Subscribe

Mental Health Conditions and Hospitalizations for Ambulatory Care Sensitive Conditions Among Veterans with Diabetes

May 2020 Vol 13, No 2 - Clinical, Original Research
Drew A. Helmer, MD, MS; Nilanjana Dwibedi, BPharm, MBA, PhD; Mazhgan Rowneki, MPH; Chin-Lin Tseng, DrPH; Dennis Fried, PhD; Danielle Rose, PhD; Nisha Jani, MPH, PhD; Usha Sambamoorthi, PhD
Dr Helmer is Director, War Related Illness and Injury Study Center (WRIISC), Veterans Affairs (VA) New Jersey Healthcare System, East Orange; Dr Dwibedi is Assistant Professor, Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown; Ms Rowneki is Health Services Data Analyst, Dr Tseng is Health Services Scientist, and Dr Fried is Epidemiologist, all at WRIISC, VA New Jersey Healthcare System; Dr Rose is Health Research Scientist, Veteran Affairs Greater Los Angeles Healthcare System, Sepulveda, CA; Dr Jani is Epidemiologist, WRIISC, VA New Jersey Healthcare System; Dr Sambamoorthi is Professor, Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy.
Download PDF
Abstract

BACKGROUND: Veterans with diabetes and mental health conditions have a higher risk for suboptimal care and complications related to their diseases than veterans with diabetes who do not have mental health conditions. We hypothesized that among veterans with diabetes, patients with mental health conditions are more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) than those without mental health conditions.

OBJECTIVE: To examine the association between depression, anxiety, and serious mental illness and hospitalizations for ACSC among veterans with diabetes after controlling for demographics and comorbidities.

METHODS: We used a retrospective cohort design with merged Veterans Health Administration (VHA) and Medicare electronic health records from 2008 to 2010. Andersen’s Behavioral Model of Health Services Use was used to select the variables associated with hospitalizations for ACSC (ie, predisposing, enabling and need characteristics, personal health practices, and external environment). We used chi-square tests and logistic regressions for our analyses.

RESULTS: Among the dual VHA/Medicare-enrolled veterans with any hospitalization in 2010, 30% had hospitalizations for ACSC. Veterans with diabetes and co-occurring depression were at increased likelihood to be hospitalized for ACSC, after adjusting for all other covariates (adjusted odds ratio, 1.08; 95% confidence interval, 1.04-1.11). Similar findings were observed for anxiety. Veterans with serious mental illness were as likely as veterans without serious mental illness to be hospitalized for ACSC.

CONCLUSION: Veterans with depression and anxiety were more likely to be hospitalized for any or acute ACSC than veterans without mental health conditions. Patients hospitalized for acute ACSC were more susceptible than patients hospitalized for chronic ACSC to have mental health conditions. As the VHA continues to evolve from care provider to community care payer (per the Veterans Affairs MISSION Act), our results highlight the ongoing importance of care coordination and communication between payers and providers.

KEY WORDS: ambulatory care sensitive conditions, anxiety, depression, diabetes, Medicare, mental health conditions, preventable hospitalization, veterans, Veterans Health Administration

Am Health Drug Benefits.
2020;13(2):61-71

Manuscript received August 14, 2019
Accepted in final form November 12, 2019

Disclosures are at end of text

Among veterans, mental health conditions, such as serious mental illness, depression, and anxiety, often coexist with diabetes.1 Veterans with coexisting diabetes and mental health conditions are often vulnerable to receiving poor-quality care.1 One important measure of quality healthcare is preventable hospitalizations, also referred to as hospitalizations for ambulatory care sensitive conditions (ACSC).2 Hospitalizations for ACSC putatively reflect quality of care, because they can be avoided by access to effective primary care.3 Thus, hospitalizations for ACSC have gained attention as a quality improvement indicator in the Veterans Health Administration (VHA) and elsewhere.4-6

Compared with veterans with diabetes only, veterans with mental health conditions and diabetes may have higher rates of hospitalization for ACSC, even when access to primary care is equivalent for all veterans enrolled in the VHA.7 The presence of mental health conditions can complicate the management of diabetes, making these conditions among the strongest risk factors for hospitalizations for ACSC in veterans.8 Veterans with diabetes and serious mental illness are at increased risk for suboptimal care and complications related to their diseases.8,9 Many published articles substantiate the vulnerability of patients with diabetes and serious mental illness in underdiagnosis, lack of preventive care, and suboptimal medical care, especially for patients with serious mental illness.8-12 Furthermore, veterans with mental health conditions may be more likely to be homeless,13 and more likely to be at risk for family instability,14 which may put them at greater risk for not receiving necessary care and for having ACSC.

