Private Hospitals and the Treatment of Severe Mental Illness: The Role of the Emergency Department

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Richard C. Lindrooth, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (550 KB).

Slide 1

Private Hospitals and the Treatment of Severe Mental Illness: The Role of the Emergency Department

• The Center for Health Economic and Policy Studies MUSC—Medical University of South Carolina.
• Presented by:
  • Richard C. Lindrooth, Ph.D.
    Medical University of South Carolina
    Charleston, SC.
• 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, Hilo.

Research support:

• 2 RO1 HS010730 04—(Agency for Healthcare Research and Quality [AHRQ] PI: Lindrooth.)
• R01 MH074151 01 A2—(National Institute of Mental Health [NIMH] Principal Investigator [PI]: Lindrooth.)
• K24 MH074468—(NIMH PI: Frueh.)

Slide 2

Background

• What is the role of acute psychiatric beds in the continuum of community care?
• Are the a safety valve for the system of community care?
• What could stem the observed growth in admissions through the emergency department (ED) ?
• Main outcome of this paper is admissions through the ED.

Slide 3

Inpatient Psychiatric Care

• State Inpatient Beds:
  • Treatment of the severely mentally ill (SMI.)
  • Deinstitutionalizaion began in the 1960s.
  • Shifted patients to community care.
  • Better treatments enabled patients to function in the community.
• Role of Acute Care Beds:
  • Acute episodes.
  • A safety valve?

Slide 4

Community Psychiatric Care

• Partial Hospitalization Programs.
  • Stabilize patients avoid admissions.
• Psychiatric specialty emergency care.
  • ED staffed by psychiatric specialists.
• Residential and Foster Care.
  • Long-term care.
• Outpatient.
  • Psychiatrists (MD); psychologists; case-managers; therapists; etc...

Slide 5

Policy Question

• To what extent can ED admissions to acute care hospitals be prevented with access to community alternatives?
  • Outpatient mental health/substance abuse (MHSA) Clinics.
  • MHSA Residential Care.
  • Community housing Services/Shelters.
  • Partial hospitalization.
  • Psychiatric emergency facilities.
  • Supply of long-term beds.

Slide 6

Prevalence of SMI in Community

• Cannot observe directly...
  • Use the closure of state beds to proxy for an increase in SMI.
• In the context of a large reduction in beds:
  • What aspects of community care prevent psychiatric admissions through the ED?
    • Hospital outpatient.
    • Psychiatric Emergency /partial hospitalization.
    • MHSA residential options.
    • Acute Beds.

Slide 7

Identification Strategy

• Treatment group: Patients with public insurance in states that experience major downsizing in state beds 1997-2000.
  • Schizophrenia and other psychoses represented the largest portion of the SMI.
• Control Group: Zip codes within a state that experienced little change in the supply of state beds between 1997-2000.
  • Public dementia patients and private mood disorder patients.
• Pre-period: 1997-2000.
• Post-period: 2001-2005.

Slide 8

Figure 1. Trends in State Hospital Beds per Capita, 1995 2005

• Line graphs compare declining trends in the Nation and each of the following States; numbers are approximate.
• Scale on left reads "Beds per 10,000":
  • Nation: From slightly above 2 to about 1.5.
  • Arizona: From about 1 to about 0.75.
  • Colorado: From about 2.75 to about 1.8.
  • Florida: From slightly above 1 to slightly below 1.
  • New Jersey: From slightly above 3 to about 2.25.
  • New York: From slightly above 5 to about 3.1.
  • Washington: From slightly above 1 to about 1.8.
  • Wisconsin: From about 1.1 to about 1.
• Notes: Vertical lines represent implementation dates. Solid line is state and checked line is national.
• Source: American Hospital Association (AHA) and Medicare Cost Reports.

Slide 9

Access to Care

• Measured spatially based on the patient's Zip code:
  • Indicate whether a hospital-based ED, Psychiatric Unit, or Stabilization/Partial Hospitalization Unit is in the HRR (HRR.)
  • Number of long term/state psychiatric beds (beds.)
  • Indicate whether hospital outpatient, freestanding outpatient or freestanding MHSA Residential is within the patient's HSA (HSA.)
• Data from American Hospital Association (AHA) Annual Survey (cleaned and smoothed) and Census of Economic Activity.

Slide 10

Methods

• Table with these column headings: Blank—State Downsized beds—HSA Residential—HSA Hospital Outpatient—HRR Hospital Stabilization.
• Z1c—Yes—Yes—Yes—Yes
• Z2c—Yes—Yes—No—Yes
• Z3c—Yes—No—No—No
• Z1—No—Yes—Yes—Yes
• Z2—No—Yes—No—Yes
• Z3—No—No—No—No

Slide 11

Healthcare Cost & Utilization Project (HCUP) State Inpatient Databases (SID) Data

• AZ, CO, FL, NJ, NY, WA, & WI discharge data 1997-2005
  • Patients admitted to ED with primary ICD9 Code.
• Treatment (Common diagnoses for persons w/ SMI):
  • Clinical Classification Software (CCS) Code 659 for Schizophrenia other psychotic disorders (Public payer= Medicare; Medicaid; Other public; Self.)
• Comparison (Less common diagnoses for person w/ SMI):
  • CCS Code 653 for Delirium, dementia, and amnestic and other cognitive disorders (Public Payer.)
  • CCS 657 Mood disorders (Private Payer.)
• Sample includes all admissions from ED to acute care hospitals.

