Alcoholism interests have created a f a r from passive environment. Points of view regarding alcoholism or its treatment, the funding of research, and public and social poliGy affecting alcohol problems easih become hot political issues.

Social Matrix and Sources of Management I nformation

Alfonso Paredes

Federal support for alcoholism programs experienced an elevenfold increase from 1971 to 1974. Most recently the level of support has remained stationary, but states’ governments and the private sector have substantially increased their commitments to alcoholism programs. The outlay of funds has led to the emergence of a large constituency of service providers, advocate organiza- tions, and clients receiving services. Advocate organizations such as the North American Association of Alcohol Programs, founded in 1960 by directors of alcoholism programs, have grown considerably. This group later adopted the name of Alcohol and Drug Abuse Problems Association of North America (ADAPA) to accommodate a larger membership. Of recent foundation is the Council of State and Territorial Alcoholism Authorities (CSTAA). The pur- poses of this organization are to foster the development of alcoholism and drug abuse programs and to assist federal, state, and territorial governments in the design, development, and implementation of cooperative federal-state alcohol- ism programs. The organization has set the aim of providing technical assis- tance to the states regarding licensure and accreditation of alcoholism rehabili- tative personnel. Another of their concerns has been the identification of eval- uation needs in the area of alcoholism treatment services, as well as the provi- sion of technical and financial assistance to selected states interested in pro- gram reporting and management information systems. Several other organi-

New Directions for Mental Health Seruices, 10, 1981 11

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zations related to the alcoholism field have been created under the sponsorship or encouragement of NIAAA. A number of private consulting firms have received contracts from NIAAA for education and training programs and to abstract literature on alcoholism and conduct evaluative monitoring projects. The National Council on Alcoholism, founded earlier, is a large voluntary agency with chapters in almost every medium- and large-sized city in Amer- ica. ‘This group has played an important role in the education and advocacy of those with alcohol problems. Alcoholics Anonymous, the remarkable self-help group, has experienced phenomenal growth since its foundation by an Akron physician in 1935. In 1970, federal legislation created the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to develop health, education, training, and research programs and to provide leadership in the area of alco- holism treatment and rehabilitation. The groups mentioned here are just a few of the organizations in the alcoholism field, all part of a large and influential constituency. Former U. S. Senator Harold Hughes, an advocate of alcoholism treatment programs, observing the growth of this large constituency, noted:

We have, in effect, a new civilian army that has now become institu- tionalized. The alcohol- and drug-industrial complex is not as powerful as its military-industrial counterpart, but, nonetheless, there are some striking similarities. We have a growing body of trained and skilled counselors who are the soldiers in the field. We have the ever enlarging structure of scientists, “think tank” personnel, administrators, consul- tants, evaluators, technical evaluators, technical assistants, and so on. A huge and influential empire (Alcoholism Report, 1974).

The sociopolitical matrix created by the many interests just described Lreates a far from passive environment. Points of view regarding alcoholism or its treatment, the funding of research, and public and social policy affecting alcohol problems easily become hot political issues. The public reactions to the first Rand Keport make it clear that the atmosphere of the alcoholism field is not one of objective equanimity (Blume, 1977). The report precipitated a nationwide debate among experts and laymen interested in alcoholism. The findings of the study were thought to contradict the strongly held assumption that alcoholics cannot return to normal drinking. The debate was carried out in the press and scientific journals.

information Management in the Alcoholism Services Delivery System

The health enterprise, like any other industry, is dependent upon the collection, interpretation, organization, storage, retrieval, and application of data. These activities affect planning, organization, and coordination of man-

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power and the utilization of facilities. Large sums of capital and many human resources have been applied for extended periods of time to the solution and management of the problems faced by the alcoholism treatment and rehabili- tation system. It is, therefore, desirable that the information used to assess these problems be reliable and well-organized. Within this framework, com- puter technology has an important role to play (Kissick, 1970). The ongoing electronics revolution has provided increasingly efficient tools for organizing knowledge (Branscomb, 1979). Computers, the main resource of information management, provide convenient storage, organization, restructuring, and access to information (Madnick, 1977). Our ability to use these technical resources will decide whether the system fulfills its mission effectively. It is striking that, in spite of the technical advantages it offers, information man- agement technology has not been used sufficiently. With the appropriate tech- nology, important functions of the delivery system, such as surveillance of per- formance, evaluation of quality efficiency, and costs could be improved sub- stantially (Murnaghan and White, 1971).

An important application of computers is in the development and oper- ation of management information systems (Davis, 1977). Information systems are methods of collecting, storing, organizing, and retrieving information with the purpose of selecting data and transforming them into the information needed for decision making (Murnaghan, 1974). Information systems may provide uniform statistical reporting, including efficient and accurate patient census information and may be used to collate evaluation and treatment infor- mation for the purposes of billing and documenting third-party payments. Information systems help institutions to control accurately the amounts of money that have been encumbered or actually expended. A computerized sys- tem provides data for the collection and reporting of all transactions by cost center and for comparisons of actual costs to those budgeted. This system also generates other such essential reports as expense reports, balance sheets, and general ledgers needed for fiscal management. It may monitor and help con- trol the property used for treatment facilities, calculating the depreciation of this property following guidelines established by programs such as Medicare. Incidentally, compliance with these guidelines is necessary to obtain reim- bursement. Information systems can be designed to monitor and help control all expendable inventories and maintenance of patient care, while providing quantitative measures of patient behavior and symptoms’ change. Finally, information systems may provide standardized data bases useful for conduct- ing clinical studies essential for improving health and patient care (Hedlund and others, 1977).

