Analyzing MHSA Hospital Treatment: Results from an AHRQ-SAMHSA Collaboration

On September 19, 2011, Carol Stocks, Sam Schildhaus, Katharine Levit, and Pat Santora made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (5.6 MB). Plugin Software Help.

Slide 1

Analyzing Mental Health and Substance Abuse (MHSA) Hospital Treatment: Results from an Agency for Healthcare Research and Quality-Substance Abuse and Mental Health Services Administration (AHRQ-SAMHSA) Collaboration

Carol Stocks, RN, MHSA
Sam Schildhaus, PhD
Katherine Levit
Pat Santora, PhD

AHRQ September 19, 2011

Slide 2

Overview of Session

• Healthcare Cost and Utilization Project (HCUP) Data Overview:
  • Carol Stocks.
• Emergency Departments:
  • MHSA Visits to Emergency Departments:
    • Carol Stocks.
  • SA Visits to Emergency Departments for the Uninsured:
    • Sam Schildhaus.
• Inpatient Stays:
  • MHSA Inpatient Stays in Community Hospitals:
    • Katharine Levit.

Slide 3

HCUP Data Overview
Carol Stocks

Slide 4

Healthcare Cost and Utilization Project (HCUP)

• What is HCUP?
  • Hospital-based administrative data.
  • Large collection going back many years.
  • Encounter-level with all "payers" including the uninsured.
  • Includes inpatient, emergency department and ambulatory surgery data.

Slide 5

The Foundation of HCUP Data is Hospital Billing Data

Demographic Data
    ↑/↓
Diagnoses
Procedures
Charges

Image: Two hospital billing forms are shown.

Slide 6

The Making of HCUP Data

Image: A flowchart depicting the following process:

• Patient enters hospital [Image: A patient with a doctor].
• Billing record created [Image: Billing records].
• Hospital sends billing data and any additional data elements to.Data Organizations [Image: A man working at a computer].
• States store data in varying formats [Image: Map of the United states].
• AHRQ standardizes data to create uniform HCUP databases [Image: HCUP logo].

Slide 7

What Are Community Hospitals?

The American Hospital Association (AHA) definition of community hospitals: Non-Federal, short-term, general, and other specialty hospitals, excluding hospital units of other institutions (e.g., prisons).

Include these hospitals:

• Multi-specialty general hospitals.
• OB-GYN.
• ENT.
• Orthopedic.
• Pediatric.
• Public.
• Academic medical centers.

Exclude these hospitals:

• Long-term care.
• Psychiatric.
• Alcoholism/chemical dependency.
• Rehabilitation.
• Department of Defense (DoD) / Department of Veterans Affairs (VA) / Indian Health Service (IHS).

Slide 8

HCUP is a Family of Databases, Tools, and Products

Image: The HCUP logo is shown in a circle. Arrows point out to the following items:

• HCUP Databases [Images of colorful data bins].
• Research Publications [Images of print publications].
• User Support [Image of a woman working at a computer].
• Research Products [Images of CDs].

Slide 9

HCUP Partners Providing 2010 Inpatient Data

Image: A map of the United States is shown with each State color-coded to show whether or not it provides inpatient data to HCUP. The non-participating States are Alaska, Idaho, Montana, North Dakota, Mississippi, and Alabama.

Slide 10

HCUP Partners Providing 2010 Emergency Department Data

Image: A map of the United States is shown with each State color-coded to show whether or not it participates in HCUP's Emergency Department Database. The non-participating States are Alaska, Oregon, Washington, Nevada, Idaho, Montana, Wyoming, Colorado, New Mexico, Texas, Oklahoma, North Dakota, Arkansas, Louisiana Mississippi, Michigan, Alabama, West Virginia, Virginia, Pennsylvania, and Delaware.

Slide 11

HCUP National Databases are Sampled from State Databases

State Inpatient Databases (SIDS):

• Nationwide Inpatient Sample (NIS).
• Kids' Inpatient Database (KID).

State Emergency Department Databases (SEDDS):

• Nationwide Emergency Department Sample (NEDS).

Slide 12

What is HCUP and What Is It Not?