Using a logistic regression analysis, Ajmera and colleagues did not find a statistically significant relationship between self-reported mental illness and hospitalizations for ACSC among dually enrolled VHA/Medicare veterans.15 In a study that was not specific to veterans, Medicare beneficiaries with multiple chronic physical conditions and mental illness were 60% more likely to be hospitalized for ACSC than individuals without multiple chronic conditions.16 Among hospitalized patients in New York, individuals with mental illness had higher rates of hospitalizations for ACSC than those without mental illnesses.17 In a study by Davydow and colleagues, older Americans with neuropsychiatric disorders were at greater risk for hospitalizations for ACSC than patients without neuropsychiatric disorders.18 Using data from 2000 through 2009, Bhattacharya and colleagues showed that among Medicare beneficiaries with at least 1 of 7 prevalent chronic conditions, patients with depression were more likely to have higher rates of any hospitalizations for ACSC compared with those without depression (adjusted odds ratio, 1.53; 95% confidence interval, 1.26-1.86; P <.0001).19

It is important to study the relationship between mental health conditions and hospitalizations for ACSC among VHA/Medicare dually enrolled veterans with diabetes for several reasons. Of VHA-enrolled veterans with diabetes, 31% have mental health conditions.20 Veterans with diabetes require care from multiple specialists and may require greater coordination of ambulatory care to mitigate the increased risk for hospitalizations for ACSC.21 Among veterans with diabetes, dual healthcare system use has been associated with compromised glycemic control, and may increase the risk for hospitalizations for ACSC.22

Between 2001 and 2014, the total costs associated with diabetes-related preventable hospitalizations in the United States increased by $92.9 million annually (from $4.5 billion to $5.9 billion).23 In 2016, Mkanta and colleagues reported that hospitalizations for ACSC have the potential to increase the overall cost of hospitalizations in the Medicaid program.24 Because Medicare has stopped paying for some potentially preventable hospitalizations and other healthcare payers have followed,25,26 more of the burden of preventable hospitalizations is now falling on hospitals in terms of uncompensated care, making this a topic of considerable interest in healthcare administration.

Therefore, the main objective of our study was to examine the association between depression, anxiety, and serious mental illness and hospitalizations for ACSC among veterans with diabetes after controlling for factors based on Andersen’s Behavioral Model of Health Services Use (ie, predisposing, enabling and need characteristics, personal health practices, and external environment). Our hypothesis was that among veterans with diabetes, patients with mental health conditions would be more likely to be hospitalized for ACSC than those without mental health conditions.

We used an adapted Andersen’s Behavioral Model of Health Services Use to guide our selection of variables associated with preventable hospitalizations.27 According to this theoretical framework, preventable hospitalizations may be affected by (1) predisposing factors (eg, age, sex, and race/ethnicity); (2) enabling factors (eg, prescription drug insurance coverage); (3) need factors (eg, physical health); (4) personal health practices (eg, smoking); and (5) external environment (eg, region of residence).27

We selected the Andersen’s model framework for this study for the following reasons: (1) it enabled us to adjust for a comprehensive list of factors associated with preventable hospitalizations; (2) it is well-suited for studies that have many variables representing the same domain; and (3) it is extensively used in health services research to explain healthcare utilization.28 The variables included in each domain were derived from the standard list of variables cited in a systematic review of 328 studies published between 1998 and 2011 that used Andersen’s behavioral model as the conceptual framework.28

Methods

We used a retrospective dynamic cohort design with 2 calendar years (2008 and 2009) for the baseline period, and 1 calendar year (2010) for the follow-up period.

The study population was restricted to all elderly (aged ≥66 years) VHA users who were enrolled in a Medicare fee-for-service program and were diagnosed with diabetes. Veterans with diagnosed diabetes were identified using a previously validated algorithm.29 This algorithm uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for diabetes from inpatient or outpatient physician visits (VHA and Medicare) over a 24-month period. We restricted the study population to VHA/Medicare dual enrollees aged ≥66 years who were eligible for Medicare Part A and Part B and were not enrolled in a Medicare HMO (Figure).

Figure

We excluded veterans with diagnosed diabetes who received care in long-term care facilities during the study period. We also excluded veterans who died before the start of the follow-up period, and those who did not have any hospitalizations in 2010. Thus, our final study population consisted of 151,614 elderly veterans with diabetes mellitus who were dually enrolled in VHA and Medicare services and had at least 1 hospitalization in 2010 (Figure).

We linked VHA administrative data with Medicare claims data from 2008 through 2010. The data included demographic summary; inpatient, outpatient, and long-term care file extracts from VHA Corporate Data Warehouse production tables30; Managerial Cost Accounting System tables30; and Veterans Affairs Information Resource Center (VIReC) Medicare data files.31 We also used Medicaid long-term care files from VIReC.

Dependent Variable: Hospitalizations for Ambulatory Care Sensitive Conditions

We used patient hospitalizations during the outcome year 2010. We restricted our analysis to a cohort of hospitalized patients who were hospitalized for specific reasons. Our focus was on hospitalizations that can be prevented. Some hospitalizations may be appropriate (eg, hospitalizations for the treatment of cancer, heart procedures) given the health status of individuals. In addition, some hospitalizations (eg, for mental health conditions) are considered good-quality care.32 Therefore, including individuals without hospitalizations may not inform programs or policies regarding the prevention of avoidable hospitalizations. In addition, standard practice in the literature has been to use hospital discharge databases or hospitalized patients.33 Furthermore, by restricting our analysis to hospitalized patients, we can ensure that veterans in our sample are similar in terms of their illness severity.

We adopted the Agency for Healthcare Research and Quality (AHRQ)’s definition of the Prevention Quality Indicators (PQIs) as our definition of hospitalizations for ACSC.34 We identified the PQIs based on the associated ICD-9-CM diagnostic codes. The PQIs we measured included diabetes, the short-term complications of diabetes, the long-term complications of diabetes, chronic obstructive pulmonary disease (COPD), asthma, hypertension, congestive heart failure, dehydration, bacterial pneumonia infections, urinary tract infections, angina without a procedure, uncontrolled diabetes, and lower-­extremity amputations.

Based on the AHRQ’s definitions of the following terms, we distinguished between any hospitalizations for ACSC; hospitalizations for ACSC for acute conditions, including dehydration, bacterial infection, and urinary infection; and hospitalizations for ACSC for chronic conditions, including the long-term complications of diabetes, the short-term complications of diabetes, COPD/asthma, hypertension, congestive heart failure, angina without a procedure, uncontrolled diabetes, and lower-extremity amputation.

Key Independent Variables: Serious Mental Illness, Depression, and Anxiety

We used a previously published algorithm20 and ICD-9-CM codes to identify serious mental illness, which included schizophrenia (295.x), bipolar disorder (296.0-296.1, 296.4-296.8), and other psychoses (296.9, 297.x, 298.x). Depression was identified with the ICD-9-CM codes 296.20 to 296.25, 296.30 to 296.35, 300.4, 309.1, and 311.35 The ICD-9-CM codes 300.0x, 300.2x, 300.3, and 308.3 defined generalized anxiety disorders. All of these variables were measured in 2008 and 2009, which were the years before the outcome measurement.

