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Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 18, Issue 3, 2015. Pages: 115-124
Published Online: 1 September 2015

Copyright © 2015 ICMPE.


 

Thirty-Day Hospital Readmission for Medicaid Enrollees with Schizophrenia: The Role of Local Health Care Systems

Alisa B. Busch,1* Arnold M. Epstein,2 Thomas G. McGuire,3 Sharon-Lise T. Normand,4 Richard G. Frank5

1MD, MS, Assistant Professor of Psychiatry & Health Care Policy, Harvard Medical School; Chief, Health Services Research Division, Partners Psychiatry and Mental Health; Director, Integration of Clinical Measurement & Health Services Research, McLean Hospital, Belmont, MA, USA
2MD, MA, John H. Foster Professor of Health Policy and Management, Harvard School of Public Health; Chair, Department of Health Policy and Management, Harvard School of Public Health; Professor of Medicine and Health Care Policy, Harvard Medical School, Boston, MA, USA
3PhD, Professor of Health Economics, Harvard Medical School, Boston, MA, USA
4PhD, Professor of Health Care Policy (Biostatistics), Harvard Medical School; Professor of Biostatistics, Harvard School of Public Health, Boston, MA, USA
5PhD, Margaret T. Morris Professor of Health Economics, Harvard Medical School, Boston, MA, USA

* Correspondence to:  Alisa Busch, MD, McLean Hospital, Mailstop 226, 115 Mill St., Belmont, MA 02478, USA
Tel.  +1-617-855 2989
Fax: +1-617-855 2174
E-mail: abusch@partners.org

Source of Funding: NIMH R01 MH081819.

Abstract

Hospital readmission, an increasing focus in healthcare policy, may reflect substandard care and is costly.  Persons with schizophrenia have among the highest readmission rates. We examine 30-day mental health readmission for persons with schizophrenia and county-level community treatment characteristics in 18 U.S. state Medicaid programs using Medicaid administrative and the Area Health Resource File data from 2005. We fit 30-day readmission regression models that included county-level characteristics (treatment quality, mental health hospital utilization, community treatment capacity), while controlling for enrollee demographic and comorbiidty characteristics. Higher county rates of mental health visits within 7-days post-hospitalization and lower rates of mental health hospitalization were associated with lower readmission rates. Although not a primary focus, enrollee substance use disorder and medical comorbidity were associated with readmission.To reduce 30-day mental health readmissions, healthcare policy should focus on county-level factors that contribute to hospitalization in general, improving transitions to community care, and patient comorbidity.

 

Background: Examining health care system characteristics possibly associated with 30-day readmission may reveal opportunities to improve healthcare quality as well as reduce costs.

Aims of the Study: Examine the relationship between 30-day mental health readmission for persons with schizophrenia and county-level community treatment characteristics.

Methods: Observational study of 18 state Medicaid programs (N = 274 counties, representing 103,967 enrollees with schizophrenia -28,083 of whom received ³1 mental health hospitalization) using Medicaid administrative and United States Area Health Resource File data from 2005. Medicaid is a federal-state program and major health insurance provider for low income and disabled individuals, and the predominant provider of insurance for individuals with schizophrenia. The Area Health Resource File provides county-level estimates of providers. We first fit a regression model examining the relationship between 30-day mental health readmission and enrollee characteristics (e.g., demographics, substance use disorder [SUD], and general medical comorbidity) from which we created a county-level demographic and comorbidity case-mix adjuster. The case-mix adjuster was included in a second regression model examining the relationship between 30-day readmission and county-level factors: (i) quality (antipsychotic/visit continuity, post-hospital follow-up); (ii) mental health hospitalization (length of stay, admission rates); and (iii) treatment capacity (e.g., population-based estimates of outpatient providers/clinics). We calculated predicted probabilities of readmission for significant patient and county-level variables.

Results: Higher county rates of mental health visits within 7-days post-hospitalization were associated with lower readmission probabilities (e.g., county rates of 7-day follow up of 55% versus 85%, readmission predicted probability (PP) [95%CI] = 16.1% [15.8%-16.4%] versus 13.3% [12.9%-13.6%]). In contrast, higher county rates of mental health hospitalization were associated with higher readmission probabilities (e.g., country admission rates 10% versus 30%, readmission predicted probability = 11.3% [11.0%-11.6%] versus 16.7% [16.4%-17.0%]). Although not our primary focus, enrollee comorbidity was associated with higher predicted probability of 30-day mental health readmission: PP [95%CI] for enrollees with SUD = 23.9% [21.5%-26.3%] versus 14.7% [13.9%-15.4%] for those without; PP [95% CI] for those with = three chronic medical conditions = 25.1% [22.1%-28.2%] versus none = 17.7% [16.3%-19.1].

Discussion: County rates of hospitalization and 7-day follow-up post hospital discharge were associated with readmission, along with patient SUD and general medical comorbidity. This observational design limits causal inference and utilization patterns may have changed since 2005. However, overall funding for U.S. Medicaid programs remained constant since 2005, reducing the likelihood significant changes. Last, our inability to identify community capacity variables associated with readmission may reflect imprecision of some variables as measured in the Area Health Resource File.

Implications for Health Care Provision and Use & for Health Policies: Healthcare policy and programming to reduce 30-day mental health readmissions should focus on county-level factors that contribute to hospitalization in general and improving transitions to community care, as well as patient comorbidity.

Implications for Further Research: Given the likely importance of local care systems, to reduce readmission future research is needed to refine community-level capacity variables that are associated with reduced readmissions; and to evaluate models of care coordination in this population.

Received 17 March 2015; accepted 20 July 2015

Copyright 2015 ICMPE