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Simplifying outcome monitoring

December 12, 2012
by Norman G. Hoffmann, PhD
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The time has come for addiction treatment organizations to implement outcomes-based treatment strategies. This can be accomplished by routine monitoring of client characteristics prior to treatment and basic outcomes during the normal continuum of care. Research is clear that the continuum of care should extend for a minimum of six months for reasonable expectation of durable recovery. Ideally, some contact over a 12-month continuum yields a rational balance between investment and outcome.

Why do treatment programs need an outcomes-based strategy? Implementing the so-called “evidence-based” models does not guarantee that the results obtained in rigorous research trials will translate into the same results with unselected populations. Even if the models are implemented with fidelity, they might not produce the desired results in routine clinical practice.

Another potential shortcoming in clinical trials supporting a given treatment model concerns the possible use of arbitrary metrics. These are defined as measures that are reliable, scientifically valid, and irrelevant to the real world. One such metric is days of use in the last 30 days. A person who has one glass of wine with dinner will register a maximum score, while the binge drinker who drinks only on weekends but experiences a host of consequences from it will score much lower.

Almost free outcome documentation

The solution is to utilize pragmatic outcome monitoring during the normal period of maintenance, or aftercare, contact. Most programs consist of relatively brief residential or intensive outpatient phases followed by lower-level, or weekly, contact for a longer period. Ideally, the overall duration of contact with the treatment program, or provider, should extend between 6 and 12 months. This provides an opportunity to monitor the extent to which the client is able to achieve initial indications of recovery.

Most proximal outcome measures should already be in the clinical record. These include such clinical variables as whether the individual has used any substances during the monitored period, whether such use has resulted in consequences, whether the individual is attending scheduled sessions, whether the individual is attending mutual-help groups, etc.

Monitoring outcomes does not require a sophisticated or expensive “tool” or standardized scales. The primary additional requirement to routine record keeping is that the information be entered numerically or be numerically retrievable into such available software as Excel or common statistical packages. Most electronic record systems or MIS software should have this capability.

Once basic baseline information routinely collected at or near intake is matched with initial outcome data, a program or provider should be able to conduct routine analyses. For more sophisticated applications, a variety of consultants or local academics should be able to provide analyses at a reasonable cost. Some of the potential applications are described in the following pages.

Identifying differential relapse risks

Subpopulations defined by demographic and clinical characteristics may emerge as being more or less likely to be successful with a given program. For example, one study found that a four-item demographic composite variable indentified high-risk adults. Those matching at least three of the following characteristics had higher relapse rates: being under the age of 25, not having graduated from high school, never having married, and being unemployed.

The same study also identified clinical indicators of higher relapse risk. These include such factors as multiple substance dependence, injection of substances, conduct disorder indications as an adolescent, etc.1

Monitoring outcomes from a given program may also identify which clients are more or less likely to be successful with that program. This might be a function of the orientation of the program, the characteristics and expertise of the staff, or other factors unique to a given clinical setting.

Client empowerment and motivation

Being able to provide clients with clear and credible information about their probability of recovery given their level or extent of participation in the program will not only enable clients to make informed decisions about their care but also will enhance their motivation for appropriate engagement in recovery efforts. This can take the form of mutual support group attendance and/or remaining engaged in maintenance (aftercare) services.

For example, one study of older alcohol-dependent populations found that the probability of abstinence after treatment was differently influenced by both clinical severity and whether they remained engaged in Alcoholics Anonymous (AA) and aftercare. Those who did not engage in either had relatively poor outcomes, while those who attended AA regularly and attended the aftercare sessions had the best outcomes. For the low-severity cases, AA attendance seemed to provide a substantial improvement in the odds of success, but those with high severity appeared to require the professional aftercare services of the program to be successful.2

Program improvement

Much lip service is given to continuous quality improvement, but only routine monitoring of results can provide the vehicle for increasing the success rates for a given treatment program. We found that asking clients about the helpfulness of various program components at about six months after completion of the intensive phase could often identify strengths and weaknesses. The question was not one of client “satisfaction,” but of how helpful the components were.