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Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992–2001
Schizophrenia Research 110 (2009) 28–32
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Schizophrenia Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s
Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992–2001 Anand Pandya a,b, Gregory Luke Larkin c,⁎, Ryan Randles d, Annette L. Beautrais e, Rebecca P. Smith f a
Department of Psychiatry, Cedars-Sinai Medical Center, United States Department of Psychiatry, NYU School of Medicine, United States c Department of Surgery, Division of Emergency Medicine, Yale University School of Medicine, United States d Department of Surgery, Division of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, United States e Department of Psychological Medicine, University of Otago, Christchurch, New Zealand f Department of Psychiatry, Mount Sinai School of Medicine, United States b
a r t i c l e
i n f o
Article history: Received 27 August 2008 Received in revised form 12 December 2008 Accepted 17 December 2008 Available online 20 March 2009 Keywords: Psychosis Epidemiology Emergency Departments NHAMCS Mental health
a b s t r a c t Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Mental illness constitutes the second-largest disease burden in the United States (Hansen and Elliott, 1993). Changes in financing since 1990 have ushered in an era where treatment for these diseases is restricted, fragmented, managed, outpatient, and out-of-pocket: access remains an issue (Appelbaum, 2003; Lamb and Weinberger, 2005; New Freedom Commission on Mental Health, 2003). A few population data characterize prevalence or trends in acute service utilization among patients with serious mental illness (SMI). The Healthcare for Communities Survey showed increased ED use by SMI patients, but the study was crosssectional, of small sample size (n = 170) and lacked annual, population-based, longitudinal data (Mechanic and Bilder, 2004). The only nationally-representative study of trends in
mental health services in the 1990s reported increased utilization (12% in 1990–92 to 20% in 2000–02) (Kessler et al., 2005), independent of both socio-demographic factors and illness severity. However, this survey lacked information about ED utilization for psychosis. Understanding ED utilization is important: In the U.S. only EDs provide this vulnerable population with guaranteed access to medical care (Centers for Medicare and Medicaid Services: EMTALA; Fields et al., 2001). From 1992 to 2001 ED mental health visits increased overall (38%) (Larkin et al., 2005), as did visits for anxiety (Smith et al., 2008) and suicide attempts (Larkin et al., 2008). However, no studies have examined national trends in psychosis-related ED visits from 1992–2001. We sought to address this gap using a national probability sample. 2. Methods
⁎ Corresponding author. E-mail address: [email protected] (G.L. Larkin). 0920-9964/$ – see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2008.12.015
Conducted annually, the National Hospital Ambulatory Medical Care Survey's (NHAMCS) ED component measures
A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
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Psychotic disorder-related visits were assigned specific DSM-compatible categories: ICD 9 CM: 295–295.9 (Schizophrenia), 297.3 (Folie á deux), 298.8 (Brief Psychotic Disorder), 298.9 (Atypical Psychosis, or Psychosis NOS), and the non-DSM-based code used by the National Center for Health Statistics (NCHS) to describe reasons-for-visit 1155.0 (delusions or hallucinations). Absolute numbers of ED visits were estimated using census-based, NCHS-assigned patient weights. ED visit rates per-population were calculated using denominator estimates of the civilian, non-institutionalized US population, adjusted for under-enumeration (Census U Bot). We analyzed cases by age, sex, race/ethnicity, insurance status, location in a metropolitan statistical area (MSA), and region of the country. We report only estimates with a relative standard error less than 30% and more than 29 raw data records per cell (Hing et al., 2003; McCaig, 2004). Confidence intervals (95%CI) for visit rates were calculated using the relative standard error of the estimate, controlling for weighting, four-stage sampling, and cluster effects using generalized estimating equations from SUDAAN-8.0 (Research Triangle Park, NC). “Least squares” linear regression was used for trend analysis (STATA 7.0, StataCorp, College Station, TX). Differences in continuous variables were assessed using two-tailed independent samples t-tests or repeated measures ANOVA. Bonferroni corrections (p b 0.01) were used to adjust for multiple comparisons between groups.
emergency health care utilization, employing a 4-stage probability sample of visits to U.S. non-institutional general and short-stay hospitals, excluding federal, military, and Veterans Affairs facilities (Ciompi, 1987; Cohen, 1993; Cohen et al., 2000, 1996; Cohen and Kochanowicz, 1989; Cohen and Talavera, 2000; Cohler and Beeler, 1996; Cohler and Ferrono, 1987). NHAMCS covers geographic primary sampling units (approximately 112), hospitals within primary sampling units (approximately 600 total), EDs within hospitals, and patients within EDs (http://www.cdc.gov/nchs/about/major/ahcd/ ahcd1.htm). Data are collected by hospital staff during annual, randomly-assigned, 4-week periods, and coded using ICD-9CM (International Classification of Diseases, 9th Revision, Clinical Modification, 1991). ED visits from 1992–2001were categorized as mentalhealth-related if records met any of the three criteria: 1. Diagnosis-based psychiatric problems (ICD-9-CM diagnoses 290.0–305; 307–310; 311–319.0 or V-codes 61.1– 71.02); 2. NCHS-assigned Patient Reason-for-Visit Classification codes related to mental health (79), 1100.0–1199.9; or 3. Injury E-codes related to suicide/suicide attempts, E950.0– E959.9. Visits not meeting at least one of the above criteria were deemed non-mental-health visits. ICD-9-CM codes 290–319 were excluded if they lacked corresponding DSM-based diagnoses.
