5 (February, 1999)
Researchers at NIDA Symposium Discuss New Directions for Health Services Research
By Steven Stocker, NIDA NOTES Contributing Writer
To help shape NIDA's agenda for health services research, the Institute sponsored a symposium in June titled "Forging the Link: Health Services Research on Drug Abuse Prevention and Treatment." The symposium was held in conjunction with the annual conference of the Association for Health Services Research in Washington, D.C.
Health services research is crucial to determining the practical value of drug abuse treatment and prevention interventions, Dr. Barbara Havassy of the University of California, San Francisco, told participants. Dr. Havassy described drug abuse health services research as seeking to determine how real-world factors - such as the organization, management, and financing of programs - affect outcomes such as quality of care, costs, or effectiveness. For example, a health services study may assess whether a treatment or prevention strategy that has shown promise under rigorously controlled conditions continues to be effective on a larger scale in a real-world setting when factors such as managing and financing operate, she said.
Treatment in the Real World
The organization and management of treatment programs can have considerable effect on whether patients engage and stay in treatment, said Dr. Thomas D'Aunno of the University of Chicago. "There's a tremendous variation in effectiveness from one drug abuse treatment program to the next, and I think a lot of that has to do with their organizational policies and practices," he said.
The organization of services can affect treatment outcomes, particularly for patients with multiple needs, said Dr. Havassy. For example, providing drug abuse and mental health services in the same location may improve outcomes for patients with both drug abuse and psychiatric disorders, she said. With "one-stop shopping," these patients usually are able to obtain more services than if they had to deal with separate treatment programs in different locations. Another example of a promising organizational strategy is case management, in which case managers help drug abuse patients maneuver through the often complicated social service system to obtain drug abuse treatment and other needed services. "Case management is believed to be both effective and cost-effective, but we need more research to verify that," said Dr. Havassy.
Funding levels obviously affect how treatment programs operate, said Dr. Jeffrey Alexander of the University of Michigan in Ann Arbor. Reductions in funding often lead to a reduction in the work force and more competition for resources among remaining workers, he said. In addition, research shows that funding reductions can lead to more rigid interpretation of existing procedures and less participation in decision making by the staff. "As funding decreases, the organization becomes more rigid when, in fact, the opposite should be happening," said Dr. Alexander. "As funding becomes tighter, organizations need to become more flexible and creative."
Drug abuse treatment programs can better meet the diverse needs of patients by developing relationships with other organizations, such as mental health centers, hospitals, and social service agencies, Dr. Alexander said. A "patient-centered information system," in which patient information is shared via computer, could help patients move across these different health care systems, he said.
Economic evaluations of drug abuse treatment programs are useful for determining resource allocations for these programs, said Dr. Michael French of the University of Miami School of Medicine in Miami, Florida. However, few of these studies have been conducted, partly because addiction services research is so complex. For example, treatment programs may use many different interventions, and many different outcomes can be measured. The dollar values associated with some of these outcome measures - such as reduced drug use, improved family relationships, and changes in quality of life - may be difficult to determine, Dr. French said.
One area in which economic studies are needed is the impact of managed care on drug abuse treatment programs, said Dr. Paul Solano of the University of Delaware in Newark. Although managed care has been used since the late 1980s as a strategy for containing health care costs, its effects on drug abuse treatment have not been sufficiently studied, he noted.
Dr. Solano also called for studies on the effects of different mechanisms used by the Federal Government for financing drug abuse treatment services, such as Medicaid and block grants to the States. "The major question for the Federal Government is what its role should be in providing and financing drug abuse treatment services," said Dr. Solano. "How much money should be spent, how should the money flow be organized, and what should State and local governments be responsible for?"
Approximately 30 years of research have demonstrated that real-world treatment dramatically reduces drug use, said Dr. Christine Grella of the University of California, Los Angeles. In addition to reducing their drug use, patients improve their medical, psychiatric, and legal status as well as their social functioning, she said.
Prevention in the Real World
Other investigators at the symposium discussed health services research involving prevention programs. Dr. Linda Dusenbury of Cornell University Medical College in New York City said that many small studies have shown that prevention efforts can indeed reduce drug abuse and that a few large-scale health services studies have substantiated those findings. However, most studies have dealt with focused interventions, usually targeted solely at school children, said Dr. Leonard Saxe of the City University of New York Graduate School and University Center. "We need to think about research differently if we want to advance prevention science," he said. "We know some things about several focused interventions, but we don't know how these interventions operate together in communities." The effectiveness of school-based programs can be compromised if both the community and home environments are not involved in the prevention program, he added.
Both speakers stressed that researchers should communicate more effectively with schools concerning which prevention programs work and which do not. "Schools often are not aware of the most promising programs and strategies," said Dr. Dusenbury.
NIDA NOTES - Volume 13, Number 5
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