VHA operates 61 substance abuse residential rehabilitation treatment programs and domicillaries (SARRTPs) with over 1,600 total beds and employed over 800 full-time clinical staff. Demand for SARRTP beds is high. Balancing competing pressures, clinicians and clinical managers must attempt to avoid stays that are either too short, thereby reducing effectiveness and increasing the probability of relapse, or too long, thereby reducing access for waiting patients and unnecessarily increasing costs. One likely reflection of this tension is substantial variability among programs in average length of stay (ALOS), from approximately two weeks to over four months. However, it is unknown if programs with longer average stays treat more symptomatic patients, produce better outcomes, how much more cost is incurred compared to shorter alternatives, or whether there is a threshold LOS beyond which no additional benefit is observable.
We investigated the association of patient and facility-level LOS with self-reported clinical outcomes, examined if patient characteristics (e.g., homelessness, psychiatric severity) moderated the associations of LOS and program-level LOS with outcomes, and explored if observed associations were mediated by treatment received between residential discharge and the follow-up outcome assessment. We also examined the effects of program average LOS on average daily cost, total cost, and staff intensity.
Using pre-existing outcome data from 1,307 patients from 28 programs, we examined if patient and program average LOS were associated with improvement on Addiction Severity Index (ASI) Alcohol and Drug Composite scores in covariate-adjusted, multi-level regression models.
Programs with greater than 90 days average LOS had the least improvement in ASI Alcohol Composite scores and significantly less than 15-30 and 31-45 day programs in fully adjusted, mixed-effects regression models (p values =.04 and =.04, respectively). The l programs with the longest average LOS also had the least improvement in days of alcohol use, days of alcohol intoxication, and days of alcohol problems in the past month, although comparisons reached statistical significance only relative to the 15-30 days programs in days of alcohol problems (p = .03). No significant differences in improvement in ASI Drug Composite scores by average LOS were observed. Improvement in days of drug problems in the past month was lowest, but not significantly so, in the longest programs. Programs with an average LOS >90 days had less intensive staffing (mean staff hours per resident day), and correspondingly lower daily per resident costs, but higher total costs per resident, than programs with shorter average LOS.
These results run counter to the conventional wisdom that longer stays are inherently beneficial and justified. At least from the perspective of substance use disorder symptom reduction, there appears to be no justification for programs with average length of stay greater than 90 days. These results have been presented to and were well-received by operational leadership. They are being used to address programs with excessively long average LOS.
- Chou LB, Chandran S, Harris AH, Tung J, Butler LM. Increased breast cancer prevalence among female orthopedic surgeons. Journal of women's health (2002). 2012 Jun 1; 21(6):683-9.
- Harris AH, Fernandes-Taylor S, Giori N. "Not statistically different" does not necessarily mean "the same": the important but underappreciated distinction between difference and equivalence studies. The Journal of Bone and Joint Surgery. 2012 Mar 7; 94(5):e29.
- Harris AH, Kivlahan D, Barnett PG, Finney JW. Longer length of stay is not associated with better outcomes in VHA's substance abuse residential rehabilitation treatment programs. The journal of behavioral health services & research. 2012 Jan 1; 39(1):68-79.
- Finney JW, Humphreys K, Harris AH. Cross-level bias and variations in care. [Letter to the Editor]. JAMA : the journal of the American Medical Association. 2011 Nov 16; 306(19):2096-7; author reply 2097.
- Harris AH, Kivlahan DR, Barnett PG, Finney JW. Is Longer Duration of Treatment Associated with Better Outcomes in VHA's Substance Abuse Residential Rehabilitation Treatment Programs? Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.
- Harris AH, Kivlahan D, Barnett PG, Finney JW. Do Substance Abuse Residential Rehabilitation Treatment Programs with Longer Average Lengths of Stay Have Better Outcomes? Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR.