PrefaceReport of the Subcommittee on Health Services Research
Subcommittee on Health Services Research
NIAAA Staff Liaisons
Appendix A: Subcommittee Structure and Process
Appendix B: Panel Reports and Commissioned Papers
National Advisory Council on Alcohol Abuse and Alcoholism
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.
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.
SUBCOMMITTEE ON HEALTH SERVICES RESEARCH
National Advisory Council on Alcohol Abuse and Alcoholism
Subcommittee on Health Services Research
Anne Geller, M.D.,*
Nancy L. Day,
Stephen C. Crane,
Alice S. Hersh,
Robert M. Morse,
Marc A. Schuckit,
Richard T. Suchinsky,
|*Member, National Advisory Council on Alcohol Abuse and Alcoholism|
NIAAA STAFF LIAISONS
National Advisory Council on Alcohol Abuse and Alcoholism
Subcommittee on Health Services Research
on Health Services Research
Chief, Health Services Research Program
Richard K. Fuller,
Stephen W. Long
Health Services Research Program
Office of Policy Analysis
Health Services Research Program
Robert B. Huebner, Ph.D.
|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|
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:
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.
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.
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.
|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.|
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.
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:
Related goals for research include the following:
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:
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:
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:
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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:
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:
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:
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:
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:
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:
|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.|
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.
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,
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.
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.|
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:
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.
Panel Reports and Commissioned Papers
on Financing and Organization
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.
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
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.
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, 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.
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
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
P.O. Box 10686
Rockville, MD 20849-0686
Updated: October 2000