Habitually wandering patients

Leveraging Electronic Health Records to Assess Residential Mobility Among Veterans in the Veterans Health Administration

BACKGROUND

Residential mobility, or a change in residence, can influence health care utilization and outcomes. Health systems can leverage their patients' residential addresses stored in their electronic health records (EHRs) to better understand the relationships among patients' residences, mobility, and health. The Veteran Health Administration (VHA), with a unique nationwide network of health care systems and integrated EHR, holds greater potential for examining these relationships.

METHODS

We conducted a cross-sectional analysis to examine the association of sociodemographics, clinical conditions, and residential mobility. We defined residential mobility by the number of VHA EHR residential addresses identified for each patient in a 1-year period (1/1-12/31/2018), with 2 different addresses indicating one move. We used generalized logistic regression to model the relationship between a priori selected correlates and residential mobility as a multinomial outcome (0, 1, ≥2 moves).

RESULTS

In our sample, 84.4% (n=3,803,475) veterans had no move, 13.0% (n=587,765) had 1 move, and 2.6% (n=117,680) had ≥2 moves. In the multivariable analyses, women had greater odds of moving [aOR=1.11 (95% CI: 1.10,1.12) 1 move; 1.27 (1.25,1.30) ≥2 moves] than men. Veterans with substance use disorders also had greater odds of moving [aOR=1.26 (1.24,1.28) 1 move; 1.77 (1.72,1.81) ≥2 moves].

DISCUSSION

Our study suggests about 16% of veterans seen at VHA had at least 1 residential move in 2018. VHA data can be a resource to examine relationships between place, residential mobility, and health.

Therapeutic Duplication in Taiwan Hospitals for Patients With High Blood Pressure, Sugar, and Lipids: Evaluation With a Mobile Health Mapping Tool

BACKGROUND

Cardiovascular disease causes approximately half of all deaths in patients with type 2 diabetes. Duplicative prescriptions of medication in patients with high blood pressure (hypertension), high blood sugar (hyperglycemia), and high blood lipids (hyperlipidemia) have attracted substantial attention regarding the abuse of health care resources and to implement preventive measures for such abuse. Duplicative prescriptions may occur by patients receiving redundant medications for the same condition from two or more sources such as doctors, hospitals, and multiple providers, or as a result of the patient's wandering among hospitals.

OBJECTIVE

We evaluated the degree of duplicative prescriptions in Taiwanese hospitals for outpatients with three types of medications (antihypertension, antihyperglycemia, and antihyperlipidemia), and then used an online dashboard based on mobile health (mHealth) on a map to determine whether the situation has improved in the recent 25 fiscal quarters.

METHODS

Data on duplicate prescription rates of drugs for the three conditions were downloaded from the website of Taiwan's National Health Insurance Administration (TNHIA) from the third quarter of 2010 to the third quarter of 2016. Complete data on antihypertension, antihyperglycemia, and antihyperlipidemia prescriptions were obtained from 408, 414, and 359 hospitals, respectively. We used scale quality indicators to assess the attributes of the study data, created a dashboard that can be traced using mHealth, and selected the hospital type with the best performance regarding improvement on duplicate prescriptions for the three types of drugs using the weighted scores on an online dashboard. Kendall coefficient of concordance (W) was used to evaluate whether the performance rankings were unanimous.

RESULTS

The data quality was found to be acceptable and showed good reliability and construct validity. The online dashboard using mHealth on Google Maps allowed for easy and clear interpretation of duplicative prescriptions regarding hospital performance using multidisciplinary functionalities, and showed significant improvement in the reduction of duplicative prescriptions among all types of hospitals. Medical centers and regional hospitals showed better performance with improvement in the three types of duplicative prescriptions compared with the district hospitals. Kendall W was 0.78, indicating that the performance rankings were not unanimous (Chi square₂=4.67, P=.10).

CONCLUSIONS

This demonstration of a dashboard using mHealth on a map can inspire using the 42 other quality indicators of the TNHIA by hospitals in the future.

[Factitious disorders]

Patients with factitious disorders intentionally fabricate, exaggerate or feign physical and/or psychiatric symptoms for various open and covert psychological reasons. There are many issues regarding the diagnostic state and classification of factitious disorders. Both the categorical differentiation of and clinical continuum ranging from somatoform/dissociative disorders to malingering are being controversially debated. Epidemiological studies on the frequency of factitious disorder meet basic methodological difficulties. Reported rates of prevalence and incidence in the professional literature most probably have to be considered underestimations. Illness deception and self-harm as core features of the abnormal illness behaviour in factitious disorder may refer to various highly adverse and traumatic experiences during early development in a subgroup of patients. Chronic courses of illness prevail; however, there are also episodic variants.

Estimating healthcare mobility in the Veterans Affairs Healthcare System

BACKGROUND

Healthcare mobility, defined as healthcare utilization in more than one distinct healthcare system, may have detrimental effects on outcomes of care. We characterized healthcare mobility and associated characteristics among a national sample of Veterans.

