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EXECUTIVE SUMMARY
IMPROVING THE DELIVERY OF ALCOHOL TREATMENT AND
PREVENTION SERVICES

A NATIONAL PLAN FOR ALCOHOL HEALTH SERVICES RESEARCH

Executive Summary Cover Image
CONTENTS

image of green cube used as bullet      Preface
image of green cube used as bullet      Subcommittee on Health Services Research
image of green cube used as bullet      NIAAA Staff Liaisons
image of green cube used as bullet      Introduction
image of green cube used as bullet      Recommendations
image of green cube used as bullet      References
image of green cube used as bullet      Glossary
image of green cube used as bullet      Appendix A: Subcommittee Structure and Process
image of green cube used as bullet      Appendix B: Panel Reports and Commissioned Papers
Report of the Subcommittee on Health Services Research
National Advisory Council on Alcohol Abuse and Alcoholism

 

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PREFACE

 

Improving the Delivery of Alcohol Treatment and Prevention Services: A National Plan for Alcohol Health Services Research presents a comprehensive set of recommendations in the field of health services research for the treatment and prevention of alcohol-related problems. It is intended as a blueprint that will provide guidance to the National Institute on Alcohol Abuse and Alcoholism in the continued development of its research program in this important field. This document summarizes that report.

This national plan was prepared by the Subcommittee on Health Services Research for the National Advisory Council on Alcohol Abuse and Alcoholism at a time of both critical need and substantial opportunity in health services research. Health care delivery is undergoing profound and rapid change in both its organizational structure and its financing arrangements. These changes are occurring in response to the complex demands of containing costs, maintaining the quality of care, making care available to all who need treatment, and focusing resources on those forms of care that offer the best hope of successful outcomes. How these changes will affect treatment for people with alcohol dependence (including the effectiveness of care, its quality, its utilization, and its costs) are issues of great importance to researchers and policymakers alike. The National Institute on Alcohol Abuse and Alcoholism has both an opportunity and an obligation to promote state-of-the-art research on these topics. This report provides a comprehensive plan, informed by the latest scientific findings, that identifies the key areas of future research inquiry.

The Subcommittee identified a number of priority areas. First among these is the study of the effects of managed care on the access, utilization, quality, costs, and outcomes of alcohol treatment services. Understanding the diverse set of practices known as managed care and their full range of consequences on the alcohol treatment system was the most common concern that emerged during the course of the Subcommittee's work.

A key task in studying the effects of managed care is to increase our understanding of the alcohol treatment system and its many parts. This includes the interactive processes between patients, providers, government agencies, those who pay for treatment services, and those who act as financial intermediaries in the delivery of care. The study of managed care also focuses on the sets of risks and incentives that impinge on all parties involved. Understanding how these risks and incentives operate, and their consequences for the access, utilization, quality, costs, and outcomes of care, are key objectives in the study of the organization and financing of the treatment system.

A second priority area is the study of outcomes as they relate to costs. As organizational and financial changes occur, incentives and pressures are created which favor the delivery of certain forms of treatment at the expense of others. This raises the following critical questions: What are the differences in treatment outcomes that can be expected from changes in the content of treatment or the form of its delivery? and What changes in treatment costs and cost-effectiveness will occur?

Another priority identified by the Subcommittee is to make continued investments toward improving methodology. Therefore, an integral part of any program to improve alcohol health services research must be the standardization of measures and the development of data collection systems for monitoring and analyzing trends in utilization, client characteristics, costs, insurance coverage, clinical status, and treatment outcomes. Equally important is the application of appropriate research designs to meet the unique challenges involved in conducting quality research in everyday practice settings.

