Journal of Studieson Alcohol. Vol. 53. No. !. 1992
Length of Stay, Patient Severity and Treatment Outcome: Sample Data from the Field of Alcoholism EDWARD GOTTHElL,
M.D., PH.D., A. THOMAS McLELLAN,
PH.D.,* AND KEITH A. DRULEY, PH.D.*
Departmentof Psychiatryand Human Behavior,JeffersonMedical College, ThomasJeffersonUniversity,1201ChestnutStreet, 15thFloor, Philadelphia, Pennsylvania19107
ABSTRACT. Lengthsof stay (LOS) have been markedlyreduced sincethe institutionof diagnosis-related groups(DRGs). To determine whethersuch reductionsrepresentincreasedefficiencyor undertreatment,however,requiresthat LOS be examinedin relation to (l) severityof patient'simpairmentand (2) treatmentoutcome.Accordingly,a retrospective analysiswas conductedusinga data set in
which initial severityassessments and 6-monthoutcomeresultswere availablefor 126 male veteranstreated for alcohol dependence. Greaterimprovement wasfoundin patientswith lesssevereimpairment, and in suchpatientslongerperiodsof treatmentresultedin betteroutcomesthan shorterperiodsof the sametreatment.(J. Stud. Alcohol 53: 69-75, 1992)
emphasizesimplicity and ease of computation.Others
HE EMPHASIS prospective payments andCURRENT diagnosis-related groupson (DRGs) has focused intend to be more comprehensive, and someeven incorpoterest on length of stay (LOS), and especiallylength of expensivehospitaltreatment,as neverbefore. Since LOS is clearly related to treatment costs, decreasingLOS seemsdesirablefrom an economicpoint of view. But LOS is not that clearly relatedto treatmentoutcome,and from a medicalpoint of view decreasingLOS may not always be desirableor evenappropriate.Medically, LOS is essentially meaninglessunlessit is evaluatedin relation to (1) the severityof the patient'sconditionand (2) the outcome
rate assessments of severity(Gonnellaand Goran, 1975; Horn, 1981). Unfortunately,variablesreflectingqualityof care or treatmentoutcome results are not representedin these formulas.
Prospectivepaymentsystemsalter incentivesand effect changesin health-care-giving practicesin accordance with theseincentives(Englishet al., 1986; Light et al., 1986; Rupp et al., 1984; Taube et al., 1984). Since the DRGs were institutedthey haveeffectivelydecreased the length of treatmentof mostconditionsin mosthospitals.In one
results of the treatment.
Moreover, decreasingLOS may be economicallyas well as clinically disadvantageous if patients are dischargedtoo soonand persistentand worseningsymptoms, recurrencesor chronic complicationsresult in repeated costlyreadmissions. It would appear,then, that decreased LOS is costeffective only when the decreaseis also clinically appropriate.The main task, financially as well as medically,becomesthat of developingclinicallyappropriate lengthsof stay. DRGs (Fetteret al., 1976, 1980) and a variety of alternativediagnosisclassificationsystemsdesignedto provide LOS
reimbursement
formulas
were
reviewed
and com-
pared by Hornbrook(1982a,b). Some, includingDRGs,
set of studies(Freiman et al., 1987; McGuire et al., 1987;
Mitchell et al., 1987), for example,involving23,210 admissionsto psychiatricunits of 300 generalhospitalsin four states,paymentsaccordingto the DRGs constituted about65% of the admissionsto units that were exempt from the DRGs, andthe lengthsof staywerelessby about 30%. Other differencesbetweenthe exempt and nonexemptunits,however,were that the patientsin the exempt units were on averagemore severelyill and were much more likely to be treatedby a psychiatrist.The authors concludethat the DRGs clearly reducecostsand LOS, but that additionalresearchis requiredto determinewhether suchreductionsrepresentincreasedefficienciesor undertreatment.
Gonnella and his colleagues(Gonnella et al., 1984; Received: October 25, 1989. Revision: March 26, 1990. *A. Thomas McLellan is with the Substance Abuse Treatment Unit,
Louis and Gonnella, 1986) have been concernedabout the
needto considerdiseaseseverityandqualityof careissues in the development of an appropriatereimbursement system. They conductedthe mostsystematicseriesof studies demonstrating that severity,as indicatedby diseasestage,
PhiladelphiaVeteransAffairs Hospital,and the Departmentof Psychology, Universityof Pennsylvania,Philadelphia.Keith A. Druley is additionally affiliated with the SubstanceAbuse TreatmentUnit, Veterans Affairs Medical Center, Coatesville, Pa.
