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This study aimed to quantify the extent of outcome variability in the <jats:styled-content style=\"fixed-case\">E<\/jats:styled-content>nglish <jats:styled-content style=\"fixed-case\">SUD<\/jats:styled-content> treatment system after adjusting for potential confounding variables.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Prospective cohort study using data from the <jats:styled-content style=\"fixed-case\">E<\/jats:styled-content>nglish national drug treatment outcome monitoring database.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>All 149 administrative areas delivering publicly funded <jats:styled-content style=\"fixed-case\">SUD<\/jats:styled-content> services in the <jats:styled-content style=\"fixed-case\">N<\/jats:styled-content>ational <jats:styled-content style=\"fixed-case\">H<\/jats:styled-content>ealth <jats:styled-content style=\"fixed-case\">S<\/jats:styled-content>ervice and non\u2010governmental sector.<\/jats:p><\/jats:sec><jats:sec><jats:title>Participants<\/jats:title><jats:p>New adult admissions between <jats:styled-content style=\"fixed-case\">J<\/jats:styled-content>anuary 2008 and <jats:styled-content style=\"fixed-case\">O<\/jats:styled-content>ctober 2010 with illicit heroin\u2010related problems in all administrative areas, with an in\u2010treatment review conducted between 5 and 26 weeks (mean\u2009=\u2009129.5 days; <jats:styled-content style=\"fixed-case\">SD<\/jats:styled-content>\u2009=\u200940.0) up to 30 <jats:styled-content style=\"fixed-case\">A<\/jats:styled-content>pril 2011 (<jats:italic>n<\/jats:italic>\u2009=\u200965\u2009223; 75.6% of eligible clients). Individuals were divided randomly to form model developmental and internal validation samples. These were contrasted with an independent (external) sample of the same population admitted to treatment between <jats:styled-content style=\"fixed-case\">N<\/jats:styled-content>ovember 2010 and <jats:styled-content style=\"fixed-case\">A<\/jats:styled-content>pril 2011 and followed to 31 <jats:styled-content style=\"fixed-case\">O<\/jats:styled-content>ctober 2011 (<jats:italic>n<\/jats:italic>\u2009=\u200913\u2009797; 81.4% of those eligible).<\/jats:p><\/jats:sec><jats:sec><jats:title>Measurements and analysis<\/jats:title><jats:p>The outcome measure was self\u2010reported illicit heroin use, categorized as abstinent or deteriorated (the latter by Reliable Change Index), each risk\u2010adjusted by person\u2010level (demographics, clinical severity and treatment complexity) and area\u2010level (<jats:styled-content style=\"fixed-case\">SUD<\/jats:styled-content> prevalence, social deprivation and severity averages) covariates by multivariable logistic regression using multiply imputed outcome and covariate data. Risk\u2010adjusted models were assessed by information criteria and discrimination (c\u2010index). Standardized outcome rates were compared by funnel plot with 95% and 99% control limits.<\/jats:p><\/jats:sec><jats:sec><jats:title>Findings<\/jats:title><jats:p>Models of heroin abstinence (48.4%) and deterioration (3.2%) were comparable across the developmental and validation samples (c\u2010index\u2009=\u20090.70\u20130.71 and 0.82\u20130.87), with 79.2 and 94.0%, respectively, of the 149 treatment areas falling within 95% control limits. At the 99% limit, seven areas (4.7%) achieved abstinence rates above the national average, and eight had relatively poor abstinence rates (5.4%). At the 99% control limit, one area achieved very low deterioration outcomes and two (1.3%) were worse that the average. Risk adjustment served to increase abstinence rates in good performing areas by 0.63% and reduce abstinence rates by 0.37% in poor performing areas, and by 0.12% and 0.18%, respectively, for deterioration.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>There is some exceptional variability in the apparent effectiveness of the English treatment system for substance use disorders. It is important to determine the source of this variability in order to inform drug treatment delivery and its evaluation both in England and overseas.<\/jats:p><\/jats:sec>","DOI":"10.1111\/j.1360-0443.2012.03971.x","type":"journal-article","created":{"date-parts":[[2012,6,12]],"date-time":"2012-06-12T07:38:09Z","timestamp":1339486689000},"page":"2161-2172","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":27,"title":["Risk adjustment of heroin treatment outcomes for comparative performance assessment in <scp>E<\/scp>ngland"],"prefix":"10.1111","volume":"107","author":[{"given":"John","family":"Marsden","sequence":"first","affiliation":[{"name":"King's College London Addictions Department Institute of Psychiatry  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian","family":"Eastwood","sequence":"additional","affiliation":[{"name":"National Treatment Agency for Substance Misuse  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hayley","family":"Jones","sequence":"additional","affiliation":[{"name":"School of Social &amp; Community Medicine University of Bristol  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin","family":"Bradbury","sequence":"additional","affiliation":[{"name":"National Treatment Agency for Substance Misuse  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Hickman","sequence":"additional","affiliation":[{"name":"School of Social &amp; Community Medicine University of Bristol  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Knight","sequence":"additional","affiliation":[{"name":"National Treatment Agency for Substance Misuse  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kulvir","family":"Randhawa","sequence":"additional","affiliation":[{"name":"National Treatment Agency for Substance Misuse  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"White","sequence":"additional","affiliation":[{"name":"National Treatment Agency for Substance Misuse  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"the National Drug Treatment Monitoring System Outcomes Study Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2012,8,10]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1360-0443.2011.03464.x"},{"key":"e_1_2_8_3_1","first-page":"631","article-title":"Performance contracting for substance abuse treatment","volume":"32","author":"Commons C.","year":"1997","journal-title":"Health Serv Res"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1136\/jamia.1995.96010393"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1037\/0022-006X.65.4.673"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1037\/0022-006X.62.6.1141"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1081\/ADA-120001281"},{"key":"e_1_2_8_8_1","first-page":"791","article-title":"Psychiatric comorbidity measures as predictors of retention in drug abuse treatment programs","volume":"34","author":"Broome K. 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