The recommendations presented in this report were developed through an intensive process that reflects a significant effort on the part of many people whom we wish to thank. First of all, the 29 leading researchers and providers who agreed to write the commissioned background papers on which the Subcommittee's work is based. Next, the 41 experts who agreed to serve as panel members under the direction of panel chairs Nancy Day, Ph.D., Harold Holder, Ph.D., and Willard Manning, Ph.D. We have been assisted throughout this process by NIAAA staff Gregory Bloss, M.A., Richard K. Fuller, M.D., Michael Hilton, Ph.D., Robert B. Huebner, Ph.D., Harold I. Perl, Ph.D., and Stephen W. Long. Thanks to all of them for their efforts. A special note of thanks is due to Michael Hilton, Ph.D. and Robert B. Huebner, Ph.D. for serving as the authors of this report and to Sarah Brookhart for serving as report editor. Also, I would like to thank Mark W. Lipsey, Ph.D., for his contributions on the topic of research synthesis. Finally, as Chair, I would like to thank especially the members of this Subcommittee, most of whom also served on one of the panels, who have patiently and thoughtfully guided this project to its final completion. All have rendered their services from a desire to promote continued excellence in the development of the Institute and its research program.


Anne Geller, M.D.
Chairperson
Subcommittee on Health
Services Research
National Advisory Council on Alcohol
Abuse and Alcoholism




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SUBCOMMITTEE ON HEALTH SERVICES RESEARCH

 

National Advisory Council on Alcohol Abuse and Alcoholism
Subcommittee on Health Services Research

Anne Geller, M.D.,* Chairperson
Chief, Smithers Alcoholism
Treatment and Training Center
St. Luke's Roosevelt Hospital Center
New York, New York

Nancy L. Day, Ph.D.*
Director
Program in Epidemiology
Department of Psychiatry
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Stephen C. Crane, Ph.D., M.P.H.
Executive Vice President
American Academy of Physician Assistants
Alexandria, Virginia

Alice S. Hersh, M.H.H.S.
CEO
Association for Health Services Research
Washington, D.C.

Harold Holder, Ph.D.
Director
Prevention Research Center
Berkeley, California

Willard Manning, Ph.D.
Division of Health Sciences Research and Policy
School of Public Health
University of Minnesota
Minneapolis, Minnesota

Jean-Marie Mayas, Ph.D.
President
MayaTech Corporation
Silver Spring, Maryland

Robert M. Morse, M.D.*
Professor of Psychiatry
Mayo Medical School, Mayo Clinic
Rochester, Minnesota

Marc A. Schuckit, M.D.*
Director, Alcohol Research Center
Psychiatric Services
Veterans Affairs Medical Center
San Diego, California

Don Steinwachs, Ph.D.
Director
Center on Organizing and Financing of Care for the Severely Mentally Ill
School of Hygiene and Public Health
Johns Hopkins University
Baltimore, Maryland

Richard T. Suchinsky, M.D.*
Associate Director for Mental Health and Behavioral Sciences (Alcohol and Substance Abuse)
Department of Veterans Affairs
Washington, D.C.

Stan Wallack, Ph.D.
Director
Institute for Health Policy
Florence Heller Graduate School
Brandeis University
Waltham, Massachusetts

*Member, National Advisory Council on Alcohol Abuse and Alcoholism



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NIAAA STAFF LIAISONS

 

National Advisory Council on Alcohol Abuse and Alcoholism
Subcommittee on Health Services Research

Subcommittee on Health Services Research
    Robert B. Huebner, Ph.D.
    Chief, Health Services Research Program

    Richard K. Fuller, M.D.
    Director, Division of Clinical and Prevention Research

    Stephen W. Long
    Director, Office of Policy Analysis

Panel on Utilization and Cost
    Michael Hilton, Ph.D.
    Health Services Research Program
Panel on Financing and Organization
    Gregory Bloss, M.A.
    Office of Policy Analysis
Panel on Effectiveness and Outcomes
    Harold I. Perl, Ph.D.
    Health Services Research Program
Report Authors
    Michael Hilton, Ph.D.
    Robert B. Huebner, Ph.D.



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INTRODUCTION

Alcohol-related problems have a significant impact on the nation's health and welfare. Economic estimates of this impact indicate that alcoholism and alcohol abuse cost about $100 billion annually (Figure 1).1 Approximately 14 million Americans- about 7 percent of the adult population-meet the diagnostic criteria for alcohol abuse and/or alcoholism.2 About 40 percent of Americans report having a direct family experience with alcohol abuse or alcoholism.3 The misuse of alcohol is involved in approximately 30 percent of suicides, 50 percent of homicides, 52 percent of rapes and other sexual assaults, 48 percent of robberies, 62 percent of assaults, and 49 percent of all other violent crimes.4 Alcohol is also a factor in 30 percent of all accidental deaths, including up to 50 percent of motor vehicle deaths. In fact, more than 100,000 Americans die each year from alcohol-related causes, which, if it were ranked independently, would make alcohol-related problems the third leading cause of death in the United States.5


