The relationship between supply and hospitalization rates for mental illness and substance use disorders

Mental health service areas in Switzerland

OBJECTIVES

Small area analysis is a health services research technique that facilitates geographical comparison of services supply and utilization rates between health service areas (HSAs). HSAs are functionally relevant regions around medical facilities within which most residents undergo treatment. We aimed to identify HSAs for psychiatric outpatient care (HSA-PSY) in Switzerland.

METHODS

We used HSAr, a new and automated methodological approach, and comprehensive psychiatric service use data from insurances to identify HSA-PSY based on travel patterns between patients' residences and service sites. Resulting HSA-PSY were compared geographically, demographically and regarding the use of inpatient and outpatient psychiatric services.

RESULTS

We identified 68 HSA-PSY, which were reviewed and validated by local mental health services experts. The population-based rate of inpatient and outpatient service utilization varied considerably between HSA-PSY. Utilization of inpatient and outpatient services tended to be positively associated across HSA-PSY.

CONCLUSIONS

Wide variation of service use between HSA-PSY can hardly be fully explained by underlying differences in the prevalence or incidence of disorders. Whether other factors such as the amount of services supply did add to the high variation should be addressed in further studies, for which our functional mapping on a small-scale regional level provides a good analytical framework.

Small Area Analysis of Veterans Affairs Mental Health Services Data

OBJECTIVE

To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment.

METHODS

MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period.

RESULTS

A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles.

CONCLUSIONS

MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Supplier-induced demand for psychiatric admissions in Northern New England

BACKGROUND

The development of hospital service areas (HSAs) using small area analysis has been useful in examining variation in medical and surgical care; however, the techniques of small area analysis are underdeveloped in understanding psychiatric admission rates. We sought to develop these techniques in order to understand the relationship between psychiatric bed supply and admission rates in Northern New England. Our primary hypotheses were that there would be substantial variation in psychiatric admission across geographic settings and that bed availability would be positively correlated with admission rates, reflecting a supplier-induced demand phenomenon. Our secondary hypothesis was that the construction of psychiatric HSAs (PHSAs) would yield more meaningful results than the use of existing general medical hospital service areas.

METHODS

To address our hypotheses, we followed a four-step analytic process: 1) we used small area analytic techniques to define our PHSAs, 2) we calculated the localization index for PHSAs and compared that to the localization index for general medical HSAs, 3) we used the number of psychiatric hospital beds, the number of psychiatric admissions, and census data to calculate population-based bed-supply and psychiatric admission rates for each PHSA, and 4) we correlated population-based admission rates to population-based psychiatric bed supply.

RESULTS

The admission rate for psychiatric diagnosis varied considerably among the PHSAs, with rates varying from 2.4 per 100,000 in Portsmouth, NH to 13.4 per 100,000 in Augusta, ME. There was a positive correlation of 0.71 between a PHSA's supply of beds and admission rate. Using our PSHAs produced a substantially higher localization index than using general medical hospital services areas (0.69 vs. 0.23), meaning that our model correctly predicted geographic utilization at three times the rate of the existing model.

CONCLUSIONS

The positive correlation between admission and bed supply suggests that psychiatric bed availability may partially explain the variation in admission rates. Development of PHSAs, rather than relying on the use of established general medical HSAs, improves the relevance and accuracy of small area analysis in understanding mental health services utilization.

Post-discharge services and psychiatric rehospitalization among children and youth

This study examined risk and determinants of rehospitalization of children and adolescents (n = 186) following a first psychiatric hospitalization. It specifically examined the role of post-discharge services. Data were collected for a 30-month follow-up period through structured telephone interviews with caregivers and case record abstractions. 43% of youth experienced readmissions during the follow-up period. Risk of rehospitalization was highest during the first 30 days following discharge and remained elevated for 3 months. 72% of youth received 284 post-discharge services during the follow-up period, which significantly reduced the risk of rehospitalization. Longer first hospitalizations and a higher risk score at admission increased risk.

Interstate variations in psychotropic medication use among a national sample of children in the child welfare system

Geographic variations in service utilization have emerged as sentinels of quality of care. We used data from the National Survey of Child and Adolescent Well-Being (NSCAW), the Kaiser Family Foundation, and the Area Resource File to examine interstate variations in psychotropic medication use among children coming into contact with child welfare agencies. Mean probabilities of medication use differed by 13% between California (7.1%) and Texas (20.1%). On regression analyses, children in California had a fifth of the odds of medication use compared to children in Texas, principally, because child characteristics of age, gender, foster care placement, and mental health need seem to be evaluated differently in Texas compared to in other states. These findings suggest that interstate variations in psychotropic medication use are driven by child characteristics, rather than by mental health need. Understanding the clinical contexts of psychotropic medication use is necessary to assure high-quality care for these children.

Predictors of residential placement following a psychiatric crisis episode among children and youth in state custody

This study examined the extent and correlates of entry into residential care among 603 children and youth in state custody who were referred to psychiatric crisis services. Overall, 27% of the sample was placed in residential care within 12 months after their 1st psychiatric crisis screening. Among the children and youth placed in residential care, 51% were so placed within 3 months of their 1st crisis screening, with an additional 22% placed between 3 and 6 months after screening. Risk behavior and functioning, psychiatric hospitalization following screening, older age, placement type, and caregiver's capacity for supervision were associated with increased residential placement. The findings highlight the importance of early identification and treatment of behavior and functioning problems following a crisis episode among children and youth in state custody to reduce the need for subsequent residential placement. Having an inpatient psychiatric episode following a crisis episode places children at greater risk for residential placement, suggesting that the hospital is an important point for diversion programs. Children and youth in psychiatric crisis may also benefit from efforts to include their families in the treatment process.

The effects of health sector market factors and vulnerable group membership on access to alcohol, drug, and mental health care

OBJECTIVE

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.

DATA SOURCES

Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.

STUDY DESIGN

The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.

PRINCIPAL FINDINGS

Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.

CONCLUSIONS

Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.