Slide 13

Recap: Use of HCUP Databases

Benefits:

• Large sample size.
• Uniformity of coding.
• Routine, regular collection.
• Ease of access.
• All-payer.
• Available at local, state, regional, national level.
• Supplemental files available.

Limitations:

• Differences in coding across hospitals.
• no data on individuals outside hospital system.
• May not show complete episode of care.
• May not include all hospitals.
• Lack revenue information.
• Limited clinical details.
• ED data does not include time to triage, time to treatment, time to disposition, etc.

Slide 14

Mental Health and Substance Abuse (MHSA) Emergency Department (ED) Visits, 2007

Carol Stocks

Slide 15

Characteristics of MHSA-related Adult ED Visits

• 12.5 percent of all ED visits (12 million visits) were MHSA-related:
  • 41 percent of visits resulted in hospital admission—over 2.5 times the rate of admission for other conditions.
  • 54 percent of MHSA ED visits were for women.
  • 18-44 year olds comprised the largest share (47 percent) of adult ED visits.
  • Medicare was the most frequently billed payer (30 percent of visits).
  • 64 percent of visits involved MH conditions, 24 percent SA conditions, and 12 percent co-occurring MHSA conditions.

Slide 16

Most Common Reasons for MHSA-related Adult ED Visits

• Five all-listed MHSA conditions accounted for 96 percent of documented MHSA conditions during ED visits:
  • Mood disorders (43 percent of visits).
  • Anxiety disorders (26 percent of visits).
  • Alcohol disorders (23 percent of visits).
  • Drug disorders (18 percent of visits).
  • Schizophrenia and other psychoses (10 percent of visits).

Slide 17

Percentage of Hospital Admissions for Adult ED Visits with MHSA Conditions, 2007

Image: A bar chart compares percentage of ED visits for persons with mental health conditions only, substance abuse disorder only, and both for adults aged 18-44, 45-64, and over 65, and how many are admitted to the hospital versus treated and released in each category.

Slide 18

Payers for MHSA Adult Care in Community Hospitals, 2007

Image: A bar chart compares percentage of ED visits for persons with mental health conditions only, substance abuse disorder only, and both by type of insurance (Medicare, Medicaid, Private, and uninsured), and how many are admitted to the hospital versus treated and released in each category.

Slide 19

Adult ED Visits with MHSA Conditions by Age Groups, 2007

Image: A bar chart compares percentage of ED visits for adults aged 18-44, 45-64, and over 65, for types of MHSA conditions.

Slide 20

Expected Payer for ED Visits with MHSA Conditions, 2007

Image: A bar chart compares percentage of ED visits by type of insurance (Medicare, Medicaid, Private, and uninsured) for types of MHSA conditions.

Slide 21

ED Visits and MHSA-related Conditions

• MHSA conditions were documented for 12.5 percent of the 122.3 million total ED visits for all conditions:
  • Mental health diagnoses were involved in 8 percent of all ED visits (9.9 million visits).
  • Alcohol-related disorders were involved in 2.3 percent of ED visits (2.8 million visits).
  • Drug-related disorders were involved in 1.8 percent of visits (2.2 million visits).

Slide 22

MHSA Discharge Status from the ED

Image: A bar chart compares distribution of ED visits by discharge status for mental health-related, alcohol-related, and drug-related disorders with all discharges.

Distribution of All-listed Emergency Department (ED) Visits by Discharge Status for All and MHSA* Discharges, 2007

Slide 23

Most Frequent Types of MHSA-related ED Visits

Image: A bar chart compares distribution of most frequent ED visits by discharge status.

Distribution of Most Frequent Emergency Department (ED) All-Listed MHSA Visits* by Discharge Status, 2007

Slide 24

Substance Use Disorder (SUD) Emergency Department Visits for the Uninsured, 2009

Sam Schildhaus

Slide 25

Emergency Department

• Major portal for entry into hospital and institutional care.
• Emergency Department (ED) source of admission to hospital of 50% of all non-obstetric admissions in 2006, up from 36% in 1996.
• Legal mandate under Emergency Medical Treatment and Labor Act (EMTALA)—those who come to ED must receive medical screening and be stabilized regardless of insurance status or ability to pay.