METHODS

Using the Veterans Health Administration Electronic Health Record, we conducted a retrospective cohort study to quantify healthcare mobility within a four year period. We examined the association between sociodemographic and clinical characteristics and healthcare mobility, and characterized possible temporal and geographic patterns of healthcare mobility.

RESULTS

Approximately nine percent of the sample were healthcare mobile. Younger Veterans, divorced or separated Veterans, and those with hepatitis C virus and psychiatric disorders were more likely to be healthcare mobile. We demonstrated two possible patterns of healthcare mobility, related to specialty care and lifestyle, in which Veterans repeatedly utilized two different healthcare systems.

CONCLUSIONS

Healthcare mobility is associated with young age, marital status changes, and also diseases requiring intensive management. This type of mobility may affect disease prevention and management and has implications for healthcare systems that seek to improve population health.

Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines

BACKGROUND

Prescription benzodiazepine overdose continues to cause significant morbidity and mortality in the US. Multiple-provider prescribing, due to either fragmented care or "doctor-shopping," contributes to the problem.

OBJECTIVE

To elucidate the effect of provider professional relationships on multiple-provider prescribing of benzodiazepines, using social network analytics.

DESIGN

A retrospective analysis of commercial healthcare claims spanning the years 2008 through 2011. Provider patient-sharing networks were modelled using social network analytics. Care team cohesion was measured using care density, defined as the ratio between the total number of patients shared by provider pairs within a patient's care team and the total number of provider pairs in the care team. Relationships within provider pairs were further quantified using a range of network metrics, including the number and proportion of patients or collaborators shared.

MAIN MEASURES

The relationship between patient-sharing network metrics and the likelihood of multiple prescribing of benzodiazepines.

PARTICIPANTS

Patients between the ages of 18 and 64 years who received two or more benzodiazepine prescriptions from multiple providers, with overlapping coverage of more than 14 days.

RESULTS

A total of 5659 patients and 1448 provider pairs were included in our study. Among these, 1028 patients (18.2 %) received multiple prescriptions of benzodiazepines, involving 445 provider pairs (30.7 %). Patients whose providers rarely shared patients had a higher risk of being prescribed overlapping benzodiazepines; the median care density was 8.1 for patients who were prescribed overlapping benzodiazepines and 10.1 for those who were not (p < 0.0001). Provider pairs who shared a greater number of patients and collaborators were less likely to co-prescribe overlapping benzodiazepines.

CONCLUSIONS

Our findings demonstrate the importance of care team cohesion in addressing multiple-provider prescribing of controlled substances. Furthermore, we illustrate the potential of the provider network as a surveillance tool to detect and prevent adverse events that could arise due to fragmentation of care.

Residential mobility among patients in the VA health system: associations with psychiatric morbidity, geographic accessibility, and continuity of care

This paper reports on residential mobility among patients treated in the Veterans Affairs (VA) health system. We examine mobility in relation to patients' psychiatric disorders, and we assess the impact of mobility on health system geographic accessibility and continuity of care following inpatient discharge. Subjects included 534,002 patients with schizophrenia, bipolar disorder, depression, or with none of these conditions, who received VA services in both FY 01 and FY 02. We report the frequency and predictors of residential moves; we examine distance moved and changes in the proximity of VA providers; and we evaluate associations with timely receipt of outpatient care following inpatient discharges. Approximately 25% of patients with bipolar disorder, 20% with schizophrenia, 16% with depression, and 9% of patients without these conditions completed a residential move in FY 2002. When relocating, patients with schizophrenia and bipolar disorder were more likely to move closer to providers, suggesting greater sensitivity to accessibility barriers.

Fragmentation of care for frequently hospitalized urban residents

BACKGROUND

Fragmentation across sites of care may impede efficient healthcare delivery.

OBJECTIVES

The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program.

RESEARCH DESIGN

We conducted a cross-sectional study using the NYS Department of Health's Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with >or=3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patient's primary insurance adjusted for diagnosis and demographic characteristics.

MEASURES

Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patient's total number of hospitalizations over the 3-year interval.

RESULTS

Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50-4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20-1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43-3.25) or substance abuse (OR, 7.58; 95% CI, 6.55-8.77).

CONCLUSIONS

In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.

Mathematical modeling of the course and prognosis of factitious disorders: a game-theoretic approach

A mathematical model using simple concepts of repeated games is proposed to model the course and prognosis of factitious disorders. Although simple, the model seems capable of explaining the yet unknown mechanisms underlying the variable course of factitious disorders. One of the notable results of this study is the significant effect of involved physicians in the treatment process on the course of the disease. Particularly, the doctor's error rate in realizing whether the symptoms are real or factitious can considerably affect the course of the disease. This is the first paper to apply a mathematical model to factitious disorders.