69
70
JOURNAL
OF STUDIES
ON ALCOHOL
was associated with longerLOS and highercostsfor many differentdiseasesin many differenthospitals(Butler and Bentley, 1982;Garg et al., 1978;Gonnella, 1981). They alsofoundthat the type of insurancecoveragethe patients had was related to the severityof their condition at the time of their admissionto the hospital,possiblyreflecting the adequacyof their prior outpatienttreatmentand/orthe difficulty of gaining approval for hospital admission. Commentingthat "a good methodologyshouldmeasure what happensto the patient, i.e., it shouldbe directlyor indirectlyrelatedto outcome" (Gonnellaet al., 1976, p. 14), they suggested the possibilityof monitoringtreatment efficacy by comparingdiseasestageat admissionand at discharge,but this has not yet beendone. Nor havethere beenfollow-upstudiesof outcomein relationto lengthof stay with severitycontrolled. Hornbrook (1982a) was also concernedabout the relationshipbetweendiagnosisclassification systems,quality of care and treatment results. He noted the difficulties
and
costsof conductingclinicaloutcometrials on a scalethat would be required to evaluate these relationshipsand pointedout that at the presenttime we are still unable"to assessthe impacton the patient'shealth statusof an incrementalday in the hospital" (Hornbrook, 1982a,p. 13). Nevertheless, studies of LOS in relation to treatment
outcomeare feasibleas well as necessaryif we are to determinewhetherreductionsin LOS representincreasedefficienciesor undertreatment.A key methodologicalissue in the designof LOS evaluationstudiesis the needto take severityinto account.Individualswho are more severely
ill may oftenneedlongerperiodsof treatmentand, by the sametoken, may havepoorerprognoses, evenafter longer treatments. Thus, somepatientswho remainin the hospital longerbecauseof the severityof their conditionmay havepooreroutcomes,and LOS could be foundto be unrelatedto, or even inverselycorrelatedwith, outcomeresults if we do not control for severity.
Sincefew programsregularlyassesspatientseverityin an objective and systematicmanner and also conduct postdischarge outcomestudies,data to compareLOS and treatmentoutcomefor particularlevelsof severityare not generally available. Fortunately,the SubstanceAbuse TreatmentUnit (SATU) at the Coatesville, Pennsylvania,
/ JANUARY
1992
(1981), indicatedthat mostbut not all tendedto find positive relationshipsbetween treatmentduration and outcome. In contrast,more recent reviews by Annis (198586), the Institute of Medicine (1989) and Miller and Hester (1986) concluded that most but not all of the newer, controlled studies did not demonstrate differential
outcomesfor longer as comparedto shortertreatments, exceptfor patientswith markedpsychopathology or social instability. None of the studies, however,examinedrelationshipsbetweenlengthof stay and outcomefor patients groupedby severity. Method
Subjects
The subjectswere 131male veteranswho wereadmitted to the CoatesvilleVAMC during 1980 for inpatienttreatmentof alcoholdependence.All patientshad completeda 5- to 7-day detoxicationand stabilizationperiod on site prior to entering the rehabilitationprogram, but only thosepatientswho enteredand completedat least an additional 5 days on the rehabilitationprogram were included in the analysis.The averageage of thesepatients was 42 years;58% were white and 42% were black. Average education was 11.5 years; 31% were divorced or separatedand 34% were living alone. Alcohol use had beena problemfor an averageof 11 yearsandthe average number of previousepisodesof treatmentfor substance use problemswas eight. Rehabilitationprogram
The treatmentmodelwasessentiallya therapeutic community basedon the principlesof AlcoholicsAnonymous and the TwelveStepswith a recommended lengthof stay of 90 days.Transactional grouptherapy,patienteducation throughfilms anddiscussion and AA meetingson the unit threetimes weekly were the major therapeuticmodalities. The treatmentoccurredin an openinpatientward milieu andthe staff includedrecoveringindividualsas part of the treatment teams. The program has been describedin greaterdetail previously(Gottheilet al., 1979).
Veterans Affairs Medical Center (VAMC) had been in-
volved in cooperativestudieson the assessment of severity in addictedpatientsat the same time that 6-month follow-up evaluationswere being done. These data were availablefor secondaryanalysesto test the hypothesis that for alcoholdependentpatientsgroupedby severity,longer LOS will be associatedwith more improvementthan shorter LOS.
The literatureregardingthe effectsof lengthof alcoholism treatment on outcome has not been entirely consis-
tent. Reviewsof earlier studies,for example,those by Armor et al. (1976), Emrick (1975) and Gottheil et al.