Figure 1 Estimated annual economic costs of alcohol abuse, 1990. Treatment (including FAS) 12.8%; Other 0.8%; Crime(includes both direct costs of crime and indirect costs to victims and or incarceration) 11.3%; Motor vehicle crashes 3.9%; Morbidity 37.1%; Mortality 34.1%.  Total=$98.6 billion

Current Challenges in Alcohol Treatment Services

The organizations, agencies, and individual practitioners that are engaged in responding to these problems by providing effective treatment and prevention for alcohol dependence and alcohol abuse currently face significant challenges toward the fulfillment of their missions. The most significant of these challenges appear to be:

  • Need-Treatment Gap. There is an enormous gap between the number of people who report serious problems with alcohol and the number of people who actually receive treatment for alcohol problems. Recent research suggests that only 1 in 10 individuals who need services for alcohol problems actually have received any form of treatment (Figure 2).6 This gap may be the result of various factors: barriers to accessing alcohol services, including financial, geographic, and cultural barriers; denial that treatment is needed; concern about the stigma of alcoholism; or the lack of pressure from family, friends, and employers to seek treatment. It is important to understand the roles of all of these factors so that the health care system can reach more of those who need care.


Figure 2 1992 population estimates of alcohol abuse and/or dependence and prevalence of alcohol treatment in the past year.  Alcohol abuse and/or dependence and Received tretement.  Source National longitudinal alcohol epidemiologis survey, NIAAA

  • Multiple Systems of Care. People with alcohol-related problems often receive treatment services outside the alcohol treatment system.7 Because alcohol abuse is associated with a range of health and social problems, alcohol abusers come in contact with a variety of service settings-medical, educational, social welfare, and criminal justice-where alcohol problems are not the primary concern. This is true, for example, of individuals with co-occurring alcohol and mental health disorders. However, available services for these individuals can be fragmented, resulting in individuals "slipping through the cracks." We need to know more about how the different service systems interact with each other and what kinds of inter-system arrangements (e.g. referral networks) best ensure that alcohol services are available and accessible.

  • Cost Containment. One of the greatest challenges facing the alcohol treatment service system is to maintain and improve the quality of care in the face of increasing pressures to contain the costs of alcohol treatment services. The primary vehicle for containing costs has been a variety of financing strategies, organizational models, and management practices collectively labeled "managed care." The rise in the use of managed care has been dramatic over the last decade in both public and private sectors (Figure 3). Managed care has produced significant changes in the delivery of alcohol treatment services-most notably, reductions in the use of inpatient care, increases in the use of various forms of outpatient care, fewer individual therapy sessions and more group therapy sessions, and use of less costly providers. However, the effects of managed care on access to services and on outcomes of services are largely unknown.


  • Figure 3 Growth in managed care enrollment, 1988-1996. 1988: PPO/Point of Service=11%; HMO=18%; Conventional=71%.  1996: Point of Service=16%; PPO=25%; HMO=33%; Conventional=26%.


    The Role of Health Services Research in Meeting These Challenges

    Health services research is an intellectual tool designed to provide information on issues such as these. Broadly defined, health services research is the scientific study of the range of factors that facilitate or inhibit the delivery of health services. More specifically, health services research examines the impact of the organization, financing, management, and delivery of health services on accessibility, utilization, quality, cost, and outcomes. It also examines how characteristics of the individual, his or her family, and his or her social and cultural environment affect how, when, where, and if a person will seek care; what types of care are chosen or provided; what happens during the delivery of care; the impact of care on the course of disease; and how satisfied the patient is with that care.

    Health services research also examines how the economic, social, political, and cultural environment of the service system and providers within that system affect the organization, financing, management, and delivery of services, and the impact of those interactions on accessibility, utilization, quality, cost, and outcomes. Like basic and clinical research, health services research starts with questions or hypotheses grounded in science and uses replicable methods, sound measurement tools, and appropriate analytic techniques. But services research has an additional objective: it includes the state of public health, health care practice, and the policy environment as factors to consider in research.