Slide 26

Increase in ED Visits

• Between 1997 and 2007, ED visits increased by 23% from 95 million to 117 million*.
• ED is crucial to patients with substance use disorders (SUD), saving the lives of those with drug/alcohol overdoses and treating the consequences of SUD.

*National Hospital Ambulatory Medical Care Survey: 1997 Emergency Department Summary, Vital and Health Statistics, Centers for Disease Control and Prevention, National Center for Health Statistics, number 304, May 6, 1999, Table 1, page 4; National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary, Centers for Disease Control and Prevention, National Center for Health Statistics, number 26, August 6, 2010,Table 1, page 7.

Slide 27

Prior Related Research

• Owens and Mutter: HCUP-NEDS (2006):
  • Treat-and-Release (routine discharge) 1.4 times higher among the uninsured than the insured.
  • Admission among insured 2.1 times higher among insured than uninsured.
• Owens, Mutter, and Stocks: HCUP-NEDS (2007):
  • Uninsured mental health and substance use related ED visits were two to four times less likely to result in hospitalization than patient visits with insurance coverage.

Slide 28

Study Purpose

• Analyze ED visits with principal or secondary SUD diagnosis (Dx) to examine the following:
  • Does payer status differ among types (e.g., alcohol only, drug only, both) of SUD patients?
  • When the relationships are statistically controlled, is discharge of SUD patients to hospital or institution associated with patient, payer, and hospital characteristics?

Slide 29

Operational Definition: SUD

• Any SUD diagnosis (Dx), both principal and secondary Dx.
• ICD-9-CM:
  • Alcohol Abuse: 291.0-291.9 303.00-303.92, 305.00-305.02, but excluding remission code of 303.03.
  • Drug Abuse: 292.0-292.9, 304.00-304.92, 305.20-305.92,648.30-648.34, 965.00-965.02, but excluding medication error and remission codes 292.81,304.03, 304.13, 304.23, 304.33, 304.43, 304.63, 304.73, 304.83, 305.43, 305.53, 305.63, 305.73.

Slide 30

Findings

• Approximately 19 million of 77 million (25%) emergency department visits were by the uninsured ages 18-64 years.
• Approximately 1.4 million of the 19 million (7%) had a diagnosed substance use disorder.

Slide 31

Findings

• Payer status of ED visits by those 18-64:
  • Uninsured: 25%.
  • Private insurance: 39%.
  • Medicaid: 20%.
  • Medicare: 9%.
  • Other payers: 6%.
• SUD discharges more likely than non-SUD discharges to be uninsured (35% vs. 25%).

Slide 32

Multivariate Analysis

• Would the substantial difference in discharge disposition between the SUD and non-SUD patients be associated with many patient and facility characteristics?
• To test the relationship among the characteristics, we used a multivariate model that statistically controls for patients' socio-demographic characteristics, chronic conditions, self harm, insurance, and hospital characteristics.

Slide 33

Likelihood of Discharge to Hospital/institution After ED Visit

• Older patients (45-64) 9% less likely than younger (18-44) patients.
• Women 21% less likely than men.
• Patients residing in poorest zip codes 17% less likely than patients residing in wealthier zip codes.
• Patients with Medicare 15% more likely than uninsured.
• Patients with private insurance 41% more likely than uninsured.

Slide 34

Likelihood of Discharge to Hospital/Institution After ED Visit

• Patients with other insurance 57% more likely than uninsured.
• Patients with higher number of Dx 42% more likely than with lower number of Dx.
• Visits by patients with higher number of chronic conditions 31% more likely than with lower number of chronic conditions.
• Visits by patients who intended to hurt self 3.9 times more likely than others.
• Visits at teaching hospital 31% more likely than visits at nonteaching hospital.

Slide 35

Issues

• Over one third (35%) of MHSA visits treated in community hospital EDs are uninsured.
• Lack of insurance is associated with decreased post-ED care in community hospitals even after demographic, diagnostic, and hospital characteristics are statistically controlled.
• Important to monitor this relationship under expanded insurance coverage through the Affordable Care Act.