Severity
The Addiction Severity Index (ASI), developedby McLellan and his associates(1982, 1983a) is a structured
clinical interview that is administeredby a trainedtechnician or counselorin 30 to 40 minutes. It is designedto assessproblemseverityin sevenareasusuallyaffectedin alcohol-and drug-abusing patients.Within eachof these ASI problemareasseverityis measuredin terms of the number, duration, frequency and intensity of problem symptoms.Five of the standardizedcompositefactor
GOTTHEIL
scores comprised the outcome measuresused in this study: Medical, Employment, Alcohol Use, Legal and Psychiatric.Each of thesefactorswas found in previous researchto demonstrateacceptableinternal consistency and to be valid as a generalmeasureof outcomestatusin each area (McLellan et al., 1983b, 1985). Two other ASI scales(Drug Use and Family/Social)were omitted from our analysesbecauseat the time thesedata werecollected (1) the groupof older, male, serviceveteran,alcoholdependentpatientsreportedalmost no drug problemsand (2) the Family/Socialscale in the secondversionof the ASI that was being used was not found to be useful or valid and has sincebeen changed. The Psychiatricfactorscalewas usedas the indexmeasure upon which to categorizetheseinpatientalcoholdependentpatients.Items includedin the scalequestionthe
patient'sexperiencewith "significantperiods"of depression, anxiety,confusion,persecution or paranoia,inability to concentrateand inabilityto controlviolent behavior,but not alcohol or drug use which are assessedseparately.It hasbeenfoundto be highly reliableand to correlatequite favorably with other validated measuresof psychiatric symptomatologysuch as the Global AssessmentScale (r = .76), the total score on the SCL-90 (r = .64), the MaudsleyNeuroticismScale(r = .60), the Beck Depression Inventory (r = .71), a measureof cognitive impairment or brain damage(r = .62), but not with intelligence (McLellan et al., 1983b, 1985). In sum, the ASI psychiatric compositescoreprovidesa reliable,valid, globalestimate of psychopathology. Moreover,previouspredictive analyses, in which admissionseverity on each of the scales has been related to outcome, have consistently shownthe psychiatricscaleto be the one that was most generallyrelatedto patientstatusacrossall ASI scalesat follow-upassessments. This hasbeendemonstrated with a wide variety of patient populationsand treatmentprograms(McLellan et al., 1986). Anotherreasonto use the psychiatricinsteadof the alcoholscaleas a groupingvariableis that the alcoholscale has the smallestrange and least variabilityof all the ASI measures.This is not unexpectedsince a severealcohol problemis one of the few thingsthis otherwisevery diversegroupof patientshas in common.Accordingly,the Psychiatricfactor was selectedas the measureof initial severityfor the presentstudy. Procedure
Each patientwas interviewedusingthe ASI within the first week of treatmentand again at 6omonthfollow-up to assessproblemseverityduring the previous30 days. The interviews were conductedby independenttechnicians who did not take part in the treatmentprogram.A total of 126 (96%) of the patientsparticipatedin the 6omonth follow-up.
ET AL.
71
For the variousanalysesthat follow, the patientswere dividedintolow, mid andhighseveritygroupsbasedupon theiradmission scoreson the Psychiatricfactor.As in previous studies, when the patients are divided into low, middle and high thirds, althoughthe cuttingpointsdiffer with differentpopulations,the followinggroupcharacterizationspertain. The low severitygroup is characterized as being generallyasymptomaticor as having had only minor periodsof depression or anxiety at somepoint in their past but no current symptoms.Patientsin the mid severitygroup may have had recentsymptomsof anxiety, depression or cognitiveconfusionbut no clear historyof recurrentor persistentsymptoms.Patientsin the high severity group report severeand prolongedsymptomssuch as depression, suicidalideation,paranoiaand/orcognitive impairment.There are no casesof frank schizophrenia or otherovertpsychoses amongthe patients.The majorityof thesehigh severitypatientswould receiveDSM-III diagnosesof majordepressive or generalizedanxietydisorders. Length of stay (LOS) was calculatedfrom the time of admissionto the rehabilitationprogramand did not includethe time spentin detoxication.Althoughthe recommendedLOS was 90 days in 1980, the actual average (--- SD) LOS was 47 --- 40 days, with a range from 5 to 100 days. The outcome measures were the 6-month follow-upscoreson five ASI factors.As an aid to description, selectedindividualitems from each of the problem areaswere also analyzedand are presented.
