N-SSATS in the Context of the Drug and Alcohol Services Information System (DASIS)
Changes in Survey Content
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 called the National Alcoholism and Drug Abuse Program Inventory was used. 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 it was conducted annually as the Uniform Facility Data Set (UFDS) survey from 1995 to 1998. During these years, the survey was conducted by mail with telephone follow-up of non-respondents. 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). The reference date for the annual survey had always been the end of September or beginning of October. After the 2000 survey, the reference date was changed to the end of March, and no survey was conducted during 2001.
In 2000, the use of an Internet-based questionnaire was tested, and beginning in 2002, all facilities were offered the opportunity to respond via the Internet.
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 admissions to substance abuse treatment. Together, the components 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.
Treatment facilities approved by State substance abuse agencies
The largest group of facilities (about 14,000 in 2008) includes facilities that are licensed, certified, or otherwise approved by the State substance abuse agency to provide substance abuse treatment. State DASIS representatives maintain this segment of I-SATS by reporting new facilities, closures, and address changes to SAMHSA. Some facilities are not licensed, certified, or otherwise approved by the State agency. 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.
Treatment facilities not approved by State substance abuse agencies
This group of facilities (about 4,000 in 2008) represents the SAMHSA effort since the mid-1990s to make I-SATS as comprehensive as possible by including treatment facilities that State substance abuse agencies, for a variety of reasons, do not fund, 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 Special efforts to improve survey coverage below.) State substance abuse agencies are given the opportunity to review these facilities and to add them to the State agency-approved list, if appropriate.
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.
Unit of response
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.Special efforts to improve survey coverage
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 subsequent surveys. Potential new facilities are identified using data from the American Business Index, the annual American Hospital Association survey, and SAMHSA’s biannual Inventory of Mental Health Organizations, the source lists that yielded the most new facilities in 1995 and 1996. Survey participants, who are asked to report all of the treatment facilities in their administrative networks, also identify additional facilities during the survey itself. 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.
Expansion of survey coverage to include all sites within networks at which treatment was provided yielded a net increase of about 2,600 facilities between 1997 and 1998. These additions were not necessarily new facilities, but were facilities not previously included in the survey as separate sites. The number of facilities reporting continued to increase in 1999, but at a slower pace, a net increase of 1,800 facilities. The increase between 1998 and 1999 was in large part because of the improved survey response rate (95 percent in 1999 vs. 90 percent in 1998). Between 2004 and 2008, the number of facilities remained constant, at between 13,400 and 13,800. The total number is deceptive, however. There was significant turnover as facilities closed and others opened. (See Table 2.1.)
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 non-responding facilities. A representative sample of non-respondents was contacted and administered an abbreviated version of the survey instrument via telephone. In 1993 and later years, this effort was extended to all non-responding 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. Between 2004 and 2008, use of these methods and intensive telephone follow-up resulted in an annual follow-up rate (i.e., facilities in the sample either completed the survey or were determined to be closed or otherwise ineligible) of 94 to 96 percent. In 2008, the follow-up rate was 94.7 percent.
In 1997, facilities offering only DUI/DWI programs were excluded; these facilities were reinstated in 1998.
Facilities operated by the Bureau of Prisons (BOP) were excluded from the 1997 UFDS survey and subsequent surveys because SAMHSA conducted a separate survey of correctional facilities.1 During that survey, it was discovered that jails, prisons, and other organizations treating incarcerated persons only were poorly enumerated on I-SATS. Beginning in 1999, these facilities were identified during the survey and excluded from analyses and public-use data files.
I-SATS and N-SSATS are designed to include specialty substance abuse treatment facilities rather than individuals. Solo practitioners are listed on I-SATS and surveyed in N-SSATS only if the State substance abuse agency explicitly requests that they be included.
Beginning in 2000, halfway houses that did not provide substance abuse treatment were included on I-SATS and in N-SSATS so that they could be listed in the National Directory of Drug and Alcohol Abuse Treatment Programs and on the Treatment Facility Locator (http://findtreatment.samhsa.gov). These facilities are excluded from analyses and public-use data files.
Table A.1 shows the major content areas for the survey from 1995 to 2008. Since 1992, SAMHSA has made adjustments each year to the survey design, both to minimize non-response and to include areas of emerging interest. For example, questions on the number of clients in treatment receiving buprenorphine were added in 2004. Questions about clinical/therapeutic methods, standard practices, and Access to Recovery grants were added in 2007.
There have also been changes within content areas. For example, in response to concerns about over-reporting of programs or groups for specific client types, the survey question was revised in 2003 to distinguish between those facilities that accepted specific client types and those facilities that offered specially designed programs or groups for that client type. As a result, the number and proportion of facilities offering programs or groups for each of the specified client types decreased after 2002. Surveys from 2003 and later are believed to more accurately represent the number and proportions of facilities providing programs or groups for the specified client types.