Table 1 Average rates for all mental health-related ED visits (MHRV) and psychosis-related ED visits. All mental health related visits (MHRV)
All psychosis visits
Total number estimated in 1000's (Nest); 95% confidence interval (CI)
Nest = 52,774; 95%CI = 49,676, 55,872
Nest = 5245; 95% CI = 4577, 5913
Mean age (SE) years
39.5 (0.2) years
Overall b 15 years old 15–29 years old 30–49 years old 50–69 years old 70+ years old Female Male White, non-Hispanic Black, non-Hispanic Hispanic (All) Other, non-Hispanic Northeast U.S. region Midwest U.S. region Southern U.S. Region Western U.S. Region Metropolitan EDs Non-metropolitan EDs
Insurance status Private Medicare Medicaid Self-pay Other Injury/poisoning visit
45.0 (0.7) years
N (actual sampled visits)
%
/1000 ED visits
Rate per 1000 US population (95% CI)
Rate per 1000 US population (95% CI)
% of MHRV
16,774 1451 3951 7212 2411 1749 8164 8610 10,346 3862 1990 576 5502 3473 4368 3431 14,850 1924
100 8.7 23.6 43 14.4 4.4 48.7 51.3 61.7 23 11.9 3.4 32.8 20.7 26 20.5 88.5 11.5
54.2 21.6 51.8 81.7 58.1 54.1 52.1 56.5 69.2 65.5 56.2 64.5 66.4 50.4 47 60.5 55.7 48.9
19.7(18.6,20.9) 8.1(7.1,9.1) 21.6(19.7,23.4) 26.4(24.4,28.3) 16.5(14.8,18.1) 25.6(23.0,28.2) 19.5(18.2,20.8) 19.9(18.6,21.3) 18.6(17.4,19.8) 31.2(27.4,34.9) 17.6(15.6,19.5) 12.0(9.4, 14.6) 24.6(22.5,26.7) 20.7(18.9,22.6) 17.4(16.1,18.7) 18.1(16.6,19.7) 19.7(18.5,20.9) 19.8(18.1,21.6)
2.0(1.7,2.2) 0.2(0.1,0.3) 1.8(1.2,2.4) 2.9(2.4,3.4) 1.8(1.3,2.3) 3.6(2.5,4.6) 1.8(1.5,2.1) 2.2(1.8,2.5) 1.7(1.4,2.0) 4.2(3.2,5.2) 1.3(0.8,1.8) 1.5(0.4,2.6) 2.5(1.9,3.0) 2.4(1.8,2.9) 1.7(1.3,2.1) 1.6(1.1,2.0) 2.1(1.8,2.4) 1.6(1.1,2.0)
10.0 2.5 8.3 10.9 10.9 14.1 9.2 11.0 9.1 13.5 7.4 12.5 10.2 11.6 9.8 8.8 10.7 8.1
N (actual sampled visits)
Sample % (unweighted)
Population-based % of MHRV
% of psychosis visits
4552 2758 3657 3747 2333 2726
27.1% 21.8% 21.8% 20.7% 13.9% 16.3%
29(27,30)% 17(16,19)% 20(19,21)% 21(19,22)% 13(12,15)% 30(29,32)%
15(10,19)% 30(26,35)% 24(18,30)% 15(12,20)% 16(10,20)% 18(13,23)%
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A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
3. Results Psychosis-related visits accounted for approximately 10% of all mental health ED visits in 1992–2001 (Table 1). NonHispanic Black individuals had the highest visit rate (4.2/ 1000), more than twice that of non-Hispanic Whites (1.7) or Hispanics (1.3). Fewer psychosis-related visits were injury or overdose-related (18%) compared to all mental health visits (30%; Fisher's p b 0.001). Medicare (30%) and Medicaid (24%) provided insurance for most cases. Compared to all mental health visits, psychosis-related visits were approximately half as likely to be privately insured (29% v. 15%; Fisher's p b 0.001). While overall mental-health ED visits increased, the rate of psychosis-related visits per capita remained stable (Table 2). No increases were observed by gender, racial/ethnic group or geographic region. Visit rates increased in those aged 50 to 69, by 83%, from 1.2 to 2.2 per 1000 U.S. population across the decade. Psychosis-related visits in non-metropolitan (rural) areas decreased, accompanied by a reciprocal increase in metropolitan areas (Table 3). Psychosis-related visits for Medicare patients decreased (Table 4).
