• Andrew R Breton, Deborah A Taira, Eric Burns, James O'Leary, and Richard S Chung.
• APS Healthcare, Honolulu, Hawaii, USA.
• Am J Manag Care. 2007 Sep 1;13(9):497-505.

ObjectiveThe recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED).Study DesignRetrospective claims analysis.MethodsClaims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use.ResultsOf the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% nonpsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0.51) at 14 days compared with patients who had a mental health diagnosis.ConclusionsTraining ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

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