“SEVERE MENTAL ILLNESS &
CONGESTIVE HEART FAILURE OUTCOMES
AMONG VETERANS”
by
Jim Banta
UCLA Committee members: Alexander Young,
Gerald Kominksi, William Cunningham
Ronald Andersen, Chair
Special thanks to:
SAMHSA – Dissertation Year Award
Mental Illness, Research, Education and Clinical Center –
West Los Angeles VA Medical Center – Technical Support
Introduction
•Heart failure is leading cause of death among those
greater than 65 years of age.
• Estimated annual US healthcare costs of $40 to
$55 billion.
• 5 to 25% of medical inpatients have a mental
illness.
• Mentally illness often associated with greater
mortality and unfavorable utilization.
Research Questions
1. Is mental illness associated with less primary care?
2. Is mental illness associated with more readmission?
3. Is mental illness associated with more mortality?
METHODS
• Retrospective, cross-sectional design.
• Selected all inpatient veterans in FY 2001 with
congestive heart failure (not just 428.xx).
•VA National Patient Database: Inpatient (PTF) and
outpatient (OPC).
•Index hospitalization – first CHF admit of the FY.
•Utilization one year pre index admission and one
year post index discharge.
METHODS
• Used a Behavioral Model Approach.
• Merged contextual data:
County/State of veteran’s primary residence
VAMC size, academic affiliation, experience
• Medical risk adjustment
Congestive Heart Failure Index
Elixhauser method – 22 of 30 dummy variables
METHODS
•Hierarchical categorizing of mental illness
(ICD-9 CM codes of 292 to 316)
•Dementia
•Severe Mental Illness
•Schizophrenia/PTSD/Bi-Polar
•Depression
•Anxiety
•Other mental illness (excludes substance abuse)
RESULTS
Descriptive statistics
(n=15,685)
No mental illness
Dementia
SMI
Depression
Anxiety
% of
total
subjects
Mean
Age
68%
8%
6%
12%
3%
70
77
63
68
70
Died
during
study
12%
21%
12%
13%
15%
RESULTS
ODDS of Primary Care
No Inpatient
Inpatient
(n=10,861)
(n=4,824)
Dementia
0.8
0.5***
SMI
2.2***
0.9
Depression
2.4***
1.0
Anxiety
4.4***
1.7
* p<0.05, ** p<0.01, *** p<0.001
RESULTS
ODDS of Readmission (within one year)
No utilization
in Model
Utilization in
model
(n=14,760)
(n=14,760)
Dementia
1.1
1.0
SMI
1.1
1.1
Depression
1.2**
1.2**
Anxiety
1.2*
1.2*
* p<0.05, ** p<0.01, *** p<0.001
RESULTS
ODDS of Mortality (adjusting for utilization)
Died in index
hospitalization
Died after
discharge
(n=15,685)
(n=14,760)
Dementia
1.5**
1.5***
SMI
1.3
1.3
Depression
1.0
1.2
Anxiety
0.9
1.5*
* p<0.05, ** p<0.01, *** p<0.001
SUMMARY
Among inpatient veterans with heart failure:
• Veterans with a mental illness are MORE likely
to get primary care (except for those with
dementia).
• Veterans with depression and anxiety are MORE
likely to be readmitted.
• Veterans with dementia are MORE likely to die.
SIGNIFICANCE
• Mental illness plays limited role in heart failure
outcomes within the VA system: suggests that quality
care is being provided to a vulnerable population.
• Greater emphasis on primary care may decrease
mortality among those with dementia.
• Greater monitoring after discharge may reduce
readmission and mortality among those with
depression or anxiety
• Earlier targeting of veterans with severe mental
illness may delay hospitalization for heart failure.