tween the two settings of care—suggesting that the setting of care might not be an important contributor to outcome. A further analysis of data from the Alterman et al. study (McKay et al., 1995) indicated that 12-month outcomes in the day hospital group were generally at least equal to outcomes following inpatient care, and pertained to both randomized and nonrandomized subjects.
Consistent with the results of these two studies, reviews of the literature on inpatient and outpatient alcohol rehabilitation by Miller and Hester (1986) and Holder et al. (1991) also concluded that across a range of study designs and patient populations there was no significant advantage provided by inpatient care over outpatient care in the rehabilitation of alcohol dependence, despite the substantial difference in costs. In contrast, a widely cited study by Walsh et al. (1991) did find a significant difference in outcome favoring an inpatient program. However, this difference was shown among employed alcohol dependent patients who were assigned to either an inpatient program plus Alcoholics Anonymous (AA) or to AA meetings only (rather than to formal outpatient treatment). One recent review of the alcohol inpatient-outpatient literature did conclude that in studies that found an advantage to inpatient care over outpatient treatment, outpatients did not receive inpatient detoxification and the studies tended to not have social stability inclusion criteria or to require randomization (Finney et al., 1996). This review points to the need to consider "real world" factors when evaluating the effectiveness of different treatment settings.
In the field of cocaine dependence treatment, there have also been several studies examining the role of treatment setting. Again, while there is evidence for high attrition rates (e.g., Kang et al., 1991), there is still evidence indicting that outpatient treatments for cocaine dependence can be effective, even for patients with relatively limited social resources. In a recent study, Alterman and his colleagues followed up a prior comparison study of inpatient and day-hospital treatment of alcohol dependence (1994) with an identical examination comparing the effectiveness of four weeks of intensive, highly structured day hospital treatment (27 hours weekly) with that of inpatient treatment (48 hours weekly) for cocaine dependence. The subjects were primarily inner city, male African Americans treated at a Veterans Administration Medical Center. The inpatient treatment completion rate of 89% was significantly higher than the day-hospital completion rate of 54% . However, at seven months posttreatment entry self reported outcomes indicated considerable improvements for both groups in drug and alcohol use, family/social, legal, employment, and psychiatric problems. The finding of reduced self reported cocaine use was supported by urine screening results. Both self report and urine data indicated 50%-60% abstinence for both groups at the follow-up assessment. The comparability