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, 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 (AHRQ PI: Lindrooth) R01 MH074151-01 A2 (NIMH PI: Lindrooth) K24-MH074468 (NIMH PI: Frueh)
Transcript
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 CarolinaCharleston, SC
Co-authors: Anouk L. Grubaugh, Ph.D., MUSC Walter Jones, Ph. D, MUSCAnthony Lo Sasso, Ph. D., University of Illinois,
ChicagoB. Christopher Frueh, Ph. D., University of
• 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
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?
Community Psychiatric Care
• Partial Hospitalization Programs• Stabilize patients avoid admissions
• Psychiatric specialty emergency care• ED staffed by psychiatric specialists
• 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
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
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
12
34
51
23
45
12
34
5
1995 2000 20051995 2000 2005
1995 2000 2005
Arizona Colorado Florida
New Jersey New York Washington
Wisconsin
State
Nation
Bed
s pe
r 10
,000
YearNotes:Vertical lines represent implementation dates. Solid line is state and checked line is nationalSource: American Hospital Association and Medicare Cost Reports
Figure 1. Trends in State Hospital Beds per Capita, 1995-2005
• 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 AHA Annual Survey (cleaned and smoothed) and Census of Economic Activity
Access to Care
Methods
State Downsized
bedsHSA
Residential
HSA Hospital
Outpatient
HRR Hospital
StabilizationZ1c Yes Yes Yes YesZ2c Yes Yes No YesZ3c Yes No No NoZ1 No Yes Yes YesZ2 No Yes No YesZ3 No No No No
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
• Sample includes all admissions from ED to acute care hospitals.
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 zdtttst
dTtat
dTtrt
dTtst
dat
drt
dzdt CTbedThsaThrrbedhsahrrfzip ****
12
34
51
23
45
12
34
5
1995 2000 20051995 2000 2005
1995 2000 2005
Arizona Colorado Florida
New Jersey New York Washington
Wisconsin
State
Nation
Bed
s pe
r 10
,000
YearNotes:Vertical lines represent implementation dates. Solid line is state and checked line is nationalSource: American Hospital Association and Medicare Cost Reports
Figure 1. Trends in State Hospital Beds per Capita, 1995-2005
0.5
11.
50
.51
1.5
0.5
11.
5
1995 2000 20051995 2000 2005
1995 2000 2005
Arizona Colorado Florida
New Jersey New York Washington
Wisconsin
State
Nation
Bed
s pe
r 10
,000
YearNotes:Vertical lines represent implementation dates. Solid line is state and checked line is nationalSource: American Hospital Association and Medicare Cost Reports
Figure 2. Trends in Private Hospital Beds per Capita, 1995-2005
12
34
12
34
12
34
1995 2000 20051995 2000 2005
1995 2000 2005
Arizona Colorado Florida
New Jersey New York Washington
Wisconsin
State
Nation
Bed
s pe
r 10
,000
YearNotes:Vertical lines represent implementation dates. Solid line is state and checked line is nationalSource: American Hospital Association and Medicare Cost Reports
Figure 3. Trends in Private Hospital Unit Beds per Capita, 1995-2005