Hemoptise fictícia na síndrome de Munchhausen: uma entidade a ser considerada no diagnóstico diferencial

A síndrome de Munchhausen resulta de um distúrbio psiquiátrico, no qual os pacientes conscientemente procuram demonstrar sinais e sintomas de doenças orgânicas graves. Foram encontrados na literatura 23 casos de hemoptise fictícia associada à síndrome de Munchhausen, dois com o mesmo mecanismo aqui descrito. Relata-se o caso de um paciente com diversas admissões hospitalares recentes por escarros sangüíneos, que resultavam em exaustivas investigações diagnósticas inconclusivas. Insistentemente questionado, confessou que aspirava o próprio sangue com uma seringa, armazenando-o na cavidade oral, e eliminando-o para forjar a hemoptise. A síndrome de Munchhausen deve ser considerada em pacientes com hemoptise de etiologia obscura.

Admission intervention team: medical center based intensive case management of the seriously mentally ill

The purpose of this study was to investigate the effect a medical center based intensive case management team had on utilization of inpatient psychiatric treatment. A frequent user of inpatient psychiatric hospitalization was defined as any patient who had 3 or more admissions during the 12 months prior to referral to the program. A within-subjects design was used comparing rates of hospital admissions and hospital days before and after program enrollment for 185 patients in the program for 1 year, and for 50 of those patients in the program for 7 years. Cost savings across program years 1992 through 2000 were calculated using inpatient per diem rates. The number of admissions, length of stay, and cost of care were significantly reduced during the study period. The results of this study clearly demonstrate that a medical center based intensive case management team can significantly reduce admissions, length of stay, and the cost of care of frequent users of hospital inpatient services. Development of a true multidisciplinary team, enhancement of medication and treatment compliance, and a team case management model were the factors suggested as contributing to the success of this treatment program.

The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE

To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.

DESIGN

Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.

SETTING

Acute care hospitals.

PATIENTS

We studied 23,198 pneumonia hospitalizations in a statewide administrative database.

MEASUREMENTS AND MAIN RESULTS

Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p =.012). ARD-attributable increases of $1,659 ( p =.002) and $1,664 ( p =. 002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p =.188). An increase of 1 day was seen using both strategies 2 and 3 ( p =.044 and p =.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.

CONCLUSIONS

Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization.

Engaging hospitalized heroin-dependent patients into substance abuse treatment

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical center's medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.

Review of methods to determine VA health care costs

BACKGROUND

Estimates of health care cost are needed to conduct cost-effectiveness research at the facilities operated by the US Department of Veterans Affairs.

METHODS

The medical literature was searched for VA studies to characterize different cost methods and identify their advantages and disadvantages.

RESULTS

Different methods are appropriate for different studies. Analysts who wish to capture the effect of an intervention on resources used in a health care encounter may wish to create a detailed pseudo-bill by combining VA utilization data with unit costs from the non-VA sector. If a cost function can be estimated from non-VA data, VA costs may be determined more economically from a reduced list of utilization items. If the analysis involves a new intervention or a program that is unique to VA, direct measurement of staff time and supplies may be needed. It is often sufficient to estimate the average cost of similar encounters, for example, the average of all hospital stays with the same diagnosis and same length of stay. Such estimates may be made by combining VA cost and utilization data bases and by applying judicious assumptions.

CONCLUSIONS

Assumptions used to estimate costs need to be documented and tested. VA cost-effectiveness research could be facilitated by the creation of a universal cost data base; however, it will not supplant the detailed estimates that are needed to determine the effect of clinical interventions on cost.

Frequent ED users: patterns of use over time

The objective of this study was to examine the pattern of emergency department (ED) use by frequent ED users over time. This study was a retrospective study of adults with more than 10 visits to a university hospital ED from 8/90 through 7/91. ED visits of this cohort to all hospitals in the metropolitan area were followed for 3 years. Records were reviewed for the etiology of each patient's ED visits. This cohort was comprised of 76 patients making 1,119 (1.9%) of the total 59,051 ED visits. Thirty-five of the 76 (46%) were frequent ED users in only the initial year. Thirteen of the 76 (17%) made more than 10 visits in all 4 years. The remainder had sporadic episodes of ED use. Thirty-five (46%) were evaluated at three or more EDs in years in which they were frequent users. Forty-two (55%) had a medical problem for the cause of the majority of their ED visits. Fifty-eight percent of patients making more than 10 visits in more than 1 year had psychiatric or substance abuse problems. The pattern of ED use in this cohort changed over time and was influenced by substance abuse and psychiatric problems. These data suggest that most patients do not remain frequent ED users over time.

Triage services: a profile of high utilization

With challenges continuing to be presented to health care delivery, inappropriate out-patient service utilization is of utmost concern to all health care service providers. This study is an examination of the utilization patterns of 189 veterans in an urban Veterans Administration Medical Center (VAMC). Factors found to be related to high utilization of ambulatory care triage clinic services for veterans who had presented for at least two unscheduled visits in the past six months include: patient perception of health status; number of prescription medications; and social needs. Implications for social work practice, program development and research are discussed.