Table 2 Trends in rates for all mental health-related ED Visits (MHRV) and psychosisrelated ED visits — by gender, age and race/ethnicity. Trend
By year
Overall
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Female
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
1642 1387 1401 1580 2154
Male
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
1718 1447 1506 1727 2212
White, non-Hispanic
1992–1993 2163 1994–1995 1766 1996–1997 1800 1998–1999 1902 2000–2001 2715
Black, non-Hispanic
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
721 650 696 888 907
Hispanic (all)
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
372 306 318 428 566
b 15 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
308 260 263 260 360
15–29 years
1992–1993 819 1994–1995 711 1996–1997 645 1998–1999 773 2000–2001 1003
30–49 years
1992–1993 1396 1994–1995 1239 1996–1997 1305 1998–1999 1451 2000–2001 1821
50–69 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
478 361 406 487 679
N =70 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
359 263 288 336 503
4. Discussion Psychosis-related ED visits remained stable while mental health ED visits increased by more than a third (Larkin et al., 2005). This stability is notable given radical changes in treatment and prescribing practices for psychosis during this decade. In 1992, clozapine was the only SecondGeneration Antipsychotic (SGA) available, but by 2001, 84.5% of all office-based physician visits for antipsychotics included a SGA prescription (Aparasu et al., 2005). Our finding suggests that, overall, increased prescription of SGAs did not reduce ED visits. Psychosis-related ED visit rates for Medicare beneficiaries decreased significantly while ED Medicare visits for mental health, mood, anxiety, substance, and suicide-related problems increased (Larkin et al., 2005, 2008; Smith et al., 2008), and while the number of Medicare enrollees also increased (“Centers for Medicare and Medicaid Services: Medicare Enrollment Reports”; Program Information on Medicaid & State Children's Health on Medicaid & State Children's Health Insurance Program (SCHIP)). Increased Medicaid enrollment may represent greater penetration among populations with low rates of psychosis and/or low rates of ED utilization, perhaps especially likely where enrollment growth has been attributable to waiver programs like the California Family Planning Access Care and Treatment program (“Family Planning, Access, Care and Treatment Program”). It is also possible that managed care had a greater cost-containment effect for psychosis-related visits than other mental-health visits, since individuals with higher levels of psychosis are more likely to have had a period of enrollment in public managed mental health plans (Wingerson et al., 2001). Diversion of those with SMI to jails and prisons (Greenberg and Rosenheck, 2008; Lamb and Weinberger, 2005) might also help explain this trend. Visit rates increased only in 50- 69-year-olds. Because we corrected for population growth by age, this trend cannot be explained by the general aging of the population, unless the shift to an older age distribution is greater for those with
N⁎ = Actual sampled visits.
All MHRV
Psychosis visits
N⁎
Rate per 1000
Rate per 1000
3360 2834 2907 3307 4366
16.7(15.0,18.3) 17.7(16.0,19.3) 19.8(17.9,21.6) 21.8(19.6,23.9) 22.3(20.5,24.1) p = 0.002 16.2(14.4,18.1) 17.1(15.3,19.0) 19.5(17.4,21.6) 21.7(19.3,24.2) 22.4(20.3,24.4) p = 0.002 17.1(15.2,19.0) 18.2(16.2,20.1) 20.0(17.9,22.2) 21.8(19.3,24.2) 22.3(20.2,24.4) p = 0.002 15.2(13.6,16.8) 16.4(14.8,18.0) 18.0(16.2,19.8) 21.0(18.8,23.2) 22.3(20.4,24.3) p = 0.002 26.1(22.2,30.0) 27.1(22.9,31.3) 36.0(31.0,41.0) 34.7(29.6,39.9) 31.4(27.4,35.3) p = 0.234 18.6(14.9,22.2) 18.0(14.5,21.4) 17.3(13.8,20.8) 17.7(14.1,21.2) 19.0(16.0,22.0) p = 0.853 7.7(5.9,9.5) 6.8(5.1,8.5) 8.4(6.3,10.5) 8.3(6.2,10.4) 9.3(7.3,11.2) p = 0.101 18.2(15.1,21.4) 20.4(17.0,23.9) 21.4(17.8,25.1) 23.4(19.2,27.7) 24.1(20.5,27.6) p = 0.002 21.6(18.4,24.8) 23.9(20.5,27.3) 26.7(23.0,30.5) 29.5(25.2,33.9) 29.6(26.0,33.2) p = 0.005 14.6(11.5,17.6) 13.7(10.6,16.7) 17.2(13.8,20.5) 17.7(14.0,21.5) 18.6(15.5,21.7) p = 0.036 20.6(15.9,25.3) 22.3(17.3,27.2) 22.4(17.3,27.6) 29.5(23.0,36.1) 32.0(26.2,37.9) p = 0.018
1.9(1.6,2.3) 1.8(1.5,2.1) 2.0(1.6,2.3) 2.0(1.6,2.5) 2.0(1.7,2.3) p = 0.182 1.6(1.2,2.0) 1.9(1.4,2.3) 1.6(1.2,2.0) 1.9(1.4,2.4) 1.9(1.4,2.3) p = 0.308 2.3(1.8,2.8) 1.7(1.2,2.2) 2.3(1.8,2.9) 2.2(1.6,2.8) 2.2(1.7,2.6) p = 0.761 1.7(1.3,2.0) 1.6(1.2,1.9) 1.6(1.2,2.0) 1.9(1.5,2.3) 1.8(1.4,2.1) p = 0.278 4.1(2.7,5.4) 3.8(2.5,5.1) 4.8(3.2,6.4) 4.1(2.6,5.7) 4.2(3.0,5.5) p = 0.728 1.02(0.4,1.6) 1.2(0.3,2.1) 1.2(0.4,1.9) 1.3(0.4,2.3) 1.8(1.0,2.6) p = 0.095 0.3 0.1 0.1 0.1 0.2 p = 0.559 2.1(1.3,2.9) 1.8(0.9,2.8) 1.7(0.9,2.5) 1.9(0.9,2.9) 1.5(0.8,2.1) p = 0.121 2.5(1.7,3.4) 2.5(1.6,3.3) 3.3(2.3,4.4) 3.2(2.1,4.3) 2.9(2.1,3.8) p = 0.255 1.2(0.5,1.9) 1.7(0.7,2.7) 1.6(0.7,2.5) 2.2(0.9,3.5) 2.2(1.3,3.2) p = 0.024 4.7(2.7,6.7) 3.7(1.9,5.4) 2.9(1.2,4.6) 2.5(1.0,4.0) 4.2(2.5,5.8) p = 0.523
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A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
psychosis than for other Americans. More plausible explanations include that older psychotic patients find it hard to break habits of seeking ED care (Parks et al., 2006) or that older individuals with late-onset psychosis in the context of dementia contribute to increased utilization by older people. Regardless of source, this trend should be considered in service planning, resource allocation and bridging gaps between emergency medicine, geriatrics and mental health (Cuffel et al., 1996; Jeste et al., 1999). We found psychosis-related ED visits increased in metropolitan areas, coincident with a reciprocal decrease in rural settings. This trend might be explained by a net migration of individuals with psychosis from rural to urban regions, in order to access urban-based psychiatric hospitals and/or specialist psychiatric care (Peen and Dekker, 2004; Mandersheid and Henderson, 1999). We found psychosis-related ED usage was higher for Black, non-Hispanic individuals, consistent with prior findings showing that racial minorities with severe mental illness exhibit greater use of EDs (Young et al., 2005). Our study has several limitations: VA hospitals were excluded; data do not permit analysis of repeat visitors; psychiatric diagnostic practice moved from use of DSM-III to
Table 4 Trends in rates for all mental health-related ED visits and psychosis-related ED visits — by insurance status.
