Chapter 1 N-SSATS

This report presents tabular information and highlights from the 2000 National Survey of Substance Abuse Treatment Services (N-SSATS), conducted between October 2000 and April 2001, with a reference date of October 1, 2000. It is the 24th in a series of national surveys designed to collect data on the location, characteristics, and use of alcohol and drug abuse treatment facilities and services throughout the 50 States, the District of Columbia, and other U.S. jurisdictions.¹ The Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, plans and directs N-SSATS.

N-SSATS is designed to collect information from all facilities² in the United States, both public and private, that provide substance abuse treatment.

N-SSATS provides the mechanism for quantifying the dynamic character and composition of the U.S. substance abuse treatment delivery system. The objectives of N-SSATS are to collect multipurpose data that can be used to—

Survey History

N-SSATS has evolved from national survey efforts begun in the 1970s by the National Institute on Drug Abuse (NIDA) to measure the scope and use of drug abuse treatment services in the United States. The sixth of these surveys, conducted in 1976, introduced the data elements and format that have formed the core of subsequent surveys. These include organizational focus, service orientation, services available, clients in treatment by type of care, and inpatient/residential capacity. The 1976 survey, called the National Drug Abuse Treatment Utilization Survey, was repeated in 1977 and 1978. In 1979, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) became a cosponsor of the survey, alcoholism treatment facilities were added, and the study was renamed the National Drug and Alcoholism Treatment Utilization Survey. This survey was repeated in 1980 and 1982. In 1984, a one-page version was used (the National Alcoholism and Drug Abuse Program Inventory). In 1987, the full version of the survey was reinstated and renamed the National Drug and Alcoholism Treatment Unit Survey (NDATUS). NDATUS was conducted annually from 1989 to 1993. In 1992, with the creation of SAMHSA, responsibility for conducting the survey shifted to SAMHSA’s Office of Applied Studies. The survey was redesigned, and conducted annually as the Uniform Facility Data Set survey from 1995 to 1998. During these years, the survey was conducted by mail with telephone follow-up of nonrespondents. The 1999 survey year was a transition year during which the survey was redesigned, and an abbreviated telephone survey of treatment facilities was conducted. In 2000, a redesigned full mail survey was reinstated with telephone follow-up; it was renamed the National Survey of Substance Abuse Treatment Services (N-SSATS).

N-SSATS in the Context of the Drug and Alcohol Services Information System (DASIS)

N-SSATS is one of the three components of SAMHSA’s Drug and Alcohol Services Information System (DASIS). The core of DASIS is the Inventory of Substance Abuse Treatment Services (I-SATS), a continuously-updated, comprehensive listing of all known substance abuse treatment facilities. The other components of DASIS are N-SSATS and the Treatment Episode Data Set (TEDS), a client-level database of persons admitted to substance abuse treatment. A unique ID number assigned to each facility by I-SATS is used in the collection of facility-level data (N-SSATS) and client-level data (TEDS) so that the three data sets can be linked. Together, they provide national- and State-level information on the numbers and characteristics of individuals admitted to alcohol and drug treatment programs and describe the facilities that deliver care to those individuals.

I-SATS is the list frame for N-SSATS. Facilities in I-SATS fall into two general categories and are distinguished by the relationship of the facility to its State substance abuse agency. These categories are described below.

The largest group of facilities (about 11,400 in 2000) includes facilities that are licensed, certified, or otherwise approved by the State substance abuse agency to provide substance abuse treatment. The majority of these facilities are required by the State agency to provide TEDS client-level data. State DASIS representatives maintain this segment of I-SATS by reporting new facilities, closures, and address changes to SAMHSA. Some facilities are not required by the State agency to provide TEDS client-level data. Some private for-profit facilities fall into this category. This group also includes programs operated by Federal agencies, the Department of Veterans Affairs (VA), the Department of Defense, and the Indian Health Service. I-SATS records for Federally-operated facilities are updated annually through lists provided by these agencies.

This group of facilities (about 2,100 in 2000) represents the SAMHSA effort in recent years to make I-SATS as comprehensive as possible by including treatment facilities that State substance abuse agencies, for a variety of reasons, do not license or certify. Many of these facilities are private for-profit, small group practices, or hospital-based programs. Most of them are identified through periodic screening of alternative source databases (see Expansion of survey coverage). State substance abuse agencies are given the opportunity to review these facilities and to add them to the State agency-approved list, if appropriate.

Survey Coverage

The use of I-SATS as the list frame for N-SSATS imposes certain constraints related to the unit of response and the scope of facilities included. In addition, the expansion of I-SATS in recent years to provide a more complete enumeration of substance abuse treatment facilities means that year-to-year comparisons of the numbers of facilities reporting to N-SSATS must be interpreted with caution.