Several information systems have been developed to monitor the alco- holism services delivery system. The best known is the National Alcoholism Program Information System (NAPIS), developed in 1973 by the Stanford Research Institute (SRI International) under a contract with the National

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Institute on Alcohol Abuse and Alcoholism. The system is used to oversee the clinical performance of treatment programs funded by SRI International. Data collected by the staff of alcoholism programs is processed by a contractor who provides computed outputs to SRI International and grant recipients.

The author and his associates, following closely the NAPIS model, developed a computerized system, the Oklahoma Mental Health Information System (OMHIS). This system has special features that increase its practica- bility. For example, the system is designed to operate within a third-party reimbursement format adaptable to various third-party reimbursement schemes. Data from the system have been used to perform various studies of therapeutic resource use; therapeutic outcome, cost efficiency, and cost bene- fit (Paredes, 1977; Paredes and Gregory, 1978; Rundell and Paredes, 1979). Studies have also been conducted to examine the relationship between amount of resources applied and therapeutic outcomes obtained. The system uses nomenclature for recording procedures common to the general field of health care and captures pertinent sociodernographic data on admission to programs. Infbrmation related to the clients’ level of functioning, social adjustment, and specific clinical problems are part of the data recorded on admission. These data provide baseline information that may be compared to follow-up data col- lected later. A special feature of the system is that, using a random sampling routine, follow-up data is collected at ninety-day intervals.

The information system captures data every time a significant interaction between the patient and the staff of an agency occurs. These data include med- ical procedures and rehabilitative techniques provided, date and time the ser- vices are delivered, identification of the staff person providing care, payment source, and therapeutic outcome indices. The information is summarized for individual clients, staff members, and agencies. Changes in the patient’s treat- ment status, such as movement from inpatient to outpatient facilities, is captured by the system. For each client the information includes level of functioning, legal status, source of referral, diagnosis and presenting problem, date and time of day the transaction occurred. Routine outputs include individual client reports listing sociodemographic information, admission clinical status, and client’s statement of services provided; third-party claims and reimbursements; such agency reports as edit routines, file maintenance, sociodemographic intake data; follow-up information; services rendered, problem/symptom diagnoses; reimbursements and billing analyses. A report summarizing data aggregates from all agencies includes sociodemographic information, intake and follow-up characteristics, services rendered, problem/symptom diagnoses, reimbursable activity, and amount payable (Paredes, 1977).

Needs Assessment

Assessment of the need for health services has been mandated by legisla- tive action incorporated into such acts of Congress as Public Law 89-749, the

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Comprehensive Health Planning and Public Services Amendments of 1966, more recently, Public Law 93-641, the National Health Planning and Resources Development Act of 1974, and Public Law 94-63, the Community Mental Health Centers Amendment of 1975. The latter requires centers to evaluate their programs so as to meet the needs of those in their catchment areas. Similarly, Public Law 91-616, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act, extended through Public Law 93-282, mandates needs assessment in the area of alcoholism (Paredes, 1976; Warheit, Bell, and Schwab, 1979).

Need may be interpreted in different ways. Or, perhaps more accu- rately stated, there are many dimensions of need. Need is often indicated by the total number of community residents who have significant impairment attributable to the excessive use of alcohol. Strictly speaking, need should be distinguished from demand for services, which, as we will see later, is affected by factors other than the proportion of impaired individuals in the population. Demand is generated by the total number of community residents who seek out treatment services within a given period. A number of approaches are available to assess need. These include (1) Key Informant, (2) Community Forums, (3) Rates-Under-Treatment, (4) Social Indicators, and ( 5 ) Field Sur- veys. These approaches can be used independently or as part of an integrated sequential program. The Key Informant approach is a research activity based on information secured from those in an area who are in a position to know the community’s needs. The Community Forum approach relies on individuals asked to assess the needs and service patterns of those in the community. However, in contrast with the Key Informant approach, the Community Forum is designed around a series of public meetings to which all the residents are invited and asked to express their beliefs about the needs and services of the community. The Rates- Under- Treatment approach is based on a descriptive enumeration of those who have used the available alcoholism programs. The Social Indicators approach is based on inferences of need derived from descrip- tive, alcohol-related morbidity statistics found in public records and reports. The Field Survey approach is based on the collection of data from a sample or entire population.