Table 3 Geographic trends in rates for all mental health-related ED visits (MHRV) and psychosis-related ED VISITS. Trend
By year
All MHRV
Rate per 1000 Rate per 1000 US US
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
967 772 877 1330 1556
Midwest
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
753 734 652 572 762
South
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
878 716 777 844 1153
West
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
762 612 601 561 895
18.1(15.6,20.6) 23.3(20.3,26.3) 25.3(22.0,28.6) 28.5(24.4,32.5) 27.8(24.6,31.0) p = 0.022 20.5(17.8,23.2) 18.8(16.3,21.4) 21.2(18.4,24.0) 21.5(18.6,24.5) 21.5(19.0,24.0) p = 0.232 13.7(11.9,15.4) 15.1(13.2,17.0) 16.9(14.8,19.0) 20.0(17.5,22.6) 20.8(18.6,23.0) p = 0.002 16.0(13.6,18.3) 15.4(13.1,17.7) 18.0(15.5,20.4) 19.0(16.1,21.8) 21.8(19.2,24.4) p = 0.018 15.1(13.5,16.7) 17.5(15.9,19.2) 19.6(17.8,21.5) 22.1(19.8,24.3) 24.5(22.5,26.6) p = 0.000 26.9(23.1,30.7) 18.3(15.5,21.0) 20.2(17.4,23.0) 20.8(17.8,23.7) 16.1(13.8,18.3) p = 0.035
Metropolitan area
Non-metropolitan area
1992–1993 3010 1994–1995 2561 1996–1997 2470 1998–1999 2903 2000–2001 3906 1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
N⁎ = Actual sampled visits.
350 273 437 404 460
% of All MHRV
% of psychosis visits
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Medicare
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Medicaid
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Self-pay
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Other
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
27.1% 28.5% 29.2% 26.7% 31.1% p = 0.331 18.6% 15.3% 14.9% 18.1% 19.7% p = 0.535 22.9% 17.8% 18.8% 21.3% 19.1% p = 0.608 18.8% 19.5% 23.5% 21.3% 19.6% p = 0.643 12.5% 18.9% 13.6% 12.6% 10.5% p = 0.374
12.4% 20.8% 16.8% 9.4% 15.2% p = 0.766 36.9% 21.3% 27.2% 31.5% 34.5% p = 0.046 30.9% 18.9% 18.5% 28.0% 22.3% p = 0.677 16.5% 17.1% 21.5% 15.6% 16.5% p = 0.116 9.3% 16.8% 9.0% 8.8% 8.0% p = 0.618
Psychosis visits
N⁎ Northeast
Year Private
2.1(1.4,2.9) 2.0(1.2,2.8) 2.1(1.3,3.0) 3.0(1.9,4.1) 3.0(2.1,3.9) p = 0.059 3.4(2.5,4.3) 1.9(1.3,2.6) 2.5(1.6,3.4) 2.0(1.3,2.7) 2.0(1.3,2.7) p = 0.206 1.2(0.8,1.6) 1.7(1.1,2.2) 1.7(1.2,2.1) 2.0(1.3,2.6) 1.8(1.4,2.3) p = 0.101 1.3(0.8,1.9) 1.7(1.0,2.4) 1.8(1.2,2.4) 1.4(0.8,2.0) 1.6(1.0,2.1) p = 0.711 1.8(1.5,2.2) 1.8(1.4,2.1) 2.2(1.8,2.6) 2.2(1.8,2.7) 2.3(1.9,2.7) p = 0.027 2.5 2.0 1.2(0.7, 1.8) 1.4(0.8,2.1) 1.2(0.7,1.7) p = 0.047
DSM-IV during the study period, incorporating criteria changes for psychotic disorders. While coders used a consistent definition of psychosis, their dependence on clinical documentation may have led to some diagnostic drift as clinicians became increasingly familiar with DSM-IV criteria. Against the national backdrop of rising ED oversubscription, stable visit rates for psychosis warrant further investigation. Future work should explore trends toward increased age and urbanization of ED-reliant psychotic patients, as these trends have important resource implications for both emergency and mental health care systems. Role of funding source The authors of this study received no funds for this research. Conflict of interest The authors have no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence, or be perceived to influence, their work. Acknowledgment None.