    Health Services Research at NIAAA

    The mission of NIAAA is to support scientific research on the causes, consequences and treatment, and prevention of alcohol problems. The research enterprise includes a broad continuum of research activities that begins with biomedical research on the causes and mechanisms of alcoholism. Understanding the causes of alcohol abuse and alcoholism lays the scientific groundwork for the development of new and potentially efficacious treatments. Potentially efficacious treatments are tested under the ideal conditions of controlled clinical trials. Health services research examines the effectiveness of treatments as they are implemented in everyday practice settings and how organizational and financial factors affect the accessibility, utilization, quality, costs, and outcomes of alcohol services.

    The role of health services research at NIAAA was given special emphasis in 1992 when Congress mandated the Institute to obligate at least 15 percent of its research budget for health services research.8 Given the importance of health services research to the mission of NIAAA, this mandate represented an opportunity for the Institute to expand its already strong commitment to this area of research. Congress also requested that the National Advisory Council on Alcohol Abuse and Alcoholism develop a "national plan for research on services."9 In response to this report language, the National Advisory Council on Alcohol Abuse and Alcoholism created the Subcommittee on Health Services Research.


    NIAAA's Subcommittee on Health Services Research

    The Subcommittee on Health Services Research was appointed in 1993 to develop a national plan for alcohol health services research. The broad purpose of this national plan was to assess what was known in the alcohol health services research field, identify major gaps in that knowledge base, and make recommendations for research to fill those gaps. The Subcommittee was composed of Council members and experts in the field of health services research. The Subcommittee created three working panels to develop the national plan (Figure 4).

    The Subcommittee commissioned twenty-one papers by leading experts in the field. Each paper summarized the current state of knowledge in alcohol health services research and recommended research strategies for filling gaps in that knowledge.



    Figure 4 Organizational chart of the subcommittee on health services research. National advisory council on alcohol abuse and alcoholism to Subcommitte on health services research Chair: Ann Geller, M.D. goes to: Panel on effectiveness and outcomes Chair: Nancy Day, Ph.D.; Panel on utilization and cost Chair: Harold Holder, Ph.D.; Panel on financing and organization Chair:Willard Manning, Ph.D.

    The Subcommittee, and its constituent panels, distilled these recommendations, selecting those with the greatest significance for inclusion in its report. The remainder of this document summarizes these highest priority recommendations. More detail on how the Subcommittee completed its work is provided in Appendix A.



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    RECOMMENDATIONS

    The first half of the Subcommittee's recommendations are organized into the basic component areas of health services research: organization, financing, managed care, access and utilization, effectiveness and outcomes, cost and cost-effectiveness, and prevention. The remaining recommendations were developed for issues that cut across these areas. These are presented separately under the following categories: research methodology, dissemination and adoption of research findings, and research infrastructure. Taken as a whole, these recommendations provide a "blueprint" for the future development of health services research at NIAAA.


    Organization

    Improving the delivery of alcohol services requires sound information on who delivers what kinds of services to whom. The system that delivers alcohol treatment and prevention services is complex, with many interconnected elements. The task of understanding this system is made more difficult in the current era of rapid change, in which new structures and roles are quickly emerging as others are re-defined. This rapid change creates a special need for descriptive research to better understand the functions and operations of changing system elements. To increase current understanding about the organization of alcohol treatment and prevention services, research should:

    • Develop comprehensive models of the varied elements of the alcohol treatment system and explain the relationships, structure, incentives, integration, and interaction at work in those components.
    Emphasis should be given to identifying general organizational models or structures, especially those of emerging importance; the incentives employed by various models, including their strengths and weaknesses; and the factors that lead to greater integration or interaction among components.

    Related goals for research include the following:

    • Study the role played by government-as purchaser, provider, and regulator-in the provision, delivery, and quality of alcohol treatment services.

    • Identify the factors that impede or facilitate the receipt of care by different client populations and the characteristics of the treatment services received by those client populations.