Results
Overall
outcome
To assessoveralloutcome,a between-groups (low, mid, high severity), repeatedmeasures(admissionto 6omonth follow-up) multiple analysisof varianceusingfive of the ASI compositescoreswas performed.Significantmain effectsof time (p < .0001) and severity(p < .001) as well as a significant (p < .001) interaction effect indicated that patientswere generallyimprovedfollowingtreatment and that the amountof improvementvaried accordingto the level of severity. Pre- to post-treatmentdifferencesfor each of the five ASI problem areas and selected individual items were then examinedby repeatedmeasuresanalysesof variance and thesecomparisonsare presentedin Table 1. As can be seen, following treatment,significantimprovementwas found to occur on each of the factor scores(high scores indicategreaterseverity)and individualitems. Outcomeby psychiatricseverity
In orderto determinethe contributionof psychiatricseverity to the outcomeresultsof alcohol abuse treatment,
72 TABLE 1.
JOURNAL
OF STUDIES
ON ALCOHOL
Outcome from alcohol treatment in 126 male veterans
/ JANUARY
1992
Outcomeby lengthof stay (LOS)
Factor Scores
Factors
Admission
Medical
419
*
306
Daysof med.probs. Employment
11 279
* *
8 198
6
*
10
188
*
327
Days worked
Moneyearned Alcohol Use
577
Daysdrinking Daysintoxicated Legal
Crimedays Illegal income
Psychiatric Dayspsych. probs. BeckDep.Inv. * =p < .05.
LOS in this sampleof patients,was not relatedto psychiatricseverityas the averageLOS for the low, mid and high severitygroupswas 47, 50 and45 days,respectively. To examine the relationshipbetween LOS and improvement in these patients, we calculatedadmissionto 6-
6-month
*
288
13 11
* *
7 4
127
*
79
7
*
3
95
*
11
211 12 21
* * *
120 5 12
month raw changescoresfor each of the ASI factor scores and selected individual
*p < .01.
betweengroups(low, mid, high) differenceswere examined using repeated measures(admissionto 6-month follow-up)analysesof covarianceto adjustfor initial differenceson eachof the AS! compositefactorsand individual items. Theseresultsare presentedin the last column of Table2. In addition,t testswere calculatedfollowinga significant(p < .05) main effect in the ANOVA,and these results are shown for each severity group between the "pre" and "post" columnsof Table 2. Inspectionof the table revealssubstantialimprovement on nearlyall factorsand itemsfor the low and mid severity groups. There was considerablyless improvement shownby the high severitygroup.Resultsof the ANCOVA analysesindicatethat thesedifferencesbetweenthe severity groupswere significantfor 8 of the 14 comparisons. Thus, while we had found positive treatmentresultsfor the sampleas a whole, whenevaluatedby level of severity, the low and mid severitygroupsshowedmuch more improvementthan the high severitygroup. TABLE2.
items. Pearson correlation
coeffi-
cients were then calculatedbetween treatmentlength (LOS) and thesechangescores.The resultsare shownfor the total samplein the first column of Table 3 and for each of the severitygroupsin the next three columns. Greater treatment length was generally related to greaterimprovementin the total sample, significantlyso (p < .01) in the areas of employment,alcohol use and psychiatric status. More significant relationshipswere foundbetweenLOS and improvementwithin the low and mid severitygroupsthan were foundfor the total sample. In contrastthere were no significantrelationshipswithin the high severitygroup. To explore further the relationshipsbetweenseverity, lengthof stay and treatmentoutcome,the three severity groups were each divided into short- and long-stay groups.We definedlong LOS as 15 or moredaysof rehabilitation treatment(which togetherwith 5 to 7 days of detoxication
and stabilization
amounts to a total of 20 to
22 days and is not unlike currentpractice).Short LOS was definedas lessthan 15 days.We thencomparedthe outcomestatusof patientswith shortandlongLOS on the ASI factors and selected individual
items within
each of
the threepsychiatricseveritygroupsusinganalysisof covariance to adjust for differencesin initial admission scores.Theseanalysesare summarizedin Table 4, which for easeof presentation showsonly the 6-monthfollow-up values for each of the outcome measures. Table 4 also in-
Outcomefrom alcoholtreatmentby psychiatricseverity Psychiatricseveritygroup Low
Mid
High
(n = 42)
(n = 42)
( n = 42)
Factors
Pre
Medical
391
*
l0
*
5
12
Employment
257
*
186
Days worked Moneyearned Alcohol use
6 213 487
* *
13 367 129
11
*
4
8
*
112 6 102
197 11
Days of med. probs.
Daysdrinking Days intoxicated
Legal Crime days Illegal income
Psychiatric Dayspsych.probs. Beck Dep. Inv.
*p < .05bypairedt test.
19
*p < .01.
