clusions: Colocation of general medical services in the mental health setting was associated with significantly fewer preventable hospitalizations. (Psychiatric ...
Colocated General Medical Care and Preventable Hospital Admissions for Veterans With Serious Mental Illness Paul A. Pirraglia, M.D., M.P.H. Amy M. Kilbourne, Ph.D., M.P.H. Zongshan Lai, M.S. Peter D. Friedmann, M.D., M.P.H. Thomas P. O’Toole, M.D.
Objective: This study examined whether veterans with serious mental illness in mental health settings with colocated general medical care had fewer hospitalizations for ambulatory care–sensitive conditions than veterans in other settings. Methods: Using 2007 data, the study examined hospitalizations for ambulatory care–sensitive conditions with zeroinflated negative binomial regression controlling for demographic, clinical, and facility characteristics. Results: Of 92,268 veterans with serious mental illness, 9,662 (10.5%) received care at ten sites with colocated care and 82,604 (89.5%) at 98 sites without it. At sites without colocation, 5.1% had a hospitalization for an ambulatoDr. Pirraglia, Dr. Friedmann, and Dr. O’Toole are affiliated with the Primary Care Service and Systems Outcomes and Quality in Chronic Disease and Rehabilitation Research Enhancement Award Program, Providence Department of Veterans Affairs (VA) Medical Center, 830 Chalkstone Ave., Bldg. 32, Providence, RI 02908-4799 (e-mail: paul.pirraglia@va. gov). They are also with the Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island. Dr. Kilbourne and Mr. Lai are with the National Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor VA Medical Center, Ann Arbor, Michigan, and with the Department of Psychiatry, University of Michigan, Ann Arbor. 554
ry care–sensitive condition, compared with 4.3% at sites with colocation. Attendance at sites with colocated care was associated with an adjusted count of hospitalizations of .76 compared with attendance at sites with no coloβ=–.28, 95% confidence cation (β interval=.47 to –.09, p=.004). Conclusions: Colocation of general medical services in the mental health setting was associated with significantly fewer preventable hospitalizations. (Psychiatric Services 62:554–557, 2011)
P
ersons with serious mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, and other psychotic disorders, have high rates of comorbid general medical conditions. Colocation of general medical services in the mental health setting might address the concern that undertreated medical conditions of patients with serious mental illness contribute to poor outcomes, including premature mortality (1). Colocation could achieve this goal by improving access to care, continuity of care, and overall quality of care. Ambulatory care–sensitive conditions are “conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease” (2). Hospitalization for an ambulatory care–sensitive condition is an important outcome to consider PSYCHIATRIC SERVICES
in evaluating the quality of care because fewer admissions of patients with ambulatory care–sensitive conditions would indicate that good delivery of general medical services is preventing hospitalization. An analysis of New York State hospital discharge data found that persons with mental disorders had a higher risk of hospitalization for an ambulatory care–sensitive condition than persons without mental disorders and that their hospital stays also tended to be longer and more expensive (3). No previous studies have examined whether the colocation of general medical services in an outpatient mental health setting can reduce preventable hospitalizations. This study sought to examine whether Department of Veterans Affairs (VA) patients receiving care at VA mental health programs with colocated general medical care had fewer hospitalizations for ambulatory care–sensitive conditions than those receiving care in mental health programs without colocated general medical care.