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Schizophrenia Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s
Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992–2001 Anand Pandya a,b, Gregory Luke Larkin c,⁎, Ryan Randles d, Annette L. Beautrais e, Rebecca P. Smith f a
Department of Psychiatry, Cedars-Sinai Medical Center, United States Department of Psychiatry, NYU School of Medicine, United States c Department of Surgery, Division of Emergency Medicine, Yale University School of Medicine, United States d Department of Surgery, Division of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, United States e Department of Psychological Medicine, University of Otago, Christchurch, New Zealand f Department of Psychiatry, Mount Sinai School of Medicine, United States b
a r t i c l e
i n f o
Article history: Received 27 August 2008 Received in revised form 12 December 2008 Accepted 17 December 2008 Available online 20 March 2009 Keywords: Psychosis Epidemiology Emergency Departments NHAMCS Mental health
a b s t r a c t Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Mental illness constitutes the second-largest disease burden in the United States (Hansen and Elliott, 1993). Changes in financing since 1990 have ushered in an era where treatment for these diseases is restricted, fragmented, managed, outpatient, and out-of-pocket: access remains an issue (Appelbaum, 2003; Lamb and Weinberger, 2005; New Freedom Commission on Mental Health, 2003). A few population data characterize prevalence or trends in acute service utilization among patients with serious mental illness (SMI). The Healthcare for Communities Survey showed increased ED use by SMI patients, but the study was crosssectional, of small sample size (n = 170) and lacked annual, population-based, longitudinal data (Mechanic and Bilder, 2004). The only nationally-representative study of trends in
mental health services in the 1990s reported increased utilization (12% in 1990–92 to 20% in 2000–02) (Kessler et al., 2005), independent of both socio-demographic factors and illness severity. However, this survey lacked information about ED utilization for psychosis. Understanding ED utilization is important: In the U.S. only EDs provide this vulnerable population with guaranteed access to medical care (Centers for Medicare and Medicaid Services: EMTALA; Fields et al., 2001). From 1992 to 2001 ED mental health visits increased overall (38%) (Larkin et al., 2005), as did visits for anxiety (Smith et al., 2008) and suicide attempts (Larkin et al., 2008). However, no studies have examined national trends in psychosis-related ED visits from 1992–2001. We sought to address this gap using a national probability sample. 2. Methods
⁎ Corresponding author. E-mail address: [email protected] (G.L. Larkin). 0920-9964/$ – see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2008.12.015
Conducted annually, the National Hospital Ambulatory Medical Care Survey's (NHAMCS) ED component measures
A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
29
Psychotic disorder-related visits were assigned specific DSM-compatible categories: ICD 9 CM: 295–295.9 (Schizophrenia), 297.3 (Folie á deux), 298.8 (Brief Psychotic Disorder), 298.9 (Atypical Psychosis, or Psychosis NOS), and the non-DSM-based code used by the National Center for Health Statistics (NCHS) to describe reasons-for-visit 1155.0 (delusions or hallucinations). Absolute numbers of ED visits were estimated using census-based, NCHS-assigned patient weights. ED visit rates per-population were calculated using denominator estimates of the civilian, non-institutionalized US population, adjusted for under-enumeration (Census U Bot). We analyzed cases by age, sex, race/ethnicity, insurance status, location in a metropolitan statistical area (MSA), and region of the country. We report only estimates with a relative standard error less than 30% and more than 29 raw data records per cell (Hing et al., 2003; McCaig, 2004). Confidence intervals (95%CI) for visit rates were calculated using the relative standard error of the estimate, controlling for weighting, four-stage sampling, and cluster effects using generalized estimating equations from SUDAAN-8.0 (Research Triangle Park, NC). “Least squares” linear regression was used for trend analysis (STATA 7.0, StataCorp, College Station, TX). Differences in continuous variables were assessed using two-tailed independent samples t-tests or repeated measures ANOVA. Bonferroni corrections (p b 0.01) were used to adjust for multiple comparisons between groups.
emergency health care utilization, employing a 4-stage probability sample of visits to U.S. non-institutional general and short-stay hospitals, excluding federal, military, and Veterans Affairs facilities (Ciompi, 1987; Cohen, 1993; Cohen et al., 2000, 1996; Cohen and Kochanowicz, 1989; Cohen and Talavera, 2000; Cohler and Beeler, 1996; Cohler and Ferrono, 1987). NHAMCS covers geographic primary sampling units (approximately 112), hospitals within primary sampling units (approximately 600 total), EDs within hospitals, and patients within EDs (http://www.cdc.gov/nchs/about/major/ahcd/ ahcd1.htm). Data are collected by hospital staff during annual, randomly-assigned, 4-week periods, and coded using ICD-9CM (International Classification of Diseases, 9th Revision, Clinical Modification, 1991). ED visits from 1992–2001were categorized as mentalhealth-related if records met any of the three criteria: 1. Diagnosis-based psychiatric problems (ICD-9-CM diagnoses 290.0–305; 307–310; 311–319.0 or V-codes 61.1– 71.02); 2. NCHS-assigned Patient Reason-for-Visit Classification codes related to mental health (79), 1100.0–1199.9; or 3. Injury E-codes related to suicide/suicide attempts, E950.0– E959.9. Visits not meeting at least one of the above criteria were deemed non-mental-health visits. ICD-9-CM codes 290–319 were excluded if they lacked corresponding DSM-based diagnoses.
