COST-EFFECTIVENESS OF HMO RESIDENTIAL & OUTPATIENT CARE

随着越来越多的人因药物滥用和依赖而接受治疗，一个控制成本的时代对传统住院治疗的成本效益提出了挑战。临床研究表明，对酒精滥用和依赖的门诊治疗可能与住院治疗一样有效，而且通常要便宜得多，但很少有研究包括更严重的患者或研究费用更低的非医院住院治疗。此外，即使在门诊环境中，提供化学药物依赖治疗服务的费用仍然很高。为了应对为有严重问题和高复发可能性的患者提供经济有效的一揽子服务的挑战，一家大型健康维护组织（Kaiser Permanente）最近与住院康复项目签订了合同，提供一种新的住院福利。本研究对768例符合新获益条件的患者进行了对照、随机分配比较。受试者将被分配到两种治疗环境中的一种——强化门诊（每周19个小组会议）或住宅康复（每周20个小组会议）——以便在“真实世界”HMO （Kaiser Permanente Southern California）中比较两种可用的治疗类型，服务于许多城市社区的异质人群（33%的女性，22%的黑人，14%的西班牙裔）。使用意向治疗模型，该研究考虑了独立变量，包括治疗期间的服务组合/强度、保留、非正式同伴帮助和使用后护理，以及治疗后的结果和戒断、吸毒和饮酒、医疗和精神问题、就业、法律和家庭/社会问题的改善率。人种学观察将增加调查数据。由于这两种治疗的中心目标都是培养与AA/NA/CA等团体的紧密联系，因此该项目将考虑诸如社会网络对禁欲的支持以及与12步计划的联系等变量；它们在导致禁欲的因果途径中的作用也将被评估。该研究将测量患者在治疗前一年和治疗后一年对健康和社会服务的利用情况，包括Kaiser Permanente医疗服务的利用情况，并将比较提供每种治疗的成本。将分析管理式护理下密集门诊和住院康复的相对成本效益。该研究将确认治疗内容，并确定在每种情况下与成功治疗结果相关的患者特征。

As increasing numbers of individuals enter treatment for substance abuse and dependence, an era of cost containment challenges the cost effectiveness of traditional inpatient care. Clinical studies suggest that outpatient treatment for alcohol abuse and dependence may be as effective as inpatient treatment and is generally much less expensive, but few studies have included more severe patients or studied less costly non- hospital-based residential treatments. Further, it remains costly to provide chemical dependency treatment services even in the outpatient setting. In response to the challenge of providing cost effective wraparound services for patients with severe problems and high relapse potential, a large Health Maintenance Organization (Kaiser Permanente) has recently contracted with residential recovery programs to provide a new residential benefit. This study undertakes a controlled, random assignment comparison of 768 patients eligible for the new benefit. Subjects will be assigned to one of two treatment settings--intensive outpatient (19 group sessions per week) or residential recovery (20 group sessions per week)--to enable comparison of two types of treatment available in a "real world" HMO (Kaiser Permanente Southern California) serving a heterogenous population (33 percent women, 22 percent Black, 14 percent Hispanic) reflective of many urban communities. Using an intent-to-treat model, the study considers independent variables including during-treatment service mix/intensity, retention, informal peer helping, and use of aftercare, as well as post- treatment outcome and improvement rates in abstinence, drug use and alcohol consumption, medical and psychiatric problems, and employment, legal and family/social problems. Ethnographic observation will augment the survey data. Since a central goal of both treatments is fostering strong affiliation with groups such as AA/NA/CA, the project will consider variables such as social network support for abstinence and affiliation with 12- step programs; their role in the causal pathway to abstinence will also be assessed. The study will measure patient utilization of health and social services including Kaiser Permanente medical services utilization one year prior to and one year following treatment, and will also compare costs of providing each treatment. The relative cost effectiveness of intensive outpatient and residential recovery under managed care will be analyzed. The study will confirm treatment content and will identify patient characteristics associated with successful treatment outcomes in each setting.