Post
Pre
231
420
*
Post
Pre
Post
293
ANCOVA
434
369
L
Length of Stay, Patient Severity and Treatment Outcome: Sample Data from the Field of Alcoholism EDWARD GOTTHElL,
M.D., PH.D., A. THOMAS McLELLAN,
PH.D.,* AND KEITH A. DRULEY, PH.D.*
Departmentof Psychiatryand Human Behavior,JeffersonMedical College, ThomasJeffersonUniversity,1201ChestnutStreet, 15thFloor, Philadelphia, Pennsylvania19107
ABSTRACT. Lengthsof stay (LOS) have been markedlyreduced sincethe institutionof diagnosis-related groups(DRGs). To determine whethersuch reductionsrepresentincreasedefficiencyor undertreatment,however,requiresthat LOS be examinedin relation to (l) severityof patient'simpairmentand (2) treatmentoutcome.Accordingly,a retrospective analysiswas conductedusinga data set in
which initial severityassessments and 6-monthoutcomeresultswere availablefor 126 male veteranstreated for alcohol dependence. Greaterimprovement wasfoundin patientswith lesssevereimpairment, and in suchpatientslongerperiodsof treatmentresultedin betteroutcomesthan shorterperiodsof the sametreatment.(J. Stud. Alcohol 53: 69-75, 1992)
emphasizesimplicity and ease of computation.Others
HE EMPHASIS prospective payments andCURRENT diagnosis-related groupson (DRGs) has focused intend to be more comprehensive, and someeven incorpoterest on length of stay (LOS), and especiallylength of expensivehospitaltreatment,as neverbefore. Since LOS is clearly related to treatment costs, decreasingLOS seemsdesirablefrom an economicpoint of view. But LOS is not that clearly relatedto treatmentoutcome,and from a medicalpoint of view decreasingLOS may not always be desirableor evenappropriate.Medically, LOS is essentially meaninglessunlessit is evaluatedin relation to (1) the severityof the patient'sconditionand (2) the outcome
rate assessments of severity(Gonnellaand Goran, 1975; Horn, 1981). Unfortunately,variablesreflectingqualityof care or treatmentoutcome results are not representedin these formulas.
Prospectivepaymentsystemsalter incentivesand effect changesin health-care-giving practicesin accordance with theseincentives(Englishet al., 1986; Light et al., 1986; Rupp et al., 1984; Taube et al., 1984). Since the DRGs were institutedthey haveeffectivelydecreased the length of treatmentof mostconditionsin mosthospitals.In one
results of the treatment.
Moreover, decreasingLOS may be economicallyas well as clinically disadvantageous if patients are dischargedtoo soonand persistentand worseningsymptoms, recurrencesor chronic complicationsresult in repeated costlyreadmissions. It would appear,then, that decreased LOS is costeffective only when the decreaseis also clinically appropriate.The main task, financially as well as medically,becomesthat of developingclinicallyappropriate lengthsof stay. DRGs (Fetteret al., 1976, 1980) and a variety of alternativediagnosisclassificationsystemsdesignedto provide LOS
reimbursement
formulas
were
reviewed
and com-
pared by Hornbrook(1982a,b). Some, includingDRGs,
set of studies(Freiman et al., 1987; McGuire et al., 1987;
Mitchell et al., 1987), for example,involving23,210 admissionsto psychiatricunits of 300 generalhospitalsin four states,paymentsaccordingto the DRGs constituted about65% of the admissionsto units that were exempt from the DRGs, andthe lengthsof staywerelessby about 30%. Other differencesbetweenthe exempt and nonexemptunits,however,were that the patientsin the exempt units were on averagemore severelyill and were much more likely to be treatedby a psychiatrist.The authors concludethat the DRGs clearly reducecostsand LOS, but that additionalresearchis requiredto determinewhether suchreductionsrepresentincreasedefficienciesor undertreatment.
Gonnella and his colleagues(Gonnella et al., 1984; Received: October 25, 1989. Revision: March 26, 1990. *A. Thomas McLellan is with the Substance Abuse Treatment Unit,
Louis and Gonnella, 1986) have been concernedabout the
needto considerdiseaseseverityandqualityof careissues in the development of an appropriatereimbursement system. They conductedthe mostsystematicseriesof studies demonstrating that severity,as indicatedby diseasestage,
PhiladelphiaVeteransAffairs Hospital,and the Departmentof Psychology, Universityof Pennsylvania,Philadelphia.Keith A. Druley is additionally affiliated with the SubstanceAbuse TreatmentUnit, Veterans Affairs Medical Center, Coatesville, Pa.