In the assessment of need for alcoholism services, considerable reliance has been placed on data displaying the prevalence of alcoholism, estimated through the use of special formulas. The search for formulas to estimate the prevalence of alcoholism has been in progress for several years. This task would appear to be simplified by the fact that the excessive use of alcohol has negative consequences in many areas. Prevalence of alcoholism is reflected in hospital statistics and in a wide range of related and routinely recorded morbid indicators, such as convictions of drunkenness and other alcohol-related offenses, deaths due to alcohol poisoning, liver cirrhosis, and conditions wholly or partly attributable to the consumption of alcohol. Efforts to find an indirect method of measuring the prevalence of alcoholism go back to 1942, when Jelli-

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nek (1946) developed an early version of what has become known as the Jelli- nek formula. The formula, based on reported deaths due to cirrhosis of the liver, has been the most common estimation method. Methods derived from alcohol sales statistics have been developed following the work of Ledermann (1956). The Ledermann formula estimates the proportion of the population that drinks more than a certain acceptable amount of alcohol per day. Other formulas that estimate prevalence of alcoholism are based on suicide rates, the estimated life span of alcoholics, traffic data, census data, and the properties of the population in treatment. Marden (1972) has developed a method that extrapolates data on problem drinking obtained from national surveys to local communities. The method makes adjustments for local differences in demo- graphic profiles and size of populations. However, these methods lack specific- ity and their value is complicated by the lack of precision of alcoholism defini- tions.

Field surveys have been conducted on national samples of the popula- tion using specially designed interview schedules. A limitation of these studies is that, depending on the criteria used in the number of alcohol-related prob- lems counted by the interview schedules, the estimated rates may vary by a factor of three to four (Clark, 1966). Slight differences in the criteria may pro- duce sizeable differences in the resulting prevalence estimates.

Estimates have numerous sources of error when need is assessed using, as key informants, personnel of agencies handling those with alcohol-related problems. Variations in reports of alcohol-related problems may be a reflec- tion of such local policies as arrest practices of police, availability of mental health clinics and hospitals, and so on.

Differences in the operational definitions of alcoholism or alcohol-related problems would be unimportant if all the measures converged upon a single underlying phenomenon acting as the source of the alcohol-related statistics. However, considerable differences observed among sets of data derived from different estimation methods make interpretations difficult.

The demand for accurate and meaningful Prevalence estimation meth- ods has increased as greater public interest has focused on alcoholism and more funds for the treatment of alcoholism have become available. The most important question remains unanswered, however. How do we determine the number of alcoholics and alcohol abusers in need of service? Indirect estimates have implicitly assumed that alcoholism is equivalent with need for treatment, but many alcohol-related problems seem to improve with the passage of time. Belief in the almost inevitable progression from mild drinking problems to severe ones appears to hold true only for a fraction of the problem drinking population (Cahalan, 1970; Emrick, 1975; Kendell and Staton, 1966; Lemere, 1953). If' alcoholism is not inevitably progressive, the presence of troubles associated with drinking will not necessarily mean there is need for treatment.

Many other factors enter into the determination of need. Need may be

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related to the risk of death tolerated, the level of tolerance for drunken behav- ior, and the sense of urgency resulting from promotional activities by con- cerned groups in the community. Need also could be understood in terms of what planners, experts, or the public view as important for safe and rewarding living. In the absence of objective criteria for the estimation of need for ser- vices, need becomes a sociopolitical phenomenon related to a great extent to the ability of advocates and moral entrepreneurs to create public concern. The risk exists that unreliable indices of alcoholism will be adopted as guides by service providers or other concerned individuals to make the best possible argument for greater funding.

Therapeutic activities may not be directed to those who need alcohol- ism services the most. The sociodemographic profiles of people in the general population affected by serious alcohol-related problems and those of people admitted to the public alcoholism services delivery system are not identical. Clinical studies of alcoholic clients admitted to treatment facilities report a relatively high frequency of middle-aged men showing signs of alcohol addic- tion and those who have a long history of many problems in several areas of their lives. On the other hand, people with serious alcohol problems identified in surveys conducted with representative samples from the general population show a higher prevalence among the age group twenty-one to twenty-four years. The proportion of those in this age range who have a high level of alco- hol-related problems is almost twice as large as in the older groups. The inter- relationships among such alcohol problems as binge drinking, loss of control, symptomatic drinking and problems with friends and neighbors, police or finances, psychological dependence, problems with health, or drinking-con- nected injuries are complex. Problems in one area are not necessarily followed by problems in the others. Conversely, improvement in one area might not be followed by improvement in the other. The relationships among problems in various areas of a person’s life have been observed to be statistically indepen- dent (see the chapter by Jones, Rundell, and Gregory, this volume). It is quite common for people who have a serious drinking problem to have only one problem area. Furthermore, the turnover in this problem area is not unusual with remission of all problems or exchange of one for another over a fairly short time (Cahalan, 1970; Cahalan, Cissin, and Crossley, 1969).

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Alfonso Paredes I S rrgional director f o r the Lns Angeles Couny Central Menta l Heal th Region a n d professor of psychiatry and behavioral sciences at the Universi<y of Southern Cal2foniia Medical School.