Determining service variations between and within ASAM levels of care.

The American Society of Addiction Medicine (ASAM) Criteria Validity Study at Massachusetts General Hospital and Harvard Medical School randomized patients between programs in two levels of care. It therefore became critical to determine the extent to which programs met ASAM level of care (LOC) descriptions. Quantitative surveys (checklist) and qualitative case studies (field observation, key informant interviews) documented care variation within and between two ASAM LOCs in 12 substance abuse treatment units. These LOCs were: Level II (Intensive Outpatient Treatment) and Level III (Medically Monitored Residential Treatment). The Level II and Level III programs, as a group, met ASAM LOC criteria, but data showed major within-level variation by hours per day and number and type of skilled treatment services. Observational data suggest considerable within-level variation due to managed care and staff training. In multi-site PPC validity studies, it will be crucial to examine within-LOC variation and take into account payment sources and staff training when assessing patient outcomes.