69
70
JOURNAL
OF STUDIES
ON ALCOHOL
was associated with longerLOS and highercostsfor many differentdiseasesin many differenthospitals(Butler and Bentley, 1982;Garg et al., 1978;Gonnella, 1981). They alsofoundthat the type of insurancecoveragethe patients had was related to the severityof their condition at the time of their admissionto the hospital,possiblyreflecting the adequacyof their prior outpatienttreatmentand/orthe difficulty of gaining approval for hospital admission. Commentingthat "a good methodologyshouldmeasure what happensto the patient, i.e., it shouldbe directlyor indirectlyrelatedto outcome" (Gonnellaet al., 1976, p. 14), they suggested the possibilityof monitoringtreatment efficacy by comparingdiseasestageat admissionand at discharge,but this has not yet beendone. Nor havethere beenfollow-upstudiesof outcomein relationto lengthof stay with severitycontrolled. Hornbrook (1982a) was also concernedabout the relationshipbetweendiagnosisclassification systems,quality of care and treatment results. He noted the difficulties
and
costsof conductingclinicaloutcometrials on a scalethat would be required to evaluate these relationshipsand pointedout that at the presenttime we are still unable"to assessthe impacton the patient'shealth statusof an incrementalday in the hospital" (Hornbrook, 1982a,p. 13). Nevertheless, studies of LOS in relation to treatment
outcomeare feasibleas well as necessaryif we are to determinewhetherreductionsin LOS representincreasedefficienciesor undertreatment.A key methodologicalissue in the designof LOS evaluationstudiesis the needto take severityinto account.Individualswho are more severely
ill may oftenneedlongerperiodsof treatmentand, by the sametoken, may havepoorerprognoses, evenafter longer treatments. Thus, somepatientswho remainin the hospital longerbecauseof the severityof their conditionmay havepooreroutcomes,and LOS could be foundto be unrelatedto, or even inverselycorrelatedwith, outcomeresults if we do not control for severity.
Sincefew programsregularlyassesspatientseverityin an objective and systematicmanner and also conduct postdischarge outcomestudies,data to compareLOS and treatmentoutcomefor particularlevelsof severityare not generally available. Fortunately,the SubstanceAbuse TreatmentUnit (SATU) at the Coatesville, Pennsylvania,
/ JANUARY
1992
(1981), indicatedthat mostbut not all tendedto find positive relationshipsbetween treatmentduration and outcome. In contrast,more recent reviews by Annis (198586), the Institute of Medicine (1989) and Miller and Hester (1986) concluded that most but not all of the newer, controlled studies did not demonstrate differential
outcomesfor longer as comparedto shortertreatments, exceptfor patientswith markedpsychopathology or social instability. None of the studies, however,examinedrelationshipsbetweenlengthof stay and outcomefor patients groupedby severity. Method
Subjects
The subjectswere 131male veteranswho wereadmitted to the CoatesvilleVAMC during 1980 for inpatienttreatmentof alcoholdependence.All patientshad completeda 5- to 7-day detoxicationand stabilizationperiod on site prior to entering the rehabilitationprogram, but only thosepatientswho enteredand completedat least an additional 5 days on the rehabilitationprogram were included in the analysis.The averageage of thesepatients was 42 years;58% were white and 42% were black. Average education was 11.5 years; 31% were divorced or separatedand 34% were living alone. Alcohol use had beena problemfor an averageof 11 yearsandthe average number of previousepisodesof treatmentfor substance use problemswas eight. Rehabilitationprogram
The treatmentmodelwasessentiallya therapeutic community basedon the principlesof AlcoholicsAnonymous and the TwelveStepswith a recommended lengthof stay of 90 days.Transactional grouptherapy,patienteducation throughfilms anddiscussion and AA meetingson the unit threetimes weekly were the major therapeuticmodalities. The treatmentoccurredin an openinpatientward milieu andthe staff includedrecoveringindividualsas part of the treatment teams. The program has been describedin greaterdetail previously(Gottheilet al., 1979).
Veterans Affairs Medical Center (VAMC) had been in-
volved in cooperativestudieson the assessment of severity in addictedpatientsat the same time that 6-month follow-up evaluationswere being done. These data were availablefor secondaryanalysesto test the hypothesis that for alcoholdependentpatientsgroupedby severity,longer LOS will be associatedwith more improvementthan shorter LOS.
The literatureregardingthe effectsof lengthof alcoholism treatment on outcome has not been entirely consis-
tent. Reviewsof earlier studies,for example,those by Armor et al. (1976), Emrick (1975) and Gottheil et al.
