The Tradeoff between Access to Community
Treatment and Acute Hospitalizations of the
Severely Mentally Ill
Presented by:
Richard C. Lindrooth, Ph.D.
University of Colorado at Denver
Co-authors:
Anouk L. Grubaugh, Ph.D., MUSC
Walter Jones, Ph. D, MUSC
Anthony Lo Sasso, Ph. D., University of Illinois, Chicago
B. Christopher Frueh, Ph. D., University of Hawaii at Hilo
Research support:
2 RO1 HS010730-04 (AHRQ)
R01 MH074151-01 A2 (NIMH)
K24-MH074468 (NIMH PI: Frueh)
Primary Research Questions
• To what extent are emergency psychiatric admissions
to acute care hospitals related to supply of:
• State and Acute Beds?
• Community alternatives?
• To what extent are these admissions preventable?
120
125
Figure 1. Per Capita General Hospital ED Admissions, Selected Diagnoses
105
1997=100
110
115
• Utilization increased over time, especially by the
severely ill.
• Why has there been an increase?
• Does access to community care explain regional
variation in emergency psychiatric admissions?
100
• What is the role of acute inpatient care?
1996•
Are acute
a safety valve
1998 care beds
2000
2002 for community
2004
Calendar Year
care?
Psychotic Disorders
Dementia
Source: HCUP-SID in AZ, CO, FL, NJ, NY, WA, & WI, 1997-2005
Mood Disorders
2006
Explanations for the Increase
• Increased prevalence of SMI in community
• Closure of State Long-term Beds
• Decreased access to community alternatives
• Supply not keeping up with demand
• Increased incidence
• Unobserved trends
Figure 1. Trends in State Hospital Beds, 1998-2005
CO
FL
NJ
NY
WA
-600 -200
-800 -400 0
1995
2000
WI
-600 -200
-800 -400 0
Change since 1997
-600 -200
-800 -400 0
AZ
1995
2000
2005
Source: American Hospital Association and Medicare Cost Reports
Year
2005 1995
2000
2005
Data
•
AZ, CO, FL, NJ, NY, WA, & WI HCUP-SID 97-05
• Patients admitted through ED with primary dx:
•
•
Comparison Admissions:
•
•
•
Psychotic disorders
Mood disorders
Delirium, dementia, and amnestic and other cognitive
disorders
Sample includes all admissions from ED to acute
care hospitals.
The Supply of Health Care Providers
Measured spatially based on the patient’s zip code
Limit sample to patients less than 45 minutes from ED
•
Indicate whether the closest ED has a:
•
Partial Hospitalization Unit or
•
Psychiatric Emergency Services
•
Measure the Health Service Area (HSA) supply of:
•
hospital outpatient,
•
freestanding outpatient
•
freestanding MHSA Residential
Source: AHA Annual Survey (cleaned and smoothed) and Census
of Economic Activity
•
•
Methods
• Multivariate Regression
• Zip code fixed effects
• Sample Year 1997-2005
• T =State bed per capita(1997)-State bed per
capita(Time=t)
• Adjust for heteroskedastic smearing and clustering by
zip-code
• Unit of analysis: Zip-code by year
• Dependent Variable: Log per capita ED Admissions
•
d
d
zip zt = β Market zt + τ t + βT Market zt * Tst + Tst + γ z + ε zt
% Change in ED Admissions related to
observed bed closures: Public Payer
AZ
CO*
FL*
NJ
NY*
WA*
WI
Schizophrenia
5%
30%
50%
3%
20%
18%
8%
Mood
3%
17%
33%
3%
14%
14%
5%
Dementia
ns
ns
ns
ns
ns
ns
ns
*State closed significant beds between 1998-2001
Magnitude of the effect
• Public Schizophrenia: 5.27 admissions per state bed
(p<0.01)
• Public Mood: 5.31 admissions per state bed (p<0.01)
• About 11 admissions per bed closed.
• No significant effect for private payors..
Explanations for the Increase
• Increased prevalence of SMI in community
• Closure of State Long-term Beds
• Decreased access to community alternatives
• Increased incidence
• Unobserved trends
Figure 2. Access to Psych EM and Partial Hosp, 1997-2005
CO
FL
NJ
NY
WA
0 .2 .4 .6 .8
1995
2000
2005 1995
WI
0 .2 .4 .6 .8
% Population
0 .2 .4 .6 .8
AZ
Closest has nothing
Closest has PH or EM
Closest is Specialty
1995
2000
2005
Source: HCUP-SID & AHA Annual Survey 1997-2005
Calendar Year
2000
2005
% Change in ED Admissions with complete
Access to Psychiatric Emergency Services
• Public Payer, Schizophrenia
•
•
•
•
CO: -18%
FL: -16%
NY: -18%
WA: -14%
• Public Payer, Mood
•
•
•
•
CO: -27%
FL: -24%
NY: -26%
WA: -20%
• Public Payer, Dementia: Not significant
Effect of Access to Partial Hosp. Services
on ED Admissions
• Public Payers– Schizophrenia and Mood
Disorders:
• Offsetting effect if psychiatric emergency services exist
• Private Payers-- Schizophrenia
• Incremental reduction in admissions
• Large than for psychiatric emergency services
• Not significant for Dementia
Access to other services
• Hospital-based psychiatric outpatient
• Reduced admissions but not significant
• Community-based psychiatric outpatient
• About 1-3 % increase w/ state bed closure (0.5 bed)
• Community-based psychiatric residential
• Public schizophrenia and mood disorder patients:
• About 1-3 % decrease w/ state bed closure (0.5 bed)
• Not significant for private patients
Results and Conclusions
• Psychiatric emergency consistently reduce admissions
through the ED
• About 50% of the increase in admissions in the wake of a
state bed closure could be prevented
• Access to residential treatment facilities also
consistently reduces public admissions through ED.
• Access to state beds plays a large role
• No effect of acute bed capacity for public patients