Figure 1 is a time line detailing the major changes in survey scope and administration that may have affected the numbers of reporting facilities and clients. Beginning in 1992, SAMHSA introduced expanded efforts to obtain information from nonresponding facilities. This resulted in a 25 percent increase in the number of facilities and a 16 percent increase in the number of clients between 1991 and 1992. Beginning in 1995, changes in data collection methods enabled more complete identification of duplicate reporting by networks of facilities, causing a slight reduction in the total number of facilities. In subsequent years, the number of facilities again increased, as efforts were made (detailed below) to expand the survey coverage and to include all sites at which treatment was provided.

N-SSATS is designed to collect data from each physical location where treatment services are provided. Accordingly, SAMHSA requests that State substance abuse agencies use the point of delivery of service (i.e., physical location) as the defining factor for a facility. It also requests that facilities be included in I-SATS, N-SSATS, and TEDS at the same administrative level so that record linkage among the three data sets is valid. Because of the different State administrative systems, however, there are some inconsistencies in implementation. For example, in some States, multiple treatment programs (e.g., detoxification, residential, and outpatient) at the same address and under the same management have separate State licenses. These are treated as separate by the State substance abuse agency, and are given separate I-SATS ID numbers. In other States, multiple sites are included as a single entity under a parent or administrative unit. In many of these cases, individual sites can report services data in N-SSATS, but client data are available only at a higher administrative level. Beginning in 1995, efforts have been made to identify facility networks and to eliminate duplicate reporting by networks. For most facilities, reporting level remains consistent from year to year. However, beginning in 1998, an emphasis was placed on collecting minimum information from all physical locations, and this has resulted in an increase in the number of facilities.

The great majority of treatment facilities in I-SATS are administratively monitored by State substance abuse agencies. Therefore, the scope of facilities included in I-SATS is affected by differences in State systems of licensure, certification, accreditation, and the disbursement of public funds. For example, some State substance abuse agencies regulate private facilities and individual practitioners while others do not. In some States, hospital-based substance abuse treatment facilities are not licensed through the State substance abuse agency.

To address these differences, SAMHSA conducted a large-scale effort during 1995 and 1996 to identify substance abuse treatment facilities that, for a variety of reasons, were not on I-SATS. Some 15 source lists were considered, and facilities not on I-SATS were contacted to ascertain whether they provided substance abuse treatment. As expected, this yielded a number of hospital-based and small private facilities that were not on I-SATS. (These facilities were surveyed in 1995 and 1996, but they were not included in the published results of the survey until 1997.) Analysis of the results of this effort led to similar but more targeted updates before the 1998 and 1999 UFDS. Potential new facilities were identified using data from the American Business Index, the annual American Hospital Association survey, and SAMHSA’s Inventory of Mental Health Organizations, which were the three source lists from 1995 to 1996 that had yielded the most new facilities. Additional facilities are also identified during the survey itself by survey participants, who are asked to report all of the treatment facilities in their administrative networks. All newly identified facilities are initially included as not approved by the State substance abuse agency. State substance abuse agencies are given the opportunity to review these facilities and to add them to the State agency-approved list, if appropriate.

Until 1996, State substance abuse agencies distributed and collected the UFDS survey forms. Beginning in 1996, data collection was centralized; since that time, SAMHSA has mailed facility survey forms directly to and collected forms directly from the facilities, and has conducted follow-up telephone interviews with the facility director or his/her designee.

Beginning in 1992, SAMHSA expanded efforts to obtain information from nonresponding facilities. A representative sample of nonrespondents was contacted and administered an abbreviated version of the survey instrument via telephone. In 1993 and later years, this effort was extended to all nonresponding facilities. In 1997, a series of measures was introduced to enhance the survey response rate. These included advance notification and improved methods for updating address and contact information. In 2000, use of these methods and intensive telephone follow-up resulted in a nonresponse rate of only 6 percent. For 94 percent of facilities in the sample, it was possible either to complete the survey or to determine that the facilities had closed or were otherwise ineligible.

Facilities operated by the Bureau of Prisons (BOP) were excluded from the 1997 UFDS survey and subsequent suveys because SAMHSA introduced a separate survey of correctional facilities.³ In 1997, facilities offering only DUI/DWI programs were excluded (these facilities were reinstated in 1998 if they provided treatment). In 1999 and 2000, facilities treating incarcerated persons only were identified and excluded.