Other Independent Variables

The predisposing characteristics for ACSCs included age, sex, and race/ethnicity. The enabling factors consisted of VHA priority status (reflects generosity of healthcare benefits), marital status, and type of dual healthcare system use (supplemental, single system, fragmented). The need factors were represented by the complexity of illness and included the Diabetes Complications Severity Index (DCSI), hemoglobin A1c values, low-density lipoprotein cholesterol values, insulin use, and the presence of cancer, of COPD, and of dementia. The personal health practices included tobacco use, drugs and/or alcohol use, and body mass index. Geographic region and rurality represented the external environment. We used the adapted DCSI to measure the severity of diabetes.36

Statistical Analysis

We used chi-square tests to assess the statistical significance of unadjusted associations between mental health conditions and hospitalizations for ACSC. We conducted separate logistic regressions for each type of hospitalization for ACSC (ie, any, acute, or chronic) and each of the mental health conditions (ie, serious mental illness, depression, or anxiety). Given our interest in evaluating the association between serious mental illness and preventable hospitalizations, we had to make sure that the association was not affected by other factors, such as age, sex, race/ethnicity, VHA priority status, type of dual healthcare system use, marital status, tobacco use, drug and/or alcohol use, body mass index, DCSI, cancer, COPD, asthma, infectious disease, and dementia. Therefore, we controlled for all of these factors in the logistic regressions.

Results

Among the 151,614 dually enrolled VHA/Medicare users who were hospitalized in 2010 in our study, 149,057 (98.3%) were men, 132,474 (87.4%) were white, 95,304 (62.9%) were living in an urban area, 4602 (7.4%) had serious mental illness, 22,200 (38.2%) had depression, and 10,178 (18.4%) had anxiety disorders (Table 1). We observed significant differences in characteristics among patients with and without serious mental illness, with and without depression, and with and without anxiety.

Table 1

Overall, 30% of the study patients had any hospitalizations for ACSC, 12.8% had hospitalizations for acute ACSC, and 19.5% had hospitalizations for chronic ACSC during 2010 (Table 2). Among veterans who had a hospitalization for ACSC, 85.3% had an episode under Medicare, 12.8% had an episode at a VHA facility, and 1.3% had an episode at both systems (data not tabulated). A higher percentage of veterans with serious mental illness (33.4% vs 29.9%, respectively), depression (34.1% vs 29.3%, respectively), or anxiety (33.7% vs 29.8%, respectively) had any hospitalization for ACSC compared with their counterparts without these conditions (Table 2).

Table 2

The adjusted odds ratios and 95% confidence intervals from separate logistic regressions on any hospitalization for ACSC, hospitalization for acute ACSC, and hospitalization for chronic ACSC are shown in Table 3. Veterans with depression were more likely to have any hospitalizations for ACSC compared with veterans without depression. Similar findings were observed for anxiety disorders.

Table 3

Although the unadjusted relationship between serious mental illness and any hospitalizations for ACSC was significant, there was no significant difference after controlling for other independent variables. Veterans with diabetes and mental health conditions were more likely to be hospitalized for acute ACSC than veterans without mental health conditions. Of note, those with serious mental illness were less likely to have hospitalizations for acute ACSC. There were no significant differences in hospitalizations for chronic ACSC between veterans with and without mental health conditions.

We also conducted sensitivity analyses by excluding veterans with depression, anxiety, or serious mental illness from the no serious mental illness group, the no depression group, and the no anxiety group (N = 121,089). The findings remained the same as in our primary analyses.

Discussion

From the unadjusted relationships, we found that patients with mental health conditions had higher rates of any hospitalizations for ACSC than those without mental health conditions, which is consistent with the literature.19 Also consistent with the literature,37 the veterans with diabetes and coexisting depression or anxiety in our study were more likely to have any hospitalizations for ACSC and hospitalizations for acute ACSC than their counterparts without these conditions, even after controlling for diabetes complications, other coexisting chronic conditions, and diabetes and lipid control. Our findings suggest that patient complexity in terms of mental illness may be an important factor that affects hospitalizations for ACSC.

By contrast, mental health conditions were not associated with hospitalizations for chronic ACSC in our analysis. This lack of association may be a result of better management of chronic conditions in the VHA than by other groups, or better care coordination for chronic conditions. This hypothesis has some support in the literature38; the VHA tends to do well on chronic disease management measures and preventive health measures.38 It is possible, therefore, that hospitalizations for acute ACSC may be a more sensitive measure of access to and quality of ambulatory care for veterans with diabetes and comorbid mental health conditions.

