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Performance-Based Monitoring of Methadone Programs: NIDA Pilot Test Underway

Is it possible to base Federal regulation of methadone treatment programs on their performance rather than on process issues? A feasibility study being conducted by NIDA is exploring a system that would focus on results rather than process for determining the effectiveness of methadone maintenance treatment programs. Dorynne Czechowicz, M.D., is the NIDA project officer for this study.

NIDA's Methadone Treatment Quality Assurance System (MTQAS) Feasibility Study will examine whether a model based on program performance standards can reduce or replace existing process-focused Federal regulations governing methadone treatment. If implemented, MTQAS will provide a national system for evaluating the effectiveness of treatment at methadone maintenance programs, a feedback system to help treatment providers identify their program's strengths and weaknesses, and measurement tools that take into account differences in program orientation and patient characteristics.

Major issues

The feasibility study, which is being conducted for NIDA by the Research Triangle Institute with assistance from the National Association of State Alcohol and Drug Abuse Directors (NASADAD), will focus on five critical questions:

• What performance indicators, including treatment outcomes, should form the basis of a performance measurement system?
• What patient information must be gathered in order to adjust relative treatment outcomes for the program's "case-mix" (that is, to separate the contribution of patient characteristics from the program's performance)?
• How might performance feedback be structured to be of the greatest assistance to programs?
• What operational problems might arise if such a system were implemented?
• How might performance monitoring be used to modify the current Federal regulatory structure for methadone treatment programs?

Methodology

Phase 1 of the feasibility study will consist of the initial design—including measurement instruments and data collection procedures—and field testing. The first part of the field test, to involve 5 programs and 235 patients, will focus on the reliability and validity of the proposed instrumentation. Then the field test will expand to 25 programs and 2,350 patients and will focus on performance reporting, data gathering, and further refinement of the instruments. These include an initial patient assessment profile, a quarterly patient status report, and a program director's questionnaire. Patient status reports will focus on:

• Behavioral indicators such as urinalysis, employment or educational involvement, and arrest reports
• Treatment-related performance indicators such as retention, discharge rate and status, and attendance at dispensing and counseling sessions
• Tracking of change in performance indicators over time

Phase 2 of the study will feature a year-long field trial involving 150 programs and up to 23,700 patients.

A wide range of programs in study sample

Since MTQAS is designed to apply to all types of methadone programs, the feasibility study will include the widest possible array of program and patient types. These will be culled from programs registered with the Food and Drug Administration. Among the factors that will be taken into consideration in selecting program sites are a program's administrative structure (i.e., whether it is hospital-based, for-profit, or community-based) and its therapeutic orientation (i.e., its methadone dosage practices and intensity of services).

MTQAS will be in testing and design stages over the next 3 years. The Office of Management and Budget has approved funding for Phase 1 of the feasibility study, and recruitment of test programs and training is underway.

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