Changes in Survey Content

Table 1.1 Since 1992, SAMHSA has made adjustments each year to the survey design, both to minimize nonresponse and to include areas of emerging interest such as the role of managed care.

Table 1.1 shows the major content areas for the UFDS survey and N-SSATS from 1995 to 2000.

Data Collection Procedures for the 2000 N-SSATS

The field period for the 2000 N-SSATS ran from October 2000 through April 2001, with a reference date of October 1, 2000. Follow-up calls to nonresponding facilities and for correction of missing and erroneous data continued through June 2001.

The 2000 survey was sent to all active facilities that were on I-SATS as of about six weeks before the survey reference date (October 1, 2000). These facilities were contacted by mail. Facilities added by State substance abuse agencies or discovered during the survey prior to the second mailing were also included in the survey.

Table 1.1
Survey contents: UFDS - N-SSATS 1995-2000

	UFDS - N-SSATS survey year
Survey contents	1995	1996	1997-1998	1999	2000
Ownership	X	X	X	X	X
Services offered	X	X	X	X	X
Organizational setting	X	X	X	X
Primary focus				X	X
Type of treatment provided	X	X	X	X	X
No. of clients by age, sex, and race/ethnicity	X	X	X
No. of clients (total and under age 18)	X	X	X		X
No. of beds	X	X	X		X
Types of payment accepted	X			X	X
Special programs offered	X		X	X	X
Licensure/certification of staff	X			X
Licensure/certification of facility	X			X	X
Sources and amounts of revenue	X	X	X
Managed care agreements	X	X	X	X	X

The 2000 N-SSATS survey instrument was a 9-page document with 32 numbered questions (see Appendix A). Topics included:

Prior to the survey, faxes or letters were sent to all facilities to alert them to expect the survey. A secondary benefit of the letters was to update records with new address information returned from the post office. Data collection packets, including the questionnaire, SAMHSA cover letter, State-specific letters of endorsement and other enclosures, were mailed to each facility. During the data collection phase, contract personnel were available to answer facilities’ questions concerning the survey. Four to five weeks after the initial mailing, thank you/reminder letters were sent to all facilities. Approximately eight weeks after the initial mailing, nonresponding facilities were sent a second mailing. About four to five weeks after the second mailing, nonrespondents received a reminder telephone call. Those facilities that had not responded within two to three weeks of the reminder call were telephoned and asked to complete the survey by telephone.

Summary response rate information is presented in Table 1.2. Questionnaires were mailed to a total of 17,341 facilities believed to offer substance abuse treatment services. Of these facilities, 15.7 percent were found to be ineligible for the survey because they had closed, were not providing substance abuse treatment on October 1, 2000, or treated incarcerated clients only. Of the remaining 14,622 facilities, 94 percent completed the survey. Seventy-six percent of respondents completed the mail survey, 23 percent completed the survey via telephone, and 1 percent completed the survey using an experimental web-based questionnaire on the Internet. Either no response of any kind or a refusal was received from 6 percent of facilities presumed to be eligible for the survey.

	Number	Percent
Total Facilities in Survey	17,341	100.0
Closed/ineligible	2,719	15.7
Eligible	14,622	84.3
Total Eligible	14,622	100.0
Respondents	13,749¹	94.0
Nonrespondents	873	6.0
Mode of Responses	13,428	100.0
Mail	10,230	76.2
Telephone	3,048	22.7
Internet	150	1.1

¹Includes 321 facilities for which client counts were reported by another facility, but no reponse was received from the facility itself.

There were a total of 13,749 respondents to the 2000 N-SSATS. The breakdown of these responses with respect to reporting of facility data and client counts is presented in Table 1.3 and are distributed as follows:

Table 1.3
Total survey respondents: N-SSATS 2000

Type of data reported	Number of facilities reporting data	Number of facilities for which facility charateristics reported	Number of facilities for which client counts reported
Total	13,749	13,428	13,649
Facility and client counts for responding facility only	11,808	11,808	11,808*
Facility characteristics for responding facility only; client counts for other facilities as well	590	590	1,841
Facility charactersitics only(client counts reported by another facility)	930	930	0
Facility characteristics only (client counts anticipated from another facility)	100	100	0
No facility characteristics; client counts reported by another facility	321	0	0

All mail questionnaires were reviewed for inconsistencies and missing data. Calls were made to facilities to obtain missing data and to clarify questionable responses. After data entry, automated quality assurance reviews were conducted. These incorporated the rules used in manual editing, plus consistency checks not readily implemented by manual review. As a final check, the data were returned to the State substance abuse agencies for their review. State corrections received through January 2002 were incorporated into the database.