Slide 12

Methods

• Fixed Effect Negative Binomial Regression.
  • Zip code fixed effects (Include runs with State*Year FE).
  • Sample Year 1997-2005.
  • Pre-period 1997-2000 (T=0).
  • Post-period 2001-2005 (T=Change in beds b/w 97-00).
• Unit of analysis: Counts by Zip code per year.
• Dependent Variable: Number of ED Admissions in Zip.

Slide 13

Figure 1—Trends in State Hospital Beds per Capita, 1995-2005

• Line graphs compare declining trends in the Nation and each of the following States; numbers are approximate.
• Scale on left reads "Beds per 10,000":
  • Nation: From slightly above 2 to about 1.5.
  • Arizona: From about 1 to about 0.75.
  • Colorado: From about 2.75 to about 1.8.
  • Florida: From slightly above 1 to slightly below 1.
  • New Jersey: From slightly above 3 to about 2.25.
  • New York: From slightly above 5 to about 3.1.
  • Washington: From about 2. 1 to about 1.75.
  • Wisconsin: From slightly above 1 to slightly below 1.
• Notes: Vertical lines represent implementation dates. Solid line is state and checked line is national.
• Source: American Hospital Association and Medicare Cost Reports.

Slide 14

Figure 2—Trends in State Hospital Beds per Capita, 1995-2005

• Line graphs compare declining trends in the Nation and each of the following States; numbers below are approximations of points on graphs.
• Scale on left reads "Beds per 10,000":
  • Nation: From about 1.2 to about 0.7.
  • Arizona: From about 1.6 to about 0.25.
  • Colorado: From about 1 to about 0.5.
  • Florida: From about 1.4 to about 0.6.
  • New Jersey: From slightly above 3 to about 2.25.
  • New York: From about 0.6 to about 0.5.
  • Washington: From about 0.3 to about 0.25.
  • Wisconsin: From about 1.5 to about 0.6.
• Notes: Vertical lines represent implementation dates. Solid line is state and checked line is national.
• Source: American Hospital Association and Medicare Cost Reports.

Slide 15

Figure 3—Trends in Private Hospital Unit Beds per Capita, 1995-2005

• Line graphs compare trends in the Nation and in each of the following states; numbers below are approximations of points on graphs.
• Scale on left reads "Beds per 10,000":
  • Nation: From about 2 to about 1.7.
  • Arizona: From about 1.2 to about 1.
  • Colorado: From about 1.5 to about 1.2.
  • Florida: From about 2 to about 1.4.
  • New Jersey: From about 2 to about 2.
  • New York: From about 3 to about 3.
  • Washington: From about 1 to about 0.75.
  • Wisconsin: From about 1.8 to about 1.2.
• Notes: Vertical lines represent implementation dates. Solid line is state and checked line is national.
• Source: American Hospital Association and Medicare Cost Reports.

Slide 16

Schizophrenia only

• Column headings in table, from left:
  (blank)—Base—1997-1998 & 2002-2005—State Interactions.
• Specialty Psych Beds in HRR (100)— -0.0148* (0.00781)— -0.000485 (0.0106)— -0.0263*** (-.00797)
• Psych Unit Beds in HRR (100)— 0.00927*** (0.00233)— 0.0143*** (0.00314)— 0.00145 (0.00237)
• State Psych Beds Per Capital— -0.236*** (0.0237)— -0.298*** (0.0350)— -0.0821*** (0.0158)
• Psych Emergency in HRR (10)— -0.213*** (0.0267)— -0.492*** (0.0409)— -0.151*** (0.0273)
• Psych Partial Hosp. in HRR (10)— -0.353*** (0.0468)— -0.351*** (0.0636)— -0.221*** (0.0501)
• EDs in HRR (10)— 0.233*** (0.0199)— 0.367*** (0.0286)— 0.188*** (0.0210)
• Free-standing MH Outpatient in HSA ($1000)—0.0326 (0.0289)—0.0936*** (0.0417)—0.0323 (0.0302)
• Free-standing MH Residential in HSA ($1000)— -0.159*** (0.0505)— -0.203*** (0.0727)— -0.138*** (0.0533)
• Hospital-based Psych Outpatient in HSA (10s)—0.170*** (0.0494)—0.170*** (0.0711)— 0.147*** (0.0484)
• Specialty Psych Beds in Base: -0.0148*—1997-1998 & 2002-2005: -0.000485—State Interactions: -0.0263***
• HRR (100)—(0.00781)—(0.0106)—(0.00797)
• Psych Unit Beds in HRR—0.00927***—0.0143***—0.00145
• (100)—(0.00233)—(0.00314)—(0.00237)
• State Psych Beds Per Capita— -0.236**— -0.298***— -0.0821*** (0.0237)—(0.0350)—(0.0158)

Slide 17

Schizophrenia versus Dementia/Mood

• Public Schizophrenia Admissions Relative to:

Slide 18

Results

• Partial hospitalization programs reduce admissions through the ED.
  • Especially when combined with a psychiatric emergency department.
• Results consistent and robust.

Slide 19

Results and Conclusions

• Results consistent across several different specifications (i.e. discrete changes; closest ED type etc....)
• Partial hospitalization programs with Psychiatric emergency consistently reduce admissions through the ED.
• Access to residential treatment facilities also consistently reduces admissions through ED.
• Access to state beds plays a large role (unsurprising).
• Acute bed capacity matters; but not as consistent.

Slide 20

Research ongoing...

• Next steps:
  • Add more States and years (CA data next).
• Endogeneity of Acute Closures.
• Examine length of stay (LOS), discharge destination, and court-ordered admissions.