    Financing

    Arrangements for financing alcohol services are undergoing rapid and fundamental change. It is critical to understand the intended and unintended consequences of these changes. Three trends in the financing of alcohol treatment services have been important in recent years: (1) the growth in coverage of alcohol treatment by private insurance in the 1980s driven by State mandates that such treatment be offered as a benefit or option; (2) the growth of reimbursement strategies designed to contain costs; and (3) the appearance in the public sector of cost containment strategies that were pioneered in the private sector. To understand the impacts that these trends are having on the alcohol treatment system, research should conduct the following:

    • Study the allocation of risks and incentives within private and public arrangements for the financing of alcohol treatment services and the consequences of alternate financing arrangements.

    • Identify the factors that determine which individuals will be insured for alcohol-related services and the extent of the insurance coverage for those services.

    Managed Care

    What are the effects of the organizational and financial strategies being used in the delivery of alcohol treatment services under managed care? Few issues have generated as much controversy in the general health care arena and in the delivery of alcohol treatment services as managed care. Paralleling the growth of managed care for general medical services has been the dramatic growth of managed behavioral health care, which includes alcohol treatment services. Despite the rapid growth of managed behavioral health care, little is known about how alcohol treatment services are delivered under managed care arrangements or about the specific characteristics of behavioral health components of health insurance plans, managed care organizations, or managed care techniques. It is recommended that researchers:

    • Conduct research that describes and monitors the characteristics of managed care plans for alcohol treatment.
    Given the need for rigorous research on the effects of managed care on access, utilization, quality, cost, and outcomes of alcohol services, future research should:
    • Conduct research on the financial, organizational, and management arrangements known as "managed care" and their effects on the accessibility, utilization, quality, cost, and outcomes of alcohol treatment services.

    Access and Utilization

    Many people who need alcohol treatment services are not receiving them. Our knowledge of the factors involved in this gap between need and treatment must be greatly expanded in order to improve the delivery of services. Issues of access to and utilization of services focus on whether individuals who need services actually receive them, as well as whether they receive the right quantity and mix of services. These questions are particularly important for planning purposes, as well as for promoting equitable access to treatment services. In the past, research on access to and utilization of treatment services has stressed individual-level characteristics as variables of study. To achieve a more balanced view, researchers need to incorporate more emphasis on organizational and sociocultural factors that are also at work. Also important are variations in access and utilization among different groups of prospective treatment clients. Specifically, health services researchers need to do the following:

    • Study the individual-, organizational-, and sociocultural-level factors that affect access to and utilization of alcohol treatment, with emphasis on exploring the interaction of these factors.

    • Determine whether group differences in utilization rates reflect differences in need or the existence of inequities in access to treatment.

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    Effectiveness and Outcomes

    Although it is well known that treatment is effective, all participants involved in service delivery want to know more about the impact of different approaches for different individuals. Some of the most compelling questions about alcohol treatment have to do with what works-that is, What are the outcomes of different treatment modalities, for different types of clients, in different settings? and What factors help to make treatment services effective? In health services research, the focus is on outcomes in practice settings and under typical rather than ideal conditions. To address the central question of what forms of alcohol treatment work best, NIAAA should support research that focuses on the dimensions of modality, setting, intensity, and treatment goals to complement the following:

    • Investigate the relative effectiveness of competing treatment strategies for specific forms of disorders and affected populations.

    • Study whether treatments that have been shown to be efficacious in controlled trials are also effective in real-life clinical settings.

    Cost and Cost-Effectiveness

    Knowledge about the cost and cost-effectiveness of various alcohol treatment approaches is essential to ensure that people in need are receiving appropriate services. As the health care system changes, payers, providers, governments, and consumers will make a host of decisions that will determine how dollars are spent for alcohol treatment. Making wise choices involves balancing costs against outcomes. Without sound research on the cost-effectiveness of alcohol treatment, cheaper but ineffective treatments or treatments whose results do not justify their costs may be related. The crucial role that cost studies could play in health care decisionmaking suggests that future research should do the following:

    • Compare the costs of alcohol treatment programs with their outcomes, benefits, and cost offsets.

    Prevention

    Health services research is critical in realizing prevention's potential to reduce the demand for future health care. Many of the questions about the treatment of alcohol-related problems can also be asked about programs and services that are designed to prevent those problems. While there have been many studies assessing prevention outcomes in terms of reduced drinking, fewer traffic accidents, or reduced incidence of cirrhosis and other chronic diseases, researchers have seldom taken the additional step of assessing whether these reductions have lowered subsequent demand for health care. Making this link is the most significant contribution to health services research that prevention research can make. To close this gap in current knowledge, research should do the following:

    • Measure the effectiveness and cost-effectiveness of alcohol prevention in reducing the utilization of health care services.