If facilities could not be reached during the edit callbacks, responses that were clearly in error were deleted and imputed.

Careful editing and extensive follow-up have greatly reduced item nonresponse (see Appendix Table 1). There are instances of nonresponse in most data items, however, and some variables have an explicit Unknown response option. Missing data for client count variables (e.g., the number of clients in hospital inpatient, non-hospital residential, and outpatient treatment) were imputed.

For the remaining unimputed variables, facilities with missing values for a given variable are excluded from the tabulations using that variable. As a result, the number of treatment facilities on which tables are based may vary somewhat from table to table. The number of facilities actually reporting data is generally included on each table.

Methodology of Imputation of Missing Client Counts

Of the 13,428 eligible facilities that completed the survey, 1,030 facilities responded that their client counts were reported by another facility. Therefore, 12,398 facilities should have provided client figures. Of these facilities, 280 were missing client values of any modality (i.e., hospital inpatient, outpatient, or residential).

When available, 1998 client values were used to impute the missing client counts on the 2000

N-SSATS. Of the 280 facilities with missing client data, a total of 120 facilities had 1998 client figures.

For 154 of the remaining 160 facilities, the average client value stratified by State and type of ownership was used to impute the missing client counts. Client counts were imputed for each type of service (i.e., hospital inpatient detoxification, hospital inpatient rehabilitation, residential detoxification, etc.), as opposed to imputing total hospital inpatient, residential, and outpatient clients. Facilities were given imputed values for a given service if it reported that it provided such services but provided no client counts of any type. For example, a facility that reported that it provided hospital inpatient services and outpatient services was given client values for the hospital inpatient and outpatient variables. If that same facility reported that it did not provide residential services, then it was not given residential client values. The count of clients under age 18 were imputed using the percentage of clients under age 18 of each modality stratified by State and ownership. Methadone/LAAM figures were imputed using a percentage method similar to that used to impute number of clients under age 18.

Six facilities were unique in that each facility was the only facility in a state to posses a certain ownership value. These facilities were imputed using average values stratified by State only; ownership was not used.

Further Data Considerations and Limitations

As with any data collection effort, certain procedural considerations and data limitations must be taken into account when interpreting data from the 2000 N-SSATS. Some of these are outlined above. Other general issues are discussed here; considerations and limitations of specific data items are discussed where the data are presented.

Organization of the Report

The balance of this report is organized into four analytic sections. Chapter 2 presents broad trends in facility characteristics for 1996 to 2000. Chapter 3 describes key characteristics of facilities and the services they provide. Chapter 4 describes key characteristics of clients in substance abuse treatment on the reference date. Finally, Chapter 5 presents State-level detail of many of the tables presented in Chapters 3 and 4.

This report will focus on the 13,428 facilities that completed the survey. Because some of these facilities reported client counts for affiliated facilities that did not respond to the survey, the client counts in Chapters 4 and 5 actually include client data for 13,649 facilities.

Terminology

The majority of tables in the report are organized according to facility ownership and the primary focus of the facility and present data on the characteristics of facilities and clients in treatment at these facilities. Therefore, it is important to define these terms.

Ownership indicates the type of entity owning or responsible for the operation of the facility: private for-profit, private non-profit, or government (Federal, State, local, or tribal).

Primary focus indicates the type of services the facility primarily focuses on: substance abuse treatment services, mental health services, general health care, both substance abuse and mental health services, and other.

Clients in treatment are defined as: 1) hospital inpatient and residential clients receiving treatment (and not discharged) on the reference date, and 2) outpatient clients enrolled on the reference date who received a substance abuse treatment service during the prior month.

Chapter 1.
Description of the National Survey of Substance Abuse Treatment Services (N-SSATS)

Survey History

N-SSATS in the Context of the Drug and Alcohol Services Information System (DASIS)

Survey Coverage

Changes in Survey Content

Data Collection Procedures for the 2000 N-SSATS

Table 1.1
Survey contents: UFDS - N-SSATS 1995-2000

Table 1.3
Total survey respondents: N-SSATS 2000

Methodology of Imputation of Missing Client Counts

Further Data Considerations and Limitations

Organization of the Report

Terminology

Endnotes

Chapter 1. Description of the National Survey of Substance Abuse Treatment Services (N-SSATS)

Table 1.1 Survey contents: UFDS - N-SSATS 1995-2000

Table 1.3 Total survey respondents: N-SSATS 2000

Chapter 1.
Description of the National Survey of Substance Abuse Treatment Services (N-SSATS)

Table 1.1
Survey contents: UFDS - N-SSATS 1995-2000

Table 1.3
Total survey respondents: N-SSATS 2000