Table 1 Average rates for all mental health-related ED visits (MHRV) and psychosis-related ED visits. All mental health related visits (MHRV)
All psychosis visits
Total number estimated in 1000's (Nest); 95% confidence interval (CI)
Nest = 52,774; 95%CI = 49,676, 55,872
Nest = 5245; 95% CI = 4577, 5913
Mean age (SE) years
39.5 (0.2) years
Overall b 15 years old 15–29 years old 30–49 years old 50–69 years old 70+ years old Female Male White, non-Hispanic Black, non-Hispanic Hispanic (All) Other, non-Hispanic Northeast U.S. region Midwest U.S. region Southern U.S. Region Western U.S. Region Metropolitan EDs Non-metropolitan EDs
Insurance status Private Medicare Medicaid Self-pay Other Injury/poisoning visit
45.0 (0.7) years
N (actual sampled visits)
%
/1000 ED visits
Rate per 1000 US population (95% CI)
Rate per 1000 US population (95% CI)
% of MHRV
16,774 1451 3951 7212 2411 1749 8164 8610 10,346 3862 1990 576 5502 3473 4368 3431 14,850 1924
100 8.7 23.6 43 14.4 4.4 48.7 51.3 61.7 23 11.9 3.4 32.8 20.7 26 20.5 88.5 11.5
54.2 21.6 51.8 81.7 58.1 54.1 52.1 56.5 69.2 65.5 56.2 64.5 66.4 50.4 47 60.5 55.7 48.9
19.7(18.6,20.9) 8.1(7.1,9.1) 21.6(19.7,23.4) 26.4(24.4,28.3) 16.5(14.8,18.1) 25.6(23.0,28.2) 19.5(18.2,20.8) 19.9(18.6,21.3) 18.6(17.4,19.8) 31.2(27.4,34.9) 17.6(15.6,19.5) 12.0(9.4, 14.6) 24.6(22.5,26.7) 20.7(18.9,22.6) 17.4(16.1,18.7) 18.1(16.6,19.7) 19.7(18.5,20.9) 19.8(18.1,21.6)
2.0(1.7,2.2) 0.2(0.1,0.3) 1.8(1.2,2.4) 2.9(2.4,3.4) 1.8(1.3,2.3) 3.6(2.5,4.6) 1.8(1.5,2.1) 2.2(1.8,2.5) 1.7(1.4,2.0) 4.2(3.2,5.2) 1.3(0.8,1.8) 1.5(0.4,2.6) 2.5(1.9,3.0) 2.4(1.8,2.9) 1.7(1.3,2.1) 1.6(1.1,2.0) 2.1(1.8,2.4) 1.6(1.1,2.0)
10.0 2.5 8.3 10.9 10.9 14.1 9.2 11.0 9.1 13.5 7.4 12.5 10.2 11.6 9.8 8.8 10.7 8.1
N (actual sampled visits)
Sample % (unweighted)
Population-based % of MHRV
% of psychosis visits
4552 2758 3657 3747 2333 2726
27.1% 21.8% 21.8% 20.7% 13.9% 16.3%
29(27,30)% 17(16,19)% 20(19,21)% 21(19,22)% 13(12,15)% 30(29,32)%
15(10,19)% 30(26,35)% 24(18,30)% 15(12,20)% 16(10,20)% 18(13,23)%
30
A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
3. Results Psychosis-related visits accounted for approximately 10% of all mental health ED visits in 1992–2001 (Table 1). NonHispanic Black individuals had the highest visit rate (4.2/ 1000), more than twice that of non-Hispanic Whites (1.7) or Hispanics (1.3). Fewer psychosis-related visits were injury or overdose-related (18%) compared to all mental health visits (30%; Fisher's p b 0.001). Medicare (30%) and Medicaid (24%) provided insurance for most cases. Compared to all mental health visits, psychosis-related visits were approximately half as likely to be privately insured (29% v. 15%; Fisher's p b 0.001). While overall mental-health ED visits increased, the rate of psychosis-related visits per capita remained stable (Table 2). No increases were observed by gender, racial/ethnic group or geographic region. Visit rates increased in those aged 50 to 69, by 83%, from 1.2 to 2.2 per 1000 U.S. population across the decade. Psychosis-related visits in non-metropolitan (rural) areas decreased, accompanied by a reciprocal increase in metropolitan areas (Table 3). Psychosis-related visits for Medicare patients decreased (Table 4).
