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

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Private Hospitals and the Treatment of Severe
Mental Illness The Role of the Emergency
Department Presented by Richard C.
Lindrooth, Ph.D. Medical University of South
Carolina Charleston, SCCo-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 (AHRQ PI
Lindrooth) R01 MH074151-01 A2 (NIMH PI
Lindrooth) K24-MH074468 (NIMH PI
Frueh)
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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 ED?
• Main outcome of this paper is admissions through
  the ED

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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?

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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.

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Policy Question

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

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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

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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

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Access to Care

• Measured spatially based on the patients 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 patients HSA (HSA)
• Data from AHA Annual Survey (cleaned and
  smoothed) and Census of Economic Activity

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Methods

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HCUP-SID Data

• AZ, CO, FL, NJ, NY, WA, WI discharge data 97-05
• Patients admitted to ED with primary ICD9 Code
• Treatment (Common diagnoses for persons w/
  SMI)
• 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.

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Methods

• Fixed Effect Negative Binomial Regression
• Zip code fixed effects (Include runs with
  StateYear FE)
• Sample Year 1997-2005
• Pre-period 1997-2000 (T0)
• Post-period 2001-2005 (TChange in beds b/w
  97-00)
• Unit of analysis Counts by zip code per year
• Dependent Variable Number of ED Admissions in
  zip

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Schizophrenia only
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Schizophrenia versus Dementia/Mood
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Results

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

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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

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Research ongoing.

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