How the states stack up: Disparities in substance abuse outpatient treatment completion rates for minorities

Abstract

Background

This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure.

Method

This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets–Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n = 940,058).

Results

States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos.

Conclusions

Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.

Introduction

Successfully completing treatment is a major objective for clients attending substance abuse treatment. Completing treatment is usually a clinical judgment based on attending the full course as well as meeting individualized goals of the treatment program. Successful completion is a known process outcome measure because it predicts longer-term outcomes, e.g., less future criminal involvement and fewer readmissions (Evans et al., 2009, Garnick et al., 2009, Zarkin et al., 2002). Successful termination also predicts employment and income one year after treatment (Arria et al., 2003). As an outcome, successful treatment completion rates also can be used to assess national and state-level systems (Alterman et al., 2001, Garnick et al., 2009, U.S. Department of Health and Human Services, 2012).

There is recent concern that clients from ethnic minority groups are less likely than White clients to complete treatment successfully. Few reports regard macro level (e.g., state) completion rates and their disparity across racial/ethnic groups. Most studies focus on individual or treatment level factors. Thus, the goal of the current study was to assess race/ethnicity disparities in successful completion of ambulatory, non-intensive substance abuse treatment at the level of the state.

One study found that African American men successfully complete treatment less often than White men (4–1), although their lengths of stay were not significantly different (Cooper et al., 2010). Another national report shows an approximately 11 percentage point advantage for non-Hispanic Whites compared to other race and ethnic groups (Substance Abuse and Mental Health Services Administration, 2009). Other studies of race/ethnicity effects have reported more complex patterns. One such finding is that race/ethnicity effects may appear in univariate analyses, but that this client-level factor becomes nonsignificant once controlling for other variables, such as age (Ball et al., 2006).

While race/ethnicity, per se, may not consistently predict treatment completion once other client factors are taken into account (Jacobson et al., 2007), other organizational and treatment factors may play a role in the completion disparities. For example, one nationally representative study found that variables assessing culturally sensitive beliefs in program managers predicted client retention (Guerrero and Andrews, 2011). Furthermore, managers’ sensitivity to cultural issues and agency size (i.e., number of professionals) play a role in the agencies adoption of culturally sensitive treatment efforts (Guerrero, 2010, Guerrero, 2012). Another study found that Black and Latino adolescents reported receiving less informal treatment options (Alegria et al., 2011). Thus, there may be more to learn from looking at race/ethnicity disparities regarding organizational factors, including cultural competencies and clients’ program acceptance. However, some of the conflicting findings may be produced by local phenomena since many studies rely on samples within a state. Such findings may not generalize to other places if states differ markedly in their service delivery system, completion rates, or patterns of treatment completion disparities.

The current study is empirically motivated and exploratory. It assesses whether completion rate disparities vary considerably across states. To address this question, we examined crude rates and disparities of successful completion of ambulatory, non-intensive substance abuse treatment at the level of the state. After finding crude rates and disparities of successful completion to show differences across the states’ delivery systems, we estimated rates adjusted for relevant covariates since demographic (e.g., age, employment) and clinical differences (e.g., primary substance used) might vary between states and influence completion rates.