    • Assess the outcomes of prevention activities among populations having a high level of health care services use or at risk for high-cost care events.

    Figure 5. Conceptual model for the relationship of prevention to health services deman.  Pervention intervention to Alteration of drinking patterns to Reduced Risk of alcohol-involved problems to Alcohol-Involved problems to changes in health services demand.  Prevention Intervention also goes to Reduced risk of alcohol involved problems

    Methodology

    In health services research, as in all areas of research, advances in methodology are needed to produce the sophisticated tools that are used to build the knowledge base. Alcohol health services researchers bring a wide range of tools to study questions about our rapidly changing health care system. Improvements are needed in two categories of tools: data reporting systems and methods of assessing program effects. To facilitate improvement in the former, researchers should undertake the following:

    • Improve existing measures of alcohol services delivery by working towards common definitions and measures.

    • Enhance national-level data collection and reporting systems suitable for monitoring and analyzing alcohol health services delivery.

    • Refine methods used to analyze existing data sets relevant to alcohol health services research.
    With regard to the assessment of effects, future research efforts should:
    • Adapt and enhance existing research designs and analysis techniques to address the unique circumstances encountered in alcohol health services research.


    Dissemination and Adoption of Research Findings

    As our knowledge of alcohol treatment services expands, it must be translated into useful information that can be incorporated into the health care system in a timely manner. Improving clinical practice in the treatment of alcohol-related problems is a central goal of health services research. The pertinent questions for health services research are-What are the most effective methods and strategies for disseminating the results of alcohol services research? and, What are the most effective methods for promoting the diffusion of research-based, alcohol-related innovations? These questions can be answered with the help of studies that can accomplish the following:

    • Evaluate the effectiveness of approaches to the dissemination of alcohol health services research.

    • Determine the effectiveness of different approaches to promote the adoption of alcohol health services research findings in real-world, practice settings.


    Research Infrastructure: Workforce, Training, and Peer Review

    A strong enterprise in alcohol health services research requires a long-term, stable commitment to issues of "human capital," such as maintaining current investigators and attracting new researchers to the field. Health services researchers have an opportunity to provide decisionmakers with vital guidance in the years to come. It is unclear, however, whether a sufficient number of qualified scientists will be available to make this contribution. The research agenda recommended by this report must be accompanied by the development of qualified researchers and a network of supporting infrastructure. Toward these ends, NIAAA should undertake the following:

    • Expand existing human resource databases through collaboration with health services research organizations, institutes at the National Institutes of Health (NIH), and other relevant Federal agencies, in order to conduct supply and demand studies of the alcohol health services research work force.

    • Conduct studies of alcohol health services research training programs including, but nov mited to, assessments of the number and types of training programs and their effectiveness. v Study the impact of managed care on the ability of academic health centers to carry out their research training mission in the alcohol field.
    Since health services research is a rapidly growing area of research activity, it calls for a somewhat different mix of expertise than is incorporated in the current standing NIAAA review committees. To facilitate the success of this enterprise, NIAAA should increase the number of individuals with training and research expertise in areas relevant to alcohol health services research on the standing and special NIAAA committees that review health services research applications. Specifically, NIAAA should:
    • Ensure that health services research grant applications submitted to NIAAA be reviewed by standing and special Initial Review Groups (IRGs) that have an adequate range of alcohol health services research expertise.



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    REFERENCES

    1. Rice, D.P. The economic cost of alcohol abuse and alcohol dependence: 1990. Alcohol Health and Research World, 17(1), 10-11, 1993.

    2. Grant, B.F.; Harford, T.C.; Dawson, D.A.; Chou, P.; Dufour, M.; and Pickering, R. Prevalence of DSM-IV alcohol abuse and dependence; United States, 1992. Alcohol Health and Research World, 18(3):243-248, 1994.

    3. Harford, T. The family history of alcoholism in the United States: Prevalence and demographic characteristics. British Journal of Addictions, 89: 931-935, 1992.