There was an unexpected adjusted relationship between serious mental illness and less hospitalizations for chronic ACSC. This is an intriguing finding that is not consistent with the literature.39 This finding may be a survivor effect; veterans with diabetes and serious mental illness who live to age >66 years may be more like veterans with diabetes and no serious mental illness (ie, those with more debilitating serious mental illness may not survive to this age, and therefore we do not see the expected relationship of serious mental illness being associated with more hospitalizations for ACSC). It is also possible that the VHA does a better job than the private sector in managing the chronic medical conditions of veterans with diabetes and serious mental illness. Some policies and practices that are in place may proactively detect problems and direct veterans to additional services (eg, clinical reminders for veterans who are prescribed atypical antipsychotic medications, housing and employment support, intensive case management).

Although beyond the scope of this analysis, it is possible that veterans with diabetes and comorbid serious mental illness may use ambulatory healthcare more intensively, and thereby provide greater opportunity for detecting problems before they require hospitalization.

This article set out to analyze the relationship between serious mental illness, depression, anxiety, hospitalizations for ACSC, and the type of hospitalizations for ACSC among elderly VHA/Medicare dual-enrolled veterans with diabetes. A total of 30% of the study population had any hospitalizations for ACSC. This percentage is slightly higher than the rates previously reported among older adults with diabetes in California,40 among Medicare beneficiaries with diabetes,41 and among elderly Medicare beneficiaries with chronic conditions.19 These findings suggest that veterans with diabetes may be at higher risk for hospitalizations for ACSC than the general population of elderly individuals with diabetes or other chronic conditions.

Improving mental healthcare for veterans is an institutional priority for the VHA.42 Among veterans with schizophrenia, bipolar disorder, posttraumatic stress disorder, major depression, and substance use disorders, the quality of mental healthcare is better than or equal to the care delivered in the private sector.43 Despite the good-­quality mental healthcare in the VHA, VHA/Medicare-­enrolled veterans may be at risk for poor-quality hospitalizations for ACSC, because they also seek care outside the highly integrated VHA structure.

A recent report using the Access to Care module of the Medicare Current Beneficiary Survey concluded that patients with mental health conditions faced significant barriers to care, such as cost, lack of adequate insurance coverage for prescriptions, and the general avoidance of doctors.44 These barriers prevented the patients from seeking care and placed them at increased risk for hospitalizations for ACSC.44

Our findings have clinical and policy implications. As the VHA continues to focus on quality improvement efforts, these efforts need to target veterans with VHA/Medicare dual enrollment, specifically patients with mental health conditions. Our study period preceded the enactment of the Affordable Care Act and many of the healthcare delivery reform initiatives, such as accountable care organizations and patient-centered medical homes, which emphasize coordination of care among multiple providers. Future studies need to examine whether these reforms have been successful in reducing the risk for poor-quality care among patients who are enrolled in the VHA and Medicare.

The identification and awareness of risk factors by clinicians, VHA stakeholders, and the Centers for Medicare & Medicaid Services (CMS) may facilitate the development of targeted interventions that are intended to reduce the risk for preventable hospitalizations. In this context, our findings suggest that comprehensive primary care for veterans with serious mental illness is necessary to meet the missed opportunities of promoting high-quality care for older patients with diabetes who are at higher risk for hospitalizations for ACSC.40

We did not examine the relationship between treatment for mental health conditions and its impact on hospitalizations for ACSC. Among older veterans, less than 50% of veterans received mental healthcare after being diagnosed with depression.45 Although many policy initiatives have targeted removing barriers to mental health services for veterans,46 studies still report a low uptake of treatment for mental healthcare.47,48 Future studies should explore whether the risk for hospitalizations for ACSC is higher among patients with mental health conditions because of a lack of condition-­specific treatment.

Our study makes a unique contribution to the literature by analyzing the relationship between mental health conditions and hospitalizations for ACSC. The unique data set of linked VHA and Medicare fee-for-service claims enabled us to adjust for a comprehensive list of risk factors, including personal health practices and glycemic control, which are not available with claims data alone. This data set also ensured a near-complete capture of hospitalizations and diagnoses.

Our results are also relevant in the context of recently enacted legislation, the MISSION Act. The MISSION Act was passed to make timely receipt of care possible for more veterans by allowing veterans who are eligible for VHA care to obtain their healthcare from community providers at the VHA’s expense.49 As the VHA starts reimbursing for more care that is delivered by community providers, our results indicate how important it will be to develop new ways to ensure care coordination and communication among all providers.