Slide 36

Mental Health and Substance Abuse (MHSA) Community Hospital Inpatient Visits, 2008
Katharine Levit

Slide 37

MHSA Conditions Accounted for 5% of Hospital Stays

• 39.9 million inpatient stays in 2008, 1.8 million (about 5%) for MHSA.
• 6 MHSA stays per 1,000 population.
• MHSA stays averaged 7.1 days compared to 4.6 days for all stays:
  • MH stays: 10.8 days per stay.
  • SA stays: 4.7 days per stay.
• MHSA stays cost $5,500 per stay compared to $9,100 for all stays.

Slide 38

Mood Disorders Were the Single Largest Reason for an MHSA Stays

Image: A pie chart shows MHSA discharges by major reason:

• Mood disorders: 44%:
  • Bipolar disorders: 20%.
  • Depression: 24%.
• Substance abuse disorders: 26%:
  • Drug-related disorders: 12%.
  • Alcohol-related disorders: 14%.
• Schizophrenia/Other psychotic disorders: 19%.
• Adjustment disorders: 2%
• Anxiety disorders: 2%
• All other: 5%

1.8 Million MHSA Stays

Slide 39

ALOS 2.5 Days Longer for MHSA Stays than for All Diagnoses

Image: A bar graph shows inpatient hospital stays and average length of stay (ALOS) for MHSA discharges.

Number of Inpatient Hospital Stays and Average Length of Stay for Discharges with a Principal MHSA Diagnoses, 1997-2008

Slide 40

ALOS Varied Considerably by MHSA Diagnosis

Image: A bar graph shows average length of stay by MHSA diagnosis. The average ALOS for all MHSA stays is 7.1 days.

Average Length of Stay by Principal Reason for MHSA Stay, 2008

Attention-deficit/conduct/disruptive behavior disorders: 11.3

Schizophrenia/other psychotic disorders: 11.1

Impulse control disorders: 10.7

Autism/other childhood disorders: 10.1

Bipolar disorders: 7.8

Personality disorders: 6.7

Depression: 6.5

Developmental disorders: 5.4

Pregnancy-related/other misc. MH disorders: 5.2

Drug-related disorders: 4.8

Alcohol-related disorders: 4.5

Anxiety disorders: 4.4

Adjustment disorders: 3.6

Slide 41

MHSA Stays Accounted for 21% of All Discharges Leaving the Hospital Against Medical Advice (AMA)

Image: A pie chart titled "MHSA* Inpatient Hospital Discharges Against Medical Advice (AMA) as a Share of All Discharges AMA, 2008" shows MHSA discharges against medical advice:

• MH: 25,000 (7%).
• SA: 52,700 (14%).
• All other diagnoses: 292,300 (79%).

370,000 discharges against medical advice.

Slide 42

MHSA Diagnoses had a Higher Rate of Discharges AMA than All Other Diagnoses

Image: A bar graph shows discharge rate (per 1000 discharges) against medical advice for MHSA and all other diagnoses in 2008:

• MH: 19.
• SA: 107.
• All other diagnoses: 8.

Slide 43

Non-elderly Adults had a Disproportionate Share of All MHSA Stays Relative to their Share of the Total Population and All Hospital Stays

Image: A bar graph compares MHSA stays and all stays by age groups with U.S. population in 2008.

Slide 44

There Were 60 MHSA Hospital Stays Per 10,000 Population

Image: A bar graph compares number of discharges per 10,000 population by age groups for 1997 and 2008.

Slide 45

Most Frequent Principal MHSA Diagnoses by Age

• Mood disorders was the most frequent principal MHSA diagnosis across all age groups in 1997 and 2008.
• Alcohol-related disorders accounted for 12 percent of MHSA stays among 18-44 year olds, 21 percent of MHSA stays among 45-64 year olds, and 12 percent of MHSA stays for 65-84 year olds.
• The number of hospital stays for drug-related conditions rose rapidly for all age groups over 45 years old (87-117-percent increase from 1997-2008), while remaining relatively stable (11-percent decline) among 18-44 year olds:
  • The underlying causes of this increase were rapid growth in drug-induced delirium and in poisonings by opiate-based pain medications.