Severity
The Addiction Severity Index (ASI), developedby McLellan and his associates(1982, 1983a) is a structured
clinical interview that is administeredby a trainedtechnician or counselorin 30 to 40 minutes. It is designedto assessproblemseverityin sevenareasusuallyaffectedin alcohol-and drug-abusing patients.Within eachof these ASI problemareasseverityis measuredin terms of the number, duration, frequency and intensity of problem symptoms.Five of the standardizedcompositefactor
GOTTHEIL
scores comprised the outcome measuresused in this study: Medical, Employment, Alcohol Use, Legal and Psychiatric.Each of thesefactorswas found in previous researchto demonstrateacceptableinternal consistency and to be valid as a generalmeasureof outcomestatusin each area (McLellan et al., 1983b, 1985). Two other ASI scales(Drug Use and Family/Social)were omitted from our analysesbecauseat the time thesedata werecollected (1) the groupof older, male, serviceveteran,alcoholdependentpatientsreportedalmost no drug problemsand (2) the Family/Socialscale in the secondversionof the ASI that was being used was not found to be useful or valid and has sincebeen changed. The Psychiatricfactorscalewas usedas the indexmeasure upon which to categorizetheseinpatientalcoholdependentpatients.Items includedin the scalequestionthe
patient'sexperiencewith "significantperiods"of depression, anxiety,confusion,persecution or paranoia,inability to concentrateand inabilityto controlviolent behavior,but not alcohol or drug use which are assessedseparately.It hasbeenfoundto be highly reliableand to correlatequite favorably with other validated measuresof psychiatric symptomatologysuch as the Global AssessmentScale (r = .76), the total score on the SCL-90 (r = .64), the MaudsleyNeuroticismScale(r = .60), the Beck Depression Inventory (r = .71), a measureof cognitive impairment or brain damage(r = .62), but not with intelligence (McLellan et al., 1983b, 1985). In sum, the ASI psychiatric compositescoreprovidesa reliable,valid, globalestimate of psychopathology. Moreover,previouspredictive analyses, in which admissionseverity on each of the scales has been related to outcome, have consistently shownthe psychiatricscaleto be the one that was most generallyrelatedto patientstatusacrossall ASI scalesat follow-upassessments. This hasbeendemonstrated with a wide variety of patient populationsand treatmentprograms(McLellan et al., 1986). Anotherreasonto use the psychiatricinsteadof the alcoholscaleas a groupingvariableis that the alcoholscale has the smallestrange and least variabilityof all the ASI measures.This is not unexpectedsince a severealcohol problemis one of the few thingsthis otherwisevery diversegroupof patientshas in common.Accordingly,the Psychiatricfactor was selectedas the measureof initial severityfor the presentstudy. Procedure
Each patientwas interviewedusingthe ASI within the first week of treatmentand again at 6omonthfollow-up to assessproblemseverityduring the previous30 days. The interviews were conductedby independenttechnicians who did not take part in the treatmentprogram.A total of 126 (96%) of the patientsparticipatedin the 6omonth follow-up.
ET AL.
71
For the variousanalysesthat follow, the patientswere dividedintolow, mid andhighseveritygroupsbasedupon theiradmission scoreson the Psychiatricfactor.As in previous studies, when the patients are divided into low, middle and high thirds, althoughthe cuttingpointsdiffer with differentpopulations,the followinggroupcharacterizationspertain. The low severitygroup is characterized as being generallyasymptomaticor as having had only minor periodsof depression or anxiety at somepoint in their past but no current symptoms.Patientsin the mid severitygroup may have had recentsymptomsof anxiety, depression or cognitiveconfusionbut no clear historyof recurrentor persistentsymptoms.Patientsin the high severity group report severeand prolongedsymptomssuch as depression, suicidalideation,paranoiaand/orcognitive impairment.There are no casesof frank schizophrenia or otherovertpsychoses amongthe patients.The majorityof thesehigh severitypatientswould receiveDSM-III diagnosesof majordepressive or generalizedanxietydisorders. Length of stay (LOS) was calculatedfrom the time of admissionto the rehabilitationprogramand did not includethe time spentin detoxication.Althoughthe recommendedLOS was 90 days in 1980, the actual average (--- SD) LOS was 47 --- 40 days, with a range from 5 to 100 days. The outcome measures were the 6-month follow-upscoreson five ASI factors.As an aid to description, selectedindividualitems from each of the problem areaswere also analyzedand are presented.