    4. Hayward, L.; Zubrick, S.R.; and Silburn, S. Blood alcohol levels in suicide cases. Journal of Epidemiology and Community Health, 46: 256-260, 1992.

    Murdock, D.; Phil, R.O.; and Ross, D. Alcohol and crimes of violence: Present issues. International Journal of the Addictions, 25: 1065-1081, 1990.

    Wiezorek, W.F.; Welte, J.W.; Abel, E.R. Alcohol, drugs, and murder: A study of convicted offenders. Journal of Criminal Justice, 18: 217-227, 1990.

    Pernanen, K. Alcohol in Human Violence. New York: Guilford Press, 1991.

    5. National Highway Traffic Safety Adminstration. General Estimates System 1990: A review of Information on Police-Reported Traffic Crashes in the United States. DOT HS 807 781. Washington, D.C., National Highway Traffic Safety Administration, 1991.

    Stinson, F.S.; Dufour, M.C.; Staffens, R.A.; and Debakey, S.F. Alcohol-related mortality in the United States, 1979-1989. Alcohol Health and Research World, 17: 251-260, 1993.

    6. Grant, B.F.; Harford, T.C.; Dawson, D.A.; Chou, P.; Dufour, M.; and Pickering, R. Prevalence of DSM-IV alcohol abuse and dependence; United States, 1992. Alcohol Health and Research World, 18(3):243-248, 1994.

    Prevalence of treatment estimate produced from National Longitudinal Alcohol Epidemiologic Survey data, NIAAA, 1997.

    7. Schmidt, L. & Weisner, C. Developments in alcoholism treatment. In M. Galanter, ed., Recent Developments in Alcoholism, Volume 11: Ten Years of Progress. Plenum Press: New York, 1993.

    8. P.L. 101-321, the ADAMHA Reorganization Act of 1992.

    9. H. Conference Report 102-564, p. 129.



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    GLOSSARY


    Alcohol Abuse

    A maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by one (or more) of the following in a 12-month period: alcohol use that interferes with ability to fulfill major role obligations; alcohol use in situations which are physically hazardous; recurrent, alcohol-related legal problems; continued alcohol use despite adverse social or interpersonal consequences.


    Alcohol Dependence

    A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of seven conditions in a 12-month period, including the following: tolerance, withdrawal, impaired control over drinking; preoccupation with alcohol and less time spent on important social, occupational, or recreational activities; and use of alcohol despite adverse physical or psychological consequences.


    Health Services Research

    Research endeavors that study the impact of the organization, financing and management of health services on the quality, cost, access to and outcomes of care.


    HMO

    Health Maintenance Organization. Prepaid health care plans that provide a defined but comprehensive range of services through a specified group of providers for a fixed annual fee. Providers may be salaried or reimbursed on a capitated or other at-risk arrangement.


    IRG

    Initial Review Group. An NIH panel of scientific peers that reviews the scientific merit of submitted grant applications.


    Managed Care

    Various strategies that seek to maximize the value of services by controlling cost and utilization, promoting quality, and measuring performance to ensure cost-effective outcomes.


    NIAAA

    National Institute on Alcohol Abuse and Alcoholism


    NIH

    National Institutes of Health


    PPO

    Preferred Provider Organization. Provider networks with negotiated fee schedules in which the patient must use providers within the selected network.




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    APPENDIX A

    Subcommittee Structure and Process

     

    Subcommittee on Health Services Research Structure and Process

    The Subcommittee on Health Services Research, composed of members of the National Advisory Council on Alcohol Abuse and Alcoholism and experts in health services research, served as the coordinating committee for the development of this national plan. As a first step, the Subcommittee created three working panels:
    • Panel on Financing and Organization

    • Panel on Utilization and Cost

    • Panel on Effectiveness and Outcomes
    In each case, panel membership reflected a range of perspectives and expertise, including various research disciplines, policymakers, industry representatives, clinicians, payers, and government officials. Over the course of 24 months, each of the panels identified a set of core issues, commissioned outside experts to write papers addressing specific issue areas, and deliberated to select the most important research priorities that emerged from these papers. The charge given to each author was to (a) survey the state of current knowledge, (b) identify critical gaps in current knowledge, and (c) recommend strategies for filling the gaps identified. In total, 21 papers were commissioned. These commissioned papers served as the basis for each panel's final report. A list of the panel reports and the commissioned papers is provided in Appendix B.

