The Role of Mental Health Disease in Potentially Preventable Hospitalizations: Findings From a Large State.

BACKGROUND: Preventable hospitalizations are markers of potentially low-value care. Addressing the problem requires understanding their contributing factors. OBJECTIVE: The objective of this study is to determine the correlation between specific mental health diseases and each potentially preventable hospitalization as defined by the Agency for Healthcare Research and Quality. DESIGN/SUBJECTS: The Texas Inpatient Public Use Data File, an administrative database of all Texas hospital admissions, identified 7,351,476 adult acute care hospitalizations between 2005 and 2008. MEASURES: A hierarchical multivariable logistic regression model clustered by admitting hospital adjusted for patient and hospital factors and admission date. RESULTS: A total of 945,280 (12.9%) hospitalizations were potentially preventable, generating $6.3 billion in charges and 1.2 million hospital days per year. Mental health diseases [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.22-1.27] and substance use disorders (OR, 1.13; 95% CI, 1.12-1.13) both increased odds that a hospitalization was potentially preventable. However, each mental health disease varied from increasing or decreasing the odds of potentially preventable hospitalization depending on which of the 12 preventable hospitalization diagnoses were examined. Older age (OR, 3.69; 95% CI, 3.66-3.72 for age above 75 years compared with 18-44 y), black race (OR 1.44; 95% CI, 1.43-1.45 compared to white), being uninsured (OR 1.52; 95% CI, 1.51-1.54) or dual-eligible for both Medicare and Medicaid (OR, 1.23; 95% CI, 1.22-1.24) compared with privately insured, and living in a low-income area (OR, 1.20; 95% CI, 1.17-1.23 for lowest income quartile compared with highest) were other patient factors associated with potentially preventable hospitalizations. CONCLUSIONS: Better coordination of preventative care for mental health disease may decrease potentially preventable hospitalizations.

Mortality Rates and Excess Death Rates for the Seriously Mentally Ill.

OBJECTIVES: -To compute mortality rates and excess death rates for patients with serious mental illness, specific to categories of gender, age and race/ethnicity. BACKGROUND: -People with serious mental illness are known to be at greatly increased risk of mortality across the lifespan. However, the measures of mortality reported for this high-risk population are typically only summary measures, which do not provide either the mortality rates or excess death rates needed to construct life tables for individuals with serious mental illness. METHODS: -Mortality rates were computed by dividing the number of deaths by the amount of life-years lived in strata specific to gender, age and race/ethnicity. Age-specific excess death rates were determined as the difference between the study population rate and the corresponding general population rate in each stratum. To compute excess death rates beyond observed ages in the cohort, a method with documented reliability and validity for chronic medical conditions was used. RESULTS: -For the cohort with mental illness, mortality rates for Black and White females were mostly equal, and consistently greater than those for Hispanic females; excess death rates for females displayed a similar pattern. Among males, mortality rates were highest for Whites, with Hispanics and Blacks close in magnitude at all ages. Excess death rates for males showed more divergence between the categories of race/ethnicity across the age range. CONCLUSIONS: -Mortality rates specific to categories of gender, age and race/ethnicity show sufficient differences as to make them the preferred way to construct life tables. This is especially true in contrast to broader summary measures such as risk ratios, standardized incidence rates, or life expectancy.

Association between depressed mood and perceived weight in middle and high school age students: Texas 2004-2005.

Research exploring the relationship between weight perception and depressed mood among adolescents is limited in the United States. The purpose of this study is to examine the association of perceived versus actual body weight and depressed mood in a representative sample of 8th and 11th grade public school students in Texas. Using data from the 2004-2005 School Physical Activity and Nutrition (SPAN) study, logistic regression analyses were conducted to assess the association of weight perception with depressed mood. Healthy weight students who perceived themselves to be a healthy weight were the reference group for all analyses. A high prevalence of misperception of body weight was observed. Overweight and obese 8th grade girls and boys who perceived themselves to be overweight had increased odds of depressed mood [Girls: OR 1.70 (95% CI: 1.07-2.69), Boys: OR 2.05 (95% CI: 1.16-3.62)]. Healthy weight 8th grade girls who perceived themselves to be overweight had 2.5 times greater odds of depressed mood (OR 2.63, 95% CI: 1.54-4.50). Healthy weight boys who perceived themselves to be underweight had more than twice the odds (OR 2.18, 95% CI: 1.23-3.89) of depressed mood. No weight category was significantly associated with depressed mood in boys or girls in 11th grade. The present study suggests that weight misperceptions are associated with depressed mood in young adolescents. Education about healthy body size is necessary to correct the common weight misperceptions observed. The high prevalence rates of depressed mood suggest a greater need for research into understanding factors that may contribute to depressed mood in adolescents.

Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders.

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.

Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012.

BACKGROUND: Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities. METHODS: A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365. RESULTS: We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without. CONCLUSIONS: Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.

Relation of Mental Health to Alcohol and Substance Use Among Texas College Students.

We examined the effect of mental health problems and difficulties on alcohol, tobacco, and other drug (ATOD) use among college students by using the 2013 Texas College Survey of Substance Use (n=11,216), which includes the K6 screening scale for severe mental illness (SMI). Students' K6 scores were used to classify them into 3 groups: those likely to have SMI (9% with scores ≥ 13), those with some mental health problems (36%), and those without mental health issues (55% with scores ≤ 4). Questions regarding ATOD use were analyzed using these 3 groups. Alcohol use was not significantly associated with K6 scores, although problematic alcohol behaviors as measured by the CAGE test were. Higher cigarette use was significantly associated with higher K6 scores. Finally, both higher marijuana and higher drug use (across 9 other individual drugs) were significantly associated with higher K6 scores. Although higher K6 scores were associated with higher rates of drug use, most students with high K6 scores did not use drugs. However, given the higher level of risk, drug and alcohol interventions should be made available for those students who receive mental health counseling.

Mental Health Services in Texas Jails.

Jails and prisons in the United States have become the places where people with mental illness go. Texas jails were surveyed in 2012 to learn how they screened inmates for mental illness. Of these jails, 13% responded. Most screened for suicidal ideation and whether or not an inmate took a medicine. About half the jails offered in-house care, and the other half referred inmates to the local mental health authority. Most jails had a formal jail diversion program, and most thought that mental health illness was increasing. About half had an annual 4-hour training program for staff. Recommendations are made for future care in jails.

Factors Associated With Potentially Preventable Pediatric Admissions Vary by Diagnosis: Findings From a Large State.

OBJECTIVES: The objective of this study was to determine characteristics associated with potentially preventable pediatric admissions as defined by the Agency for Healthcare Research and Quality. METHODS: The Texas Inpatient Public Use Data File, an administrative database of hospital admissions, identified 747 040 pediatric admissions ages 0 to 17 years to acute care facilities between 2005 and 2008. Potentially preventable admissions included 5 diagnoses: asthma, perforated appendicitis, diabetes, gastroenteritis, and urinary tract infection. A hierarchical multivariable logistic regression model clustered by admitting hospital and adjusted for admission date estimated the patient and hospital factors associated with potentially preventable admission. RESULTS: An average of 71 444 hospital days per year and 14.1% (N = 105 055) of all admissions were potentially preventable, generating $304 million in hospital charges per year in 1 state. Younger age (odds ratio [OR]: 2.88 [95% confidence interval (CI): 2.80-2.96]), black race (OR: 1.48 [95% CI: 1.45-1.52]) or Hispanic ethnicity (OR: 1.06 [95% CI: 1.04-1.08]), lower income (OR: 1.11 [95% CI: 1.02-1.20]), comorbid substance abuse disorder (OR: 2.03 [95% CI: 1.75-2.34]), and admission on a weekend (OR: 1.05 [95% CI: 1.03-1.06]) or to a critical access hospital (OR: 1.61 [95% CI: 1.20-2.14]) were high-risk factors for potentially preventable admission, whereas Native American race (OR: 0.91 [95% CI: 0.85-0.98]), government insurance (OR: 0.83 [95% CI: 0.89-0.96]) or no insurance (OR: 0.93 [95% CI: 0.89-0.96]), and living in a rural county (OR: 0.70 [95% CI: 0.68-0.73]) were associated factors. However, most factors varied from high to low odds depending on which of the 5 potentially preventable diagnoses was examined. CONCLUSIONS: Potentially preventable admissions represent a high burden of time and costs for the pediatric population, but strategies to reduce them should be tailored to each diagnosis because the associated factors are not uniform across all potentially preventable admissions.