Limitations

Our study has several limitations. The study results may not be generalizable to all veterans with diabetes, because we excluded patients who were enrolled in Medicare HMO, who may be healthier than the fee-for-service enrollees. Therefore, we may have overestimated the rates of hospitalizations for ACSC.

In addition, we could not control for all possible explanatory factors, but we did control for the common factors for which we had data.

We also did not measure social support and other social determinants that might have affected the relationship between mental health conditions and hospitalizations for ACSC.

Conclusion

Our findings confirm the increased risk for hospitalizations for ACSC among veterans with highly prevalent mental health conditions and diabetes. Overall, our findings support the premise that veterans with diabetes and comorbid mental health conditions may be at increased risk for hospitalizations for ACSC. The unexpected association between serious mental illness and hospitalizations for ACSC could indicate that special policies and practices to promote care coordination and appropriate ambulatory care may mitigate this risk for this subset of veterans.

The relationship between mental health conditions and hospitalizations for ACSC was dependent on the type of mental health conditions and the type of ACSC hospitalizations (acute vs chronic) of the patients. Our findings also suggest that among veterans with diabetes, special attention needs to be paid to acute conditions that may result in hospitalizations for ACSC.

Acknowledgment

Support for the VA/CMS data is provided by the Department of Veterans Affairs, VHA, Office of Research and Development, Health Services Research and Development, Veterans Affairs Information Resource Center (project numbers SDR 02-237 and 98-004).

Author Disclosure Statement

Dr Helmer, Dr Dwibedi, Ms Rowneki, Dr Tseng, Dr Fried, Dr Rose, Dr Jani, and Dr Sambamoorthi have no conflicts of interest to report.

This study was supported by Veterans Health Administration (VHA) Health Services Research & Development (HSRD; grant number IIR 12-401). The VHA HSRD was not involved in designing the study; collecting, analyzing, or interpreting the data; writing the manuscript; or in the decision to submit the report for publication.