    The full Subcommittee assumed responsibility for coordinating the work of the three panels (see Figure 4 for an organizational chart). A member of the Subcommittee served as the chairperson for each of the panels, the Subcommittee convened a meeting to hear from each panel chair while the panel reports were being prepared, and the Chairperson of the Subcommittee attended all meetings of the working panels. The reports produced by the three panels served as the primary source for the Subcommittee's deliberations and as the building blocks for the findings and recommendations contained in this report.




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    APPENDIX B

    Panel Reports and Commissioned Papers

     

    Panel on Financing and Organization
    Final Report

    Panel on Financing and Organization, Final Report, Subcommittee on Health Services Research, National Advisory Council on Alcohol Abuse and Alcoholism, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, June 4, 1996.


    Commissioned Papers

    1. A System-Level View of Organizational Research on the Treatment and Clinical Prevention of Alcohol-Related Problems by Jack Scott

    2. Provider-Level View of Delivery of Alcohol Treatment and Clinical Prevention Services by Mary Ellen Marsden

    3. Financing and Reimbursement Arrangements for Provision of Alcohol Services by Constance Horgan

    4. Public Policy and Regulation of Alcohol Treatment and Prevention Services by Henrick Harwood and Douglas Fountain

    5. Financing and Organization of Prevention Initiatives in Non-Clinical Settings by Mary Jo Larson


    Panel on Utilization and Cost
    Final Report

    Panel on Utilization and Cost, Final Report, Subcommittee on Health Services Research, National Advisory Council on Alcohol Abuse and Alcoholism, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, May 22, 1996.

    Commissioned Papers

    1. Access and Need for Alcohol Treatment Services by Constance Weisner and Laura Schmidt

    2. Utilization of Alcohol Treatment by Allen Goodman and Eleanor Nishiura

    3. Private Provider and Payer Actions by Jerry Spicer, Patricia Owen, and Jane Nakken

    4. The Effects of State and Federal Policies and Practices on the Cost and Utilization of Services for Alcohol Abuse and Alcohol Dependence by Dennis McCarty

    5. Cost Research on Alcohol Treatment Services by Nancy Pindus

    6. Societal Consequences of Alcohol-Related Problems by Ted Miller

    7. Cost and Utilization of Prevention in Health Services Research by Harold Holder


    Panel on Effectiveness and Outcomes
    Final Report

    Panel on Effectiveness and Outcomes, Final Report, Subcommittee on Health Services Research, National Advisory Council on Alcohol Abuse and Alcoholism, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, August, 1996.

    Commissioned Papers

    1. Methodological Issues in Alcohol-Related Health Services Research by Michael L. Dennis, A. Thomas McLellan, and Robert B. Huebner

    2. Process-Outcome Research on Alcohol Treatment: Illustrative Studies and Potential Barriers by John Finney

    3. Effectiveness and Outcomes of Alcohol-Related Treatment Health Services by William R. Miller

    4. Health Services Research on Patient-Treatment Matching by Thomas F. Babor

    5. Methods for Prevention Services Focusing on Alcohol-Related Problems by Norman Giesbrecht

    6. Effectiveness and Outcomes of Prevention Services by Robert L. Stout

    7. Cost-Effectiveness of Alcohol Services by Brenda M. Booth and Mingliang Zhang

    Additional Commissioned Papers

    1. Gauging the Flow of Talent Into Alcohol-Related Health Services Research by Pamela Ebert Flattau

    2. A Review of Diffusion and Utilization Research Findings on Alcohol-Related Research by Judith Alamprese


    Suggested Citation

    Subcommittee on Health Services Research, National Advisory Council on Alcohol Abuse and Alcoholism. Improving the Delivery of Alcohol Treatment and Prevention Services: Executive Summary. NIH Publication No. 4224, Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 1997.

    Copies of this Executive Summary may be obtained by writing

      National Institute on Alcohol Abuse and Alcoholism
      P.O. Box 10686
      Rockville, MD 20849-0686

    Updated: October 2000