Methods This research is part of a study approved by the VA Ann Arbor Healthcare System Institutional Review Board. Data for fiscal year (FY) 2007 were obtained from the National Psychosis Registry and from the National VA Mental Health Program Survey, which was administered to all directors of VA mental health programs (N=133) in early 2007. Colocation of
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general medical services in the mental health program was determined by the response to a survey question that specifically asked about this arrangement. The Agency for Healthcare Research and Quality has published definitions of ambulatory care–sensitive conditions, along with a list of such conditions and associated ICD-9-CM codes (www.ahrq.gov/data/safetynet/ billappb.htm) (2). For this study, any hospitalization that listed one of these conditions as the primary diagnosis was counted. Zero-inflated negative binomial regression analysis was used to examine the relationship of colocation to the number of hospitalizations per veteran for ambulatory care–sensitive conditions. A negative binomial distribution was specified because it is less prone than a Poisson distribution to overdispersion, and the two-part modeling approach was used because of the large number of patients who were not hospitalized for an ambulatory care–sensitive condition (4). The model controlled for age, gender, race-ethnicity, marital status, serviceconnected disability, Charlson-Deyo Comorbidity Index score (5), primary psychiatric diagnosis (schizophrenia, schizoaffective disorder, bipolar disorder, and other psychosis), and comorbid psychiatric diagnoses (posttraumatic stress disorder, anxiety disorder, alcohol abuse or dependence, and drug abuse or dependence). Some veterans had more than one diagnosis. The model also controlled for site characteristics: rurality based on rural-urban commuting area codes (6) (characterized as rural or not), facility volume (number of unique veterans with serious mental illness receiving care at the facility), and academic affiliation of the facility (coded as affiliated or not). The model also adjusted for clustering at the level of the VA facility by using generalized estimating equations. In the final model, only factors that were significantly associated with hospitalization for an ambulatory care–sensitive condition were included in the inflated portion of the model.
Results Of the 92,268 veterans with serious mental illness from 108 mental health PSYCHIATRIC SERVICES
programs who had complete survey data, 9,664 (10.5%) received care at ten sites with colocated general medical services and 82,604 (89.5%) received care from 98 sites that did not have a colocated program. At sites with colocation, 95.7% (N=9,249) of veterans did not have a hospitalization for an ambulatory care–sensitive condition, 3.2% (N=309) had one, and 1.1% (N=106) had two or more. At sites with no colocation, 94.9% (N=78,391) had none, 3.9% (N= 3,222) had one, and 1.2% (N=991) had two or more. The final model included all covariates in the standard portion of the model; age, marital status, Charlson-Deyo score, schizoaffective disorder, bipolar disorder, other psychosis, and drug abuse or dependence were included in the zeroinflated portion of the model. Being at a site with colocation was associated with an adjusted count of hospitalizations for an ambulatory care–sensitive condition of .76 compared with patients at sites with no colocation (β=–.28, 95% confidence interval=.47 to –.09, p=.004; Table 1). A confirmatory analysis with logistic regression
for no hospitalization for an ambulatory care–sensitive condition versus any hospitalization for such a condition yielded similar results, as did another analysis that specified a zero-inflated Poisson distribution. A test for an interaction between academic affiliation of the VA facility and colocation was not significant.
Discussion Colocation of general medical services in mental health settings was independently associated with fewer hospitalizations for an ambulatory care–sensitive condition in a national cohort of VA patients with serious mental illness. This finding suggests that such an approach may result in a lower rate of preventable hospital admissions. Furthermore, because we could not discern between veterans with serious mental illness who received colocated general medical services and those who did not, the finding of fewer hospitalizations suggests that the effect of having such a program may extend to all veterans with serious mental illness at the VA facility.
Table 1
Adjusted counts of hospitalizations for veterans with ambulatory care–sensitive conditions and zero-inflated negative binomial regression model beta coefficients Variable Colocation Age (per year) Male Black Married Service-connected disability 50%–100% Charlson–Deyo Comorbidity Index Schizoaffective disorder Bipolar disorder Other psychosis Anxiety disorder Posttraumatic stress disorder Alcohol abuse or dependence Drug abuse or dependence Academically affiliated facility Facility volume Rural facility a
Adjusted counta
β
95% CI
p
.76 1.01 1.00 .87 .86
–.28 .01 .00 –.13 –.15
–.47 to –.09 .01 to .02 –.16 to .17 –.25 to –.01 –.29 to –.002
.004