References

  1. Feil DG, Pogach LM. Cognitive impairment is a major risk factor for serious hypoglycaemia; public health intervention is warranted. Evid Based Med. 2014;19:77. dx.doi.org/10.1136/eb-2013-101525.
  2. Brown AD, Goldacre MJ, Hicks N, et al. Hospitalization for ambulatory care-sensitive conditions: a method for comparative access and quality studies using routinely collected statistics. Can J Public Health. 2001;92:155-159.
  3. Rizza P, Bianco A, Pavia M, Angelillo IF. Preventable hospitalization and access to primary health care in an area of southern Italy. BMC Health Serv Res. 2007;7:134. doi.org/10.1186/1472-6963-7-134.
  4. US Department of Veterans Affairs. Quality of Care. Strategic Analytics for Improvement and Learning (SAIL) Value Model Measure Definitions. www.va.gov/QUALITYOFCARE/measure-up/SAIL_definitions.asp. Accessed July 10, 2017.
  5. Halfon P, Eggli Y, Prêtre-Rohrbach I, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44:972-981.
  6. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160:1074-1081.
  7. Hernandez SE, Taylor L, Grembowski D, et al. A first look at PCMH implementation for minority veterans: room for improvement. Med Care. 2016;54:253-261.
  8. Tseng CL, Sambamoorthi U, Helmer D, et al. The association between mental health functioning and nontraumatic lower extremity amputations in veterans with diabetes. Gen Hosp Psychiatry. 2007;29:537-546.
  9. Tiwari A, Rajan M, Miller D, et al. Guideline-consistent antidepressant treatment patterns among veterans with diabetes and major depressive disorder. Psychiatr Serv. 2008;59:1139-1147.
  10. Mangurian C, Newcomer JW, Modlin C, Schillinger D. Diabetes and cardiovascular care among people with severe mental illness: a literature review. J Gen Intern Med. 2016;31:1083-1091.
  11. Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23:934-942.
  12. Ciechanowski PS, Katon WJ, Russo JE, et al. The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes. Gen Hosp Psychiatry. 2003;25:246-252.
  13. O’Connell MJ, Kasprow W, Rosenheck RA. Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans. Psychiatr Serv. 2008;59:268-275.
  14. King DW, King LA, Foy DW, et al. Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables. J Abnorm Psychol. 1999;108:164-170.
  15. Ajmera M, Wilkins TL, Sambamoorthi U. Dual Medicare and Veteran Health Administration use and ambulatory care sensitive hospitalizations. J Gen Intern Med. 2011;26(suppl 2):S669-S675.
  16. Ajmera M, Wilkins TL, Findley PA, Sambamoorthi U. Multimorbidity, mental illness, and quality of care: preventable hospitalizations among Medicare beneficiaries. Int J Family Med. 2012;2012:823294. doi.org/10.1155/2012/823294.
  17. Li Y, Glance LG, Cai X, Mukamel DB. Mental illness and hospitalization for ambulatory care sensitive medical conditions. Med Care. 2008;46:1249-1256.
  18. Davydow DS, Zivin K, Katon WJ, et al. Neuropsychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans. J Gen Intern Med. 2014;29:1362-1371.
  19. Bhattacharya R, Shen C, Sambamoorthi U. Depression and ambulatory care sensitive hospitalizations among Medicare beneficiaries with chronic physical conditions. Gen Hosp Psychiatry. 2014;36:460-465.
  20. Banerjea R, Sambamoorthi U, Smelson D, Pogach LM. Chronic illness with complexities: mental illness and substance use among veteran clinic users with diabetes. Am J Drug Alcohol Abuse. 2007;33:807-821.
  21. Institute of Medicine. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: National Academies Press; 2013.
  22. Helmer D, Sambamoorthi U, Shen Y, et al. Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes. Prim Care Diabetes. 2008;2:73-80.
  23. Shrestha SS, Zhang P, Hora I, et al. Factors contributing to increases in diabetes-related preventable hospitalization costs among U.S. adults during 2001-2014. Diabetes Care. 2019;42:77-84.
  24. Mkanta WN, Chumbler NR, Yang K, et al. Cost and predictors of hospitalizations for ambulatory care - sensitive conditions among Medicaid enrollees in comprehensive managed care plans. Health Serv Res Manag Epidemiol. 2016;3. doi.org/10.1177/2333392816670301.
  25. Norman J. CMS announces rule on preventable conditions in Medicaid. The Commonwealth Fund. June 6, 2011. www.commonwealthfund.org/publications/newsletter-article/cms-announces-rule-preventable-conditions-medicaid. Accessed January 29, 2020.
  26. Centers for Medicare & Medicaid Services, US Department of Health & Human Services. Proposed changes to the hospital inpatient prospective payment systems for acute care hospitals and fiscal year 2010 rates and to the long-term care hospital prospective payment system and rate, year 2010 rates. Proposed rule. Fed Regist. 2009;74:24079-24128.
  27. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36:1-10.
  28. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. PsychosocMed. 2012;9. doi: 10.3205/psm000089.
  29. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. Diabetes Care. 2004;27(suppl 2):B10-B21.
  30. US Department of Veterans Affairs. 172VA10P2: VHA Corporate Data Warehouse, VA. 79 FR 4377. 2016. (Access limited to VHA employees.)