Weight changes in teens on psychotropic medication combinations at Austin State Hospital.

Psychiatrists commonly treat adolescents with multiple psychotropic medications simultaneously. We studied the effects of psychotropic medications on the weight of adolescent patients at Austin State Hospital between June 1997 and December 2001. The medication combinations that caused the largest weight increases were olanzapine with valproic acid, and olanzapine with venlafaxine. The biggest weight loss combinations were valproic acid with bupropion, and valproic acid with venlafaxine. Medications drove a substantial portion of the changes in weight, not other variables. The specific medication prescribed, rather than the total number of medications, predicted weight gain. As current inpatient adolescents are receiving multiple medications and their weight is subsequently being affected, more study is needed to better understand these effects.

General medical care external hospitalizations for patients in Texas state mental health hospitals.

We explored the characteristics of general medical hospital admissions for patients in state mental health hospitals. Data were extracted from a statewide database of all hospital discharges for 5 years identified as general medical hospital admissions that occurred during the stay of patients at state mental health hospitals. Across the 9 mental health hospitals in the state system, rates of admission to general medical hospitals varied significantly from 0.7% to 3.7%. On average, of the 1.9% of all state mental health inpatients who had a general hospital admission, 25% occurred within 4 days of admission to the mental hospital. The average general hospitalization lasted 5.7 days. The reported total charge for all stays was $34 million. Dehydration (15%), hypertension (10%), and diabetes (10%) were the most frequent diagnoses. Thirteen percent of diagnoses met preventable hospitalization criteria. Given the variability among hospitals in admission rates and the number of preventable conditions, improvements in patient care and health as well as reduced admissions to general medical hospitals may be possible.

Shortage of child and adolescent psychiatrists in Texas.

This study was conducted to determine how the current shortage of Texas child and adolescent psychiatrists (CAPs) impacts the delivery of mental health care services to indigent Texas youth. First, Texas Medical Board data detailed how many counties had CAPs and how many did not. Second, statewide Medicaid data revealed the number of prescriptions for psychotropics written for Medicaid youth by CAPs and non-CAPs. Third, Local Mental Health Authority (LMHA) encounter data of youth seen by a CAP were analyzed. Fourth, state census data gave the location and characteristics of youth by county. Eighty percent of counties in Texas, predominantly rural, do not have a CAP. Non-CAPs wrote 66% of psychotropic medication prescriptions written for Medicaid youth. Those in nonmetropolitan areas were more likely to see a non-CAP than were Medicaid youth in metropolitan areas. For youth seen by an LMHA, those in rural poor counties were less likely to see a CAP than were those in urban counties. The shortage of CAPs in Texas results in an unequal distribution of psychiatric care for those receiving Medicaid prescriptions or services through LMHAs, especially in rural areas. Suggestions to correct this shortage are made.

SSRI Use and Behavioral Disruption Among Children and Adolescents at Austin State Hospital.

This study examined the effect of selective serotonin reuptake inhibitors (SSRIs) on children and adolescents' disruptive behavior. Administrative data were obtained for 1 year of child and adolescent admissions at Austin State Hospital. Two measures of disruptive behavior were operationally defined as the use of mechanical restraints and emergency medication. Between-subjects analysis compared patients who did versus those who did not receive SSRIs. Within-subject analysis was conducted only for patients receiving SSRIs to examine their disruptive behavior during medication initiation. No differences were found between patients who did versus those who did not receive SSRIs. No differences were found among patients who received SSRIs during initial versus later phases of drug use. No significant relationship between SSRI use and increased agitation, hostility, or self-harm as manifested by the number of mechanical restraints or emergency medications at any time during hospitalization was found.