Table 2 Trends in rates for all mental health-related ED Visits (MHRV) and psychosisrelated ED visits — by gender, age and race/ethnicity. Trend
By year
Overall
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Female
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
1642 1387 1401 1580 2154
Male
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
1718 1447 1506 1727 2212
White, non-Hispanic
1992–1993 2163 1994–1995 1766 1996–1997 1800 1998–1999 1902 2000–2001 2715
Black, non-Hispanic
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
721 650 696 888 907
Hispanic (all)
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
372 306 318 428 566
b 15 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
308 260 263 260 360
15–29 years
1992–1993 819 1994–1995 711 1996–1997 645 1998–1999 773 2000–2001 1003
30–49 years
1992–1993 1396 1994–1995 1239 1996–1997 1305 1998–1999 1451 2000–2001 1821
50–69 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
478 361 406 487 679
N =70 years
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
359 263 288 336 503
4. Discussion Psychosis-related ED visits remained stable while mental health ED visits increased by more than a third (Larkin et al., 2005). This stability is notable given radical changes in treatment and prescribing practices for psychosis during this decade. In 1992, clozapine was the only SecondGeneration Antipsychotic (SGA) available, but by 2001, 84.5% of all office-based physician visits for antipsychotics included a SGA prescription (Aparasu et al., 2005). Our finding suggests that, overall, increased prescription of SGAs did not reduce ED visits. Psychosis-related ED visit rates for Medicare beneficiaries decreased significantly while ED Medicare visits for mental health, mood, anxiety, substance, and suicide-related problems increased (Larkin et al., 2005, 2008; Smith et al., 2008), and while the number of Medicare enrollees also increased (“Centers for Medicare and Medicaid Services: Medicare Enrollment Reports”; Program Information on Medicaid & State Children's Health on Medicaid & State Children's Health Insurance Program (SCHIP)). Increased Medicaid enrollment may represent greater penetration among populations with low rates of psychosis and/or low rates of ED utilization, perhaps especially likely where enrollment growth has been attributable to waiver programs like the California Family Planning Access Care and Treatment program (“Family Planning, Access, Care and Treatment Program”). It is also possible that managed care had a greater cost-containment effect for psychosis-related visits than other mental-health visits, since individuals with higher levels of psychosis are more likely to have had a period of enrollment in public managed mental health plans (Wingerson et al., 2001). Diversion of those with SMI to jails and prisons (Greenberg and Rosenheck, 2008; Lamb and Weinberger, 2005) might also help explain this trend. Visit rates increased only in 50- 69-year-olds. Because we corrected for population growth by age, this trend cannot be explained by the general aging of the population, unless the shift to an older age distribution is greater for those with
N⁎ = Actual sampled visits.
All MHRV
Psychosis visits
N⁎
Rate per 1000
Rate per 1000
3360 2834 2907 3307 4366
16.7(15.0,18.3) 17.7(16.0,19.3) 19.8(17.9,21.6) 21.8(19.6,23.9) 22.3(20.5,24.1) p = 0.002 16.2(14.4,18.1) 17.1(15.3,19.0) 19.5(17.4,21.6) 21.7(19.3,24.2) 22.4(20.3,24.4) p = 0.002 17.1(15.2,19.0) 18.2(16.2,20.1) 20.0(17.9,22.2) 21.8(19.3,24.2) 22.3(20.2,24.4) p = 0.002 15.2(13.6,16.8) 16.4(14.8,18.0) 18.0(16.2,19.8) 21.0(18.8,23.2) 22.3(20.4,24.3) p = 0.002 26.1(22.2,30.0) 27.1(22.9,31.3) 36.0(31.0,41.0) 34.7(29.6,39.9) 31.4(27.4,35.3) p = 0.234 18.6(14.9,22.2) 18.0(14.5,21.4) 17.3(13.8,20.8) 17.7(14.1,21.2) 19.0(16.0,22.0) p = 0.853 7.7(5.9,9.5) 6.8(5.1,8.5) 8.4(6.3,10.5) 8.3(6.2,10.4) 9.3(7.3,11.2) p = 0.101 18.2(15.1,21.4) 20.4(17.0,23.9) 21.4(17.8,25.1) 23.4(19.2,27.7) 24.1(20.5,27.6) p = 0.002 21.6(18.4,24.8) 23.9(20.5,27.3) 26.7(23.0,30.5) 29.5(25.2,33.9) 29.6(26.0,33.2) p = 0.005 14.6(11.5,17.6) 13.7(10.6,16.7) 17.2(13.8,20.5) 17.7(14.0,21.5) 18.6(15.5,21.7) p = 0.036 20.6(15.9,25.3) 22.3(17.3,27.2) 22.4(17.3,27.6) 29.5(23.0,36.1) 32.0(26.2,37.9) p = 0.018
1.9(1.6,2.3) 1.8(1.5,2.1) 2.0(1.6,2.3) 2.0(1.6,2.5) 2.0(1.7,2.3) p = 0.182 1.6(1.2,2.0) 1.9(1.4,2.3) 1.6(1.2,2.0) 1.9(1.4,2.4) 1.9(1.4,2.3) p = 0.308 2.3(1.8,2.8) 1.7(1.2,2.2) 2.3(1.8,2.9) 2.2(1.6,2.8) 2.2(1.7,2.6) p = 0.761 1.7(1.3,2.0) 1.6(1.2,1.9) 1.6(1.2,2.0) 1.9(1.5,2.3) 1.8(1.4,2.1) p = 0.278 4.1(2.7,5.4) 3.8(2.5,5.1) 4.8(3.2,6.4) 4.1(2.6,5.7) 4.2(3.0,5.5) p = 0.728 1.02(0.4,1.6) 1.2(0.3,2.1) 1.2(0.4,1.9) 1.3(0.4,2.3) 1.8(1.0,2.6) p = 0.095 0.3 0.1 0.1 0.1 0.2 p = 0.559 2.1(1.3,2.9) 1.8(0.9,2.8) 1.7(0.9,2.5) 1.9(0.9,2.9) 1.5(0.8,2.1) p = 0.121 2.5(1.7,3.4) 2.5(1.6,3.3) 3.3(2.3,4.4) 3.2(2.1,4.3) 2.9(2.1,3.8) p = 0.255 1.2(0.5,1.9) 1.7(0.7,2.7) 1.6(0.7,2.5) 2.2(0.9,3.5) 2.2(1.3,3.2) p = 0.024 4.7(2.7,6.7) 3.7(1.9,5.4) 2.9(1.2,4.6) 2.5(1.0,4.0) 4.2(2.5,5.8) p = 0.523
31
A. Pandya et al. / Schizophrenia Research 110 (2009) 28–32
psychosis than for other Americans. More plausible explanations include that older psychotic patients find it hard to break habits of seeking ED care (Parks et al., 2006) or that older individuals with late-onset psychosis in the context of dementia contribute to increased utilization by older people. Regardless of source, this trend should be considered in service planning, resource allocation and bridging gaps between emergency medicine, geriatrics and mental health (Cuffel et al., 1996; Jeste et al., 1999). We found psychosis-related ED visits increased in metropolitan areas, coincident with a reciprocal decrease in rural settings. This trend might be explained by a net migration of individuals with psychosis from rural to urban regions, in order to access urban-based psychiatric hospitals and/or specialist psychiatric care (Peen and Dekker, 2004; Mandersheid and Henderson, 1999). We found psychosis-related ED usage was higher for Black, non-Hispanic individuals, consistent with prior findings showing that racial minorities with severe mental illness exhibit greater use of EDs (Young et al., 2005). Our study has several limitations: VA hospitals were excluded; data do not permit analysis of repeat visitors; psychiatric diagnostic practice moved from use of DSM-III to
Table 4 Trends in rates for all mental health-related ED visits and psychosis-related ED visits — by insurance status.