  31. Veterans Health Administration, US Department of Veterans Affairs. National Patient Care Database: VA/CMS Datasets. Veterans Affairs Information Resource Center. 2016. http://vaww.virec.research.va.gov/Index.htm. Accessed July 10, 2017. (Access limited to VHA employees.)
  32. Ronksley PE, Hemmelgarn BR, Manns BJ, et al. Potentially preventable hospitalization among patients with CKD and high inpatient use. Clin J Am Soc Nephrol. 2016;11:2022-2031.
  33. Moy E, Chang E, Barrett M. Potentially preventable hospitalizations—United States, 2001–2009. MMWR Suppl. 2013;62(3 suppl):139-143.
  34. Agency for Healthcare Research and Quality, US Department of Health & Human Services. Prevention Quality Indicators technical specifications. Version 5.0. March 2015. www.qualityindicators.ahrq.gov/Archive/PQI_TechSpec_ICD9_v50.aspx. Accessed July 10, 2017.
  35. Sambamoorthi U, Shen C, Findley P, et al. Depression treatment patterns among women veterans with cardiovascular conditions or diabetes. World Psychiatry. 2010;9:177-182.
  36. Chang HY, Weiner JP, Richards TM, et al. Validating the adapted Diabetes Complications Severity Index in claims data. Am J Manag Care. 2012;18:721-726.
  37. Niefeld MR, Braunstein JB, Wu AW, et al. Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes. Diabetes Care. 2003;26:1344-1349.
  38. Stetler CB, Mittman BS, Francis J. Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implement Sci. 2008;3:8. doi.org/10.1186/1748-5908-3-8.
  39. Davydow DS, Ribe AR, Pedersen HS, et al. Serious mental illness and risk for hospitalizations and re-hospitalizations for ambulatory care-sensitive conditions in Denmark: a nationwide population-based cohort study. Med Care. 2016;54:90-97.
  40. Kim H, Helmer DA, Zhao Z, Boockvar K. Potentially preventable hospitalizations among older adults with diabetes. Am J Manag Care. 2011;17:e419-e426.
  41. Kuo YF, Chen NW, Baillargeon J, et al. Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians. Med Care. 2015;53:776-783.
  42. Greenberg GA, Rosenheck RA. An evaluation of an initiative to improve Veterans Health Administration mental health services: broad impacts of the VHA’s Mental Health Strategic Plan. Mil Med. 2009;174:1263-1269.
  43. Watkins KE, Pincus HA, Smith B, et al. Veterans Health Administration Mental Health Program Evaluation: Capstone Report. TR-956-VHA. Santa Monica, CA: RAND Corporation; 2011.
  44. Ewald E, Loganathan S, Hasche J, Lochner K. Access to care among Medicare beneficiaries with and without depression. June 2017. Centers for Medicare & Medicaid Services Office of Enterprise Data & Analytics. www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Downloads/ATC_Depression_2017.pdf. Accessed August 10, 2018.
  45. DiNapoli EA, Cully JA, Mott JM, et al. Mental health utilization among older Veterans with coexisting depression and dementia. SAGE Open Med. 2015;3. doi.org/10.1177/2050312114566488.
  46. Blais RK, Renshaw KD. Stigma and demographic correlates of help-seeking intentions in returning service members. J Trauma Stress. 2013;26:77-85.
  47. Seal KH, Maguen S, Cohen BE, et al. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Trauma Stress. 2010;23:5-16.
  48. Chard KM, Schumm JA, Owens GP, Cottingham SM. A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. J Trauma Stress. 2010;23:25-32.
  49. US Department of Veterans Affairs. VA MISSION Act. MISSION Act strengthens VA care. https://missionact.va.gov/. Accessed January 29, 2020.
Stakeholder Perspective
Mental Health Conditions Constitute Significant Comorbidity: The Impact on Potentially Avoidable Hospital Admissions
Gary M. Owens, MD
President, Gary Owens Associates, Ocean View, DE.

PATIENTS: Diabetes and mental health conditions are 2 common chronic conditions in the general population and among veterans. In a 2005 study of a Veterans Affairs (VA) population, Frayne and colleagues concluded, “Patients with mental illness merit special attention in national diabetes quality improvement efforts.”1 This is one of the earliest studies to link the potential negative impact of mental health conditions on diabetes care in this population.1

Additional publications show the impact of mental health conditions on hospitalizations for chronic illnesses in general. For example, in a 2018 publication, Siddiqui and colleagues noted, “patients with comorbidity of mental illness had incurred higher bed days’ use than for those without mental illness.”2 Other reliable data also show that the co-occurrence of mental health conditions with chronic conditions is increasing. Owens and colleagues noted that among approximately 30 million annual adult inpatient stays for physical health conditions or mental and/or substance use disorders, the co-occurrence of these 2 conditions increased from 38.4% of hospital stays in 2010 to 45% of hospital stays in 2014.3 These are only 2 examples that show the impact of mental health conditions on chronic illness in the general population and in the VA population specifically.

PROVIDERS: As far back as in 1993, Billings and colleagues defined ambulatory care sensitive conditions (ACSC) as a set of 28 medical conditions or diagnoses, “for which timely and effective outpatient care can