Do Reductions in VA Psychiatric
Services Lead to Increased Private
Hospital ED Utilization?
Presented by:
Anouk L. Grubaugh, Ph.D., MUSC
Ralph H. Johnson VAMC, Charleston, SC &
Medical University of South Carolina, Charleston, SC
Co-authors:
Richard C. Lindrooth, Ph.D, MUSC.
University of Colorado, Denver, CO.
Research support:
2 RO1 HS010730-04 (AHRQ PI: Lindrooth)
R01 MH074151-01 A2 (NIMH PI: Lindrooth)
Introduction
• Like private and other public-sector mental healthcare systems,
the VHA has dramatically decreased its number of inpatient
psychiatric beds in the past two decades
• There are number of studies looking at predictors of dual service
use and veterans’ reliance on non-VA care to supplement their
existing care; and data to suggest the VA serves as a safety net
provider for number of veterans
• There are few data, however, examining the interdependence of
VA and Non-VA mental health systems on one another
Introduction
• Existing studies have found that large scale reductions in VA
psychiatric beds did not have a significant or large effect on
veterans’ use of non-VA inpatient and outpatient services
• However, these studies were limited in scope and
generalizability (i.e., limited to one state or one closure)
• The purpose of the current study is to examine how changes in
the supply of VA psychiatric beds affect the number of ED
admissions at non-VA hospitals within the same HRR.
Analysis Overview
• Examine the effect of five unit closures
• Did closures lead to an increase in private hospitalizations?
• Were closures due to under-utilization of beds?
• If yes, estimates will tend towards no effect
• Was there sufficient access to community
services?
• If yes, estimates will tend towards no effect
500
Number of Psychiatric Beds
1000
1500
2000
VA Psychiatric Bed Supply 1997-2005
1996
1998
2000
year
2002
Psychiatric Unit Beds
Specialty Hospital Beds
Source: AHA Annual Survey
2004
2006
Our Approach
• Focus on ED admissions into General Acute Hospitals
• Use data on all ED admissions in 7 states (AZ, CO, FL,
NJ, NY, WA, WI)
• Pre-post closure design (1997-2005) with 5 unit closures in
sample period (HCUP-SID data)
• Comparisons between 3 age cohorts (i.e., Vietnam, Gulf
War, & Comparison) with one of 3 disorders (mood,
psychotic, anxiety)
• Control for other services
use data from HCUP-SID, American Hospital Assoc. (AHA), and Medicare
Cost Reports
Age Cohorts
• Vietnam
• Males aged 51-56 in 2000
• Gulf War
• Males aged 31-36 in 2000
• Comparison
• Males aged 41-46 in 2000
4000
Number of Admissions
6000
8000
10000
12000
Number of ED Acute Care Admissions 1997-2005, by cohort
1996
1998
2000
2002
calendar year
Viet Nam-era Cohort
Gulf War-era Cohort
Peace time Cohort
Source: HCUP-SID Data 1997-2005
2004
2006
Covariates
•
•
Fixed Effect Negative Binomial Regression
Outcome Variable: Number of ED admissions by zip
code per year, per cohort
Covariates (measured spatially based on the patient’s zip
code):
•
•
Healthcare Referral Region (Broad market area)
•
•
Per capita number of general and specialty hospital beds (control)
Healthcare Service Area (Narrow market area)
•
Per capita number Psychiatric Emergency; General Emergency; Partial
Hospitalization Units hospital outpatient, freestanding outpatient and
freestanding MHSA Residential (control)
Covariates
•
Zip code level
•
% veterans; per-capita income; % w/ mental disabilities (US Census)
Results: Psychotic, Mood, and Anxiety
Disorder Admissions
Vietnam vs. Peace
Cohort
Effect of Unit Closure on
Admits
Peace Cohort Differential
Effect of 30 bed closure,
per bed (across cohorts)
Gulf War vs. Peace
Cohort
0.330***
(0.0527)
0.307***
(0.0417)
-0.0573
(0.0651)
-0.0446
(0.0567)
2.42
1.94
Results: Psychotic Disorder Admissions
Vietnam vs. Peace
Cohort
Gulf War vs. Peace
Cohort
Effect of Unit Closure on 0.579***
Admits
(0.0781)
0.381***
(0.0582)
Psych Unit Closure* Peace -0.224**
Cohort
(0.0947)
Increase in admissions per
bed (~30 bed closure)
8.32
-0.0469
(0.0793)
1.38
Results: Mood Disorder Admissions
Vietnam vs. Peace
Cohort
Effect of Unit Closure
Admits
Psych Unit Closure*
Peace Cohort
Increase in admissions
per bed (~30 bed closure)
Gulf War vs. Peace
Cohort
0.163**
(0.0683)
0.163**
(0.0697)
0.257***
(0.0500)
0.264***
(0.0508)
0.0369
0.0292
-0.0534
-0.0677
(0.0822)
(0.0837)
(0.0680)
(0.0689)
-0.68
-0.35
1.46
2.2
Conclusions
• VA units closures associated with a small, statistically
significant increase in admissions through the ED at private
hospitals
• Increase in about 90-100 admissions per year for a 30 bed closure
• Vietnam Cohort w/ psychotic disorders
• No measurable effect for anxiety disorders, inclusive of
PTSD
• Very few admissions pre and post
Conclusions (to be continued…)
• Unit closures appear to have taken place with sufficient
outpatient resources (and there are current efforts to further
increase access to services within the VA)
• Consistent with previous research on this topic, suggesting
little impact of VA inpatient closures on non-VA inpatient
and outpatient services