Table 3 Geographic trends in rates for all mental health-related ED visits (MHRV) and psychosis-related ED VISITS. Trend
By year
All MHRV
Rate per 1000 Rate per 1000 US US
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
967 772 877 1330 1556
Midwest
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
753 734 652 572 762
South
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
878 716 777 844 1153
West
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
762 612 601 561 895
18.1(15.6,20.6) 23.3(20.3,26.3) 25.3(22.0,28.6) 28.5(24.4,32.5) 27.8(24.6,31.0) p = 0.022 20.5(17.8,23.2) 18.8(16.3,21.4) 21.2(18.4,24.0) 21.5(18.6,24.5) 21.5(19.0,24.0) p = 0.232 13.7(11.9,15.4) 15.1(13.2,17.0) 16.9(14.8,19.0) 20.0(17.5,22.6) 20.8(18.6,23.0) p = 0.002 16.0(13.6,18.3) 15.4(13.1,17.7) 18.0(15.5,20.4) 19.0(16.1,21.8) 21.8(19.2,24.4) p = 0.018 15.1(13.5,16.7) 17.5(15.9,19.2) 19.6(17.8,21.5) 22.1(19.8,24.3) 24.5(22.5,26.6) p = 0.000 26.9(23.1,30.7) 18.3(15.5,21.0) 20.2(17.4,23.0) 20.8(17.8,23.7) 16.1(13.8,18.3) p = 0.035
Metropolitan area
Non-metropolitan area
1992–1993 3010 1994–1995 2561 1996–1997 2470 1998–1999 2903 2000–2001 3906 1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
N⁎ = Actual sampled visits.
350 273 437 404 460
% of All MHRV
% of psychosis visits
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Medicare
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Medicaid
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Self-pay
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
Other
1992–1993 1994–1995 1996–1997 1998–1999 2000–2001
27.1% 28.5% 29.2% 26.7% 31.1% p = 0.331 18.6% 15.3% 14.9% 18.1% 19.7% p = 0.535 22.9% 17.8% 18.8% 21.3% 19.1% p = 0.608 18.8% 19.5% 23.5% 21.3% 19.6% p = 0.643 12.5% 18.9% 13.6% 12.6% 10.5% p = 0.374
12.4% 20.8% 16.8% 9.4% 15.2% p = 0.766 36.9% 21.3% 27.2% 31.5% 34.5% p = 0.046 30.9% 18.9% 18.5% 28.0% 22.3% p = 0.677 16.5% 17.1% 21.5% 15.6% 16.5% p = 0.116 9.3% 16.8% 9.0% 8.8% 8.0% p = 0.618
Psychosis visits
N⁎ Northeast
Year Private
2.1(1.4,2.9) 2.0(1.2,2.8) 2.1(1.3,3.0) 3.0(1.9,4.1) 3.0(2.1,3.9) p = 0.059 3.4(2.5,4.3) 1.9(1.3,2.6) 2.5(1.6,3.4) 2.0(1.3,2.7) 2.0(1.3,2.7) p = 0.206 1.2(0.8,1.6) 1.7(1.1,2.2) 1.7(1.2,2.1) 2.0(1.3,2.6) 1.8(1.4,2.3) p = 0.101 1.3(0.8,1.9) 1.7(1.0,2.4) 1.8(1.2,2.4) 1.4(0.8,2.0) 1.6(1.0,2.1) p = 0.711 1.8(1.5,2.2) 1.8(1.4,2.1) 2.2(1.8,2.6) 2.2(1.8,2.7) 2.3(1.9,2.7) p = 0.027 2.5 2.0 1.2(0.7, 1.8) 1.4(0.8,2.1) 1.2(0.7,1.7) p = 0.047
DSM-IV during the study period, incorporating criteria changes for psychotic disorders. While coders used a consistent definition of psychosis, their dependence on clinical documentation may have led to some diagnostic drift as clinicians became increasingly familiar with DSM-IV criteria. Against the national backdrop of rising ED oversubscription, stable visit rates for psychosis warrant further investigation. Future work should explore trends toward increased age and urbanization of ED-reliant psychotic patients, as these trends have important resource implications for both emergency and mental health care systems. Role of funding source The authors of this study received no funds for this research. Conflict of interest The authors have no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence, or be perceived to influence, their work. Acknowledgment None.
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