Slide 46

Rise in Drug-induced Delirium and Poisonings by Opiate-based Pain Medications Fueled Increase in Drug-related Hospitalizations for Patients 85 and Older

• Drug-induced delirium and poisonings by opiate-based pain medications accounted for 78 percent of the drug-related stays and 89 percent of the increase in drug-related stays for patients 85 and older:
  • Drug-induced delirium can result from side-effects of medications and occurs often in elderly hospitalized patients.
• Drug-induced delirium and poisonings by opiate-based pain medications were also responsible for a large number of drug-related discharges in 45-64 year olds (19 percent) and 65-84 year olds (60 percent).

Slide 47

Adults 18-44 Accounted for Large Shares of Stays for the Most Frequent MHSA Conditions

Image: A bar graph compares number of discharges by most frequent MHSA conditions by age groups for 2008.

Slide 48

The Gender Split for MHSA Stays Varied by Diagnosis

Image: A bar graph shows percent of MHSA stays for males by MHSA diagnosis, 2008.

Slide 49

14% of All Discharges Had a Secondary MH Diagnosis

Image: A bar graph compares number of discharges for MHSA conditions versus other medical conditions for 2008.

Slide 50

5% of All Discharges Had a Secondary SA Diagnosis

Image: A bar graph compares number of discharges for MHSA conditions versus other medical conditions for 2008.

Slide 51

MHSA Stays Were More Commonly Uninsured or Insured by Medicaid than All Stays

Image: A bar chart compares discharges for persons with mental health disorders, drug- and alcohol-related disorders, and all diagnoses, by type of insurance (Medicare, Medicaid, Private, Uninsured, and other) for 2008.

Slide 52

The Uninsured and Medicaid Covered a Disproportionate Share of Costs for MHSA Stays

Image: A bar chart compares aggregate costs for persons with mental health disorders, drug- and alcohol-related disorders, and all diagnoses, by type of insurance (Medicare, Medicaid, Private, Uninsured, and other) for 2008.

Slide 53

Schizophrenia Was the Most Costly MHSA Diagnosis

Image: A bar chart compares discharges (in thousands) and aggregate costs (in millions) for the most frequent MHSA diagnoses for 2008.

Slide 54

The Average MHSA Hospital Stay Cost $1,200 Less Than Stays Without a Major OR Procedure

Image: A bar chart shows average costs for a hospital stay for the most frequent MHSA diagnoses for 2008. The average cost of all hospital stays with no major operating room procedure performed is $6,700.

Schizophrenia/other psychotic disorders: $7,500

Slide 55

MH Hospitalization Rates Were Higher in Poorest Communities Than in All Other Communities

Image: A bar chart compares MH discharges in poorest communities versus all other communities for 2008. Number of discharges per 1,000,000 population.

Slide 56

SA Hospitalization Rates in Poorest Communities Were Similar to All Other Communities

Image: A bar chart compares drug- and alcohol-related disorders in poorest communities versus all other communities for 2008. Number of discharges per 1,000,000 population.

Slide 57

Summary

26% of treatment spending for MHSA conditions went for hospital care in 2005, making stays key parts of treatment

• 5% of inpatient stays are for MHSA conditions.
• MHSA stays are longer on average but less costly.
• MHSA conditions vary by age and gender and are often secondary conditions for a stay.
• MHSA stays were 2 to 5 times more likely to be uninsured, depending on the condition.
• Hospitalized patients with schizophrenia, depression, or bipolar disorder were more likely to reside in the poorest communities.
• On the Web at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp.

Slide 58

Questions and Discussion

Slide 59

For Further Information

• HCUP Facts and Figures:
  http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp.
• HCUP Topical Reports:
  http://www.hcup-us.ahrq.gov/reports/mhsa.jsp.
• HCUP Statistical Briefs:
  http://www.hcup-us.ahrq.gov/reports/statbriefs/sbtopic.jsp.