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Quality Measures and Improvement in Addiction Treatment
Kimberly Johnson, PhD, MBA
Associate Professor - University of South Florida and 43rd Annual Conference Faculty

Quality measurement for substance use disorder treatment is a relatively recent activity. Since the initiation of the Washington Circle in 19981, performance measurement of substance use disorder services has made gradual progress toward widespread acceptance. The Washington Circle measures were initially designed to assess quality of managed care plans in their ability to identify people who needed treatment (diagnosis), the percent of people that needed treatment that initiated treatment (initiation), and the percent of patients that received at least two additional services after initiation (engagement)2. These measures have been validated on different populations and in different settings,3-7endorsed by the National Quality Forum8, and adopted by the National Committee for Quality Assurance (NCQA) as Healthcare Effectiveness Data and Information Set (HEDIS®) measures9.

The NCQA, a non-profit organization, is widely recognized for its stringent process of quality measurement development and used to assess performance in a variety of healthcare settings using administrative data. NCQA reports on the two addiction treatment measures (treatment initiation and treatment engagement) that are regularly captured in their dataset. In the period between 2004-2017, initiation rates went down in all types of insurance plans and engagement either decreased or remained stable depending on the type of insurance plan10. Other groups are just beginning to develop process and outcome standards for substance use disorder treatment. For example, the International Consortium for Health Outcomes Measurement (ICHOM) has a current working group developing standards of care for “substance use and addictive behavior disorders” which will include gambling addiction as well as addiction to alcohol, tobacco and other drugs. The preliminary set which they unveiled at the Lisbon Addictions conference in October, 201911 will include process measures much like the HEDIS measures, but also outcome measures like reduced use.

The ICHOM standards will be interesting because they will include outcome measures. There is quite a bit of controversy over what are appropriate outcomes for substance use disorder treatment. More medically minded providers and organizations prefer reduction of symptoms as the appropriate measure for treatment, particularly when it involves medication designed to address a particular symptom or set of symptoms such a craving12. Historically alcohol or drug use has been used as the primary measure of outcome in clinical trials12, but how it has been measured has varied. Alcohol and drug use have been measured as a percentage reduction in use over varying periods of time, number of days of abstinence over varying periods of time, percent of days abstinent over varying periods of time etc. There is more recent interest in patient centered outcomes that attempt to describe concepts like recovery through patient reported changes in quality of life measures13,14.

This lack of clarity in what to measure and how to measure it makes it hard for systems to decide what is important to measure and how to assess the function of the treatment system. The Network for the Improvement of Addiction Treatment (NIATx)15 funded by the Robert Wood Johnson Foundation and the Substance Abuse Mental Health Administration (SAMHSA) began a national quality improvement effort aimed primarily toward specialty addiction treatment providers in 2005. NIATx taught providers standard quality improvement methods such as plan-do-study-act cycles and "walk-throughs" to understand problems from the patient perspective. NIATx proposed that programs choose measures that were meaningful to them and easy to collect rather than focusing on standardized measures.

Currently, more thought is being given to how process measures lead to outcomes and a focus on the continuum or cascade of care measures16-18. This concept is used in treatment of other conditions, most famously the 90-90-90 goals for eradicating HIV infection19,20. This method allows healthcare systems, payer systems, and regulators to look at overall system functioning to identify targets for improvement. While there seems to be consensus developing on how to measure a cascade of care for opioid use disorder21,22, measures for alcohol and other drugs have not been developed. While it is clear that people with a moderate or severe opioid use disorder have a need for immediate access to long term medication treatment, the appropriate type, dose and duration of treatment for alcohol and drugs other than opioids has not yet been adequately defined even in research, let alone clinical practice.

Where does this leave us? More research on appropriate process and outcome measures needs to be done. Meanwhile clinical practices and systems of care will need to do what NIATx has guided them to do in terms of identifying key problems and use a combination of available data, knowledge of the science of measurement and common sense to improve the quality of care for patients in their systems.

Learn more about about quality and addiction medicine - join me for “A Substance Use Disorder Panel Discussion” with Dr. Frank James of the American Society of Addiction Medicine at ABQAURP’s 43rd Annual Health Care Quality and Patient Safety Conference in Clearwater Beach, FL on October 29-30, 2020. For more information and to register, visit www.abqaurp.org/AnnualConference.

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2 Garnick, D. W., Horgan, C. M. & Chalk, M. Performance measures for alcohol and other drug services. Alcohol Research & Health 29, 19-26 (2006).
3 Harris, A. H. et al. Predictive validity of two process-of-care quality measures for residential substance use disorder treatment. Addiction science & clinical practice 10, 22 (2015).
4 Garnick, D. W. et al. The Washington circle engagement performance measures’ association with adolescent treatment outcomes. Drug and Alcohol Dependence 124, 250-258 (2012).
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8 National Quality Forum Behavioral Health Phase 1, 2012 FINAL REPORT.
9 National Committee for Quality Assurance Washington, DC, 2013.
10 Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence, (2019). At: https://www.ncqa.org/hedis/measures/initiation-and-engagement-of-alcohol-and-other-drug-abuse-or-dependence-treatment/
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