Results
Overall
outcome
To assessoveralloutcome,a between-groups (low, mid, high severity), repeatedmeasures(admissionto 6omonth follow-up) multiple analysisof varianceusingfive of the ASI compositescoreswas performed.Significantmain effectsof time (p < .0001) and severity(p < .001) as well as a significant (p < .001) interaction effect indicated that patientswere generallyimprovedfollowingtreatment and that the amountof improvementvaried accordingto the level of severity. Pre- to post-treatmentdifferencesfor each of the five ASI problem areas and selected individual items were then examinedby repeatedmeasuresanalysesof variance and thesecomparisonsare presentedin Table 1. As can be seen, following treatment,significantimprovementwas found to occur on each of the factor scores(high scores indicategreaterseverity)and individualitems. Outcomeby psychiatricseverity
In orderto determinethe contributionof psychiatricseverity to the outcomeresultsof alcohol abuse treatment,
72 TABLE 1.
JOURNAL
OF STUDIES
ON ALCOHOL
Outcome from alcohol treatment in 126 male veterans
/ JANUARY
1992
Outcomeby lengthof stay (LOS)
Factor Scores
Factors
Admission
Medical
419
*
306
Daysof med.probs. Employment
11 279
* *
8 198
6
*
10
188
*
327
Days worked
Moneyearned Alcohol Use
577
Daysdrinking Daysintoxicated Legal
Crimedays Illegal income
Psychiatric Dayspsych. probs. BeckDep.Inv. * =p < .05.
LOS in this sampleof patients,was not relatedto psychiatricseverityas the averageLOS for the low, mid and high severitygroupswas 47, 50 and45 days,respectively. To examine the relationshipbetween LOS and improvement in these patients, we calculatedadmissionto 6-
6-month
*
288
13 11
* *
7 4
127
*
79
7
*
3
95
*
11
211 12 21
* * *
120 5 12
month raw changescoresfor each of the ASI factor scores and selected individual
*p < .01.
betweengroups(low, mid, high) differenceswere examined using repeated measures(admissionto 6-month follow-up)analysesof covarianceto adjustfor initial differenceson eachof the AS! compositefactorsand individual items. Theseresultsare presentedin the last column of Table2. In addition,t testswere calculatedfollowinga significant(p < .05) main effect in the ANOVA,and these results are shown for each severity group between the "pre" and "post" columnsof Table 2. Inspectionof the table revealssubstantialimprovement on nearlyall factorsand itemsfor the low and mid severity groups. There was considerablyless improvement shownby the high severitygroup.Resultsof the ANCOVA analysesindicatethat thesedifferencesbetweenthe severity groupswere significantfor 8 of the 14 comparisons. Thus, while we had found positive treatmentresultsfor the sampleas a whole, whenevaluatedby level of severity, the low and mid severitygroupsshowedmuch more improvementthan the high severitygroup. TABLE2.
items. Pearson correlation
coeffi-
cients were then calculatedbetween treatmentlength (LOS) and thesechangescores.The resultsare shownfor the total samplein the first column of Table 3 and for each of the severitygroupsin the next three columns. Greater treatment length was generally related to greaterimprovementin the total sample, significantlyso (p < .01) in the areas of employment,alcohol use and psychiatric status. More significant relationshipswere foundbetweenLOS and improvementwithin the low and mid severitygroupsthan were foundfor the total sample. In contrastthere were no significantrelationshipswithin the high severitygroup. To explore further the relationshipsbetweenseverity, lengthof stay and treatmentoutcome,the three severity groups were each divided into short- and long-stay groups.We definedlong LOS as 15 or moredaysof rehabilitation treatment(which togetherwith 5 to 7 days of detoxication
and stabilization
amounts to a total of 20 to
22 days and is not unlike currentpractice).Short LOS was definedas lessthan 15 days.We thencomparedthe outcomestatusof patientswith shortandlongLOS on the ASI factors and selected individual
items within
each of
the threepsychiatricseveritygroupsusinganalysisof covariance to adjust for differencesin initial admission scores.Theseanalysesare summarizedin Table 4, which for easeof presentation showsonly the 6-monthfollow-up values for each of the outcome measures. Table 4 also in-
Outcomefrom alcoholtreatmentby psychiatricseverity Psychiatricseveritygroup Low
Mid
High
(n = 42)
(n = 42)
( n = 42)
Factors
Pre
Medical
391
*
l0
*
5
12
Employment
257
*
186
Days worked Moneyearned Alcohol use
6 213 487
* *
13 367 129
11
*
4
8
*
112 6 102
197 11
Days of med. probs.
Daysdrinking Days intoxicated
Legal Crime days Illegal income
Psychiatric Dayspsych.probs. Beck Dep. Inv.
*p < .05bypairedt test.
19
*p < .01.
Post
Pre
231
420
*
Post
Pre
Post
293
ANCOVA
434
369
L
