Association Between Quality Measures and Mortality in Individuals with Co-Occurring Mental Health and Substance Use Disorders

Published in: Journal of Substance Abuse Treatment, 2016

by Katherine E. Watkins, Susan M. Paddock, Teresa J. Hudson, Songthip Ounpraseuth, Amy M. Schrader, Kimberly A. Hepner, Greer Sullivan

Read More

Access further information on this document at Journal of Substance Abuse Treatment

This article was published outside of RAND. The full text of the article can be found at the link above.

Research Question

  1. Are process-based quality measures associated with decreases in one- and two-year mortality among persons with co-occurring mental illness and substance abuse disorders?


Individuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. The relationship between measures of treatment quality and mortality for these individuals is unknown.


To examine the association between 5 quality measures and 12- and 24-month mortality.

Design, Setting and Participants

Retrospective cohort study of patients with co-occurring mental illness (schizophrenia, bipolar disorder, post-traumatic stress disorder and major depression) and substance use disorders who received care for these disorders paid for by the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.

Main Outcomes Measure

Mortality 12 and 24 months after the end of the observation period.


All measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant.

Conclusions and Relevance

This is the first study to show an association between process-based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures. By devising strategies to improve performance on these measures, health care systems may be able to decrease the mortality of this vulnerable population.

Key Findings

  • Five quality of care measures—treatment initiation, treatment engagement, quarterly provider visits, and receipt of psychosocial or psychotherapy treatment—were used with data from over 140,000 Veterans Administration patients to determine associations with mortality at one and two years.
  • The measures showed strong association between more service utilization and decreased mortality, suggesting that interventions to increase service utilization may decrease mortality in this population.
  • The two-part quality measure endorsed by the National Quality Forum and the HEDIS (National Committee for Quality Assurance) may be valid for a population of co-occurring disorders.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.