Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 12--Determining Outcome
Chapter 12--Determining Outcome
Pages 313-328
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From page 313... ...
not the last~hase of our efforts to achieve an equitable health care system, of satisfactory quality, at a price we can afford Arnold Relman The Rationale for Outcome Determination This report focuses primarily on ways to improve the outcome of treatment for alcohol problems. In previous chapters it was suggested that the clarification of basic concepts, comprehensive pretreatment assessment, more precise characterizations of the treatments provided, and careful matching of individuals to treatment by means of explicitly stated and modifiable guidelines would enhance the proportion of positive outcomes.
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From page 314... ...
The results of a treatment outcome study are considered positive if, in the aggregate, the outcomes are significantly better than those following either no treatment or a comparison treatment. But it is rare that all treated subjects have positive outcomes, and the relevant clinical question is whether a particular individual had a positive outcome.
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From page 315... ...
Some Examples of Systematic Outcome Determination In some instances, concerted attempts have been made to determine the outcome of treatment for alcohol problems. The state of Oklahoma operates a mental health information system that generates data on the performance of all psychosocial treatment programs.
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From page 316... ...
More recently (as of January 1, 1988) , the state of Minnesota has instituted a requirement that all alcohol treatment programs receiving public monies must participate in a similar sort of management information system that includes regular follow-up of treated individuals.
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From page 317... ...
It does not prove that the outcomes observed following treatment are the result of the treatment provided. From the manner in which outcome information is often used in marketing treatment programs, this limitation seems not to be well understood.
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From page 318... ...
In contrast, The scope of observational studies can be expanded much more easily than that of randomized controlled trials to include large numbers of patients and providers, maximizing the opportunity to gauge the effectiveness of routine medical care practices in various clinical settings, by various clinicians, and for various patient groups. Answers to questions about the effectiveness of care for important subgroups of patients (including those with specific coexisting morbid conditions)
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From page 319... ...
Thus, an important goal for the immediate future is the increased implementation of both randomized controlled trials and routine monitoring of treatment outcome. Implementing Outcome Monitoring Setting the Stage for Outcome Monitoring Imagine a situation in which the following statement is made: "Sixty percent of the people who pass through our treatment program achieve a positive outcome.
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From page 320... ...
The Content of Outcome Monitoring Knowledge of an individual's status after completing treatment is much more meaningful if it can be compared closely with his or her status prior to treatment. Accordingly, there should be a parallelism between the coment of assessment and the content of outcome determination.
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From page 321... ...
A program could substantially improve its proportion of positive outcomes, and the ease of its staff, by choosing to deal only with problems and individuals of this kind. Although it is true that some such individuals do not do well and that persons in this group may have as profound a need for treatment as any others, a high proportion of positive outcome results in a population of this kind carries a rather different meaning than would be the case in other populations (e.g., a population of skid row inhabitants)
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From page 322... ...
It would be possible, with such a pattern, to identify both Faders" and nsleepers.n Sampling Outcome monitoring can be carried out for all persons who enter treatment. As an alternative the determination can be made on selected samples (e.g., every third admission)
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From page 323... ...
In most instances, outcome information is likely to indicate that admission to a given treatment program is followed by positive outcomes in a significant proportion of the people who seek its services; at the same time, however, it is followed by no significant change or by a worsening of problems in another but also significant proportion. A number of responses are possible in the face of such information: (a)
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From page 324... ...
Mounting research projects within treatment programs may also foster a more observing and objective attitude among staff toward their program than would otherwise be the case. As an example of a within-program evaluation, half of a group of 100 patients who were seen for initial assessment of alcohol problems were randomly sent "a personal letter expressing concern for the patient's well-being and repeating our invitation for further assistance." Fifty percent of those sent the letter returned for additional contact, as compared with 31 percent of those not sent the letter; 76 percent returned the same day the letter was received, as compared with 12.5 percent; and 80 percent returned sober, as compared with 31 percent.
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From page 325... ...
Although not a fully satisfactory method of determining treatment outcome, internal monitoring is much to be preferred to an absence of effort toward this end. The Funding of Outcome Determination It is generally assumed that the introduction of widespread, comprehensive, and ongoing outcome monitoring, whether in the alcohol treatment field or in the medical treatment field generally, will raise the costs of providing treatment.
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From page 326... ...
need is the determination of the longer-term outcome of treatment. Not a substitute for more rigorous controlled techniques that can demonstrate treatment efficacy, outcome monitoring nevertheless offers benefits in that it addresses many important issues, is more readily implemented on a broad basis, and complements significantly what can be learned in other ways.
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From page 327... ...
1982. A conceptual framework for alcoholism treatment evaluation.
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From page 328... ...
1987. Alcohol treatment outcome evaluation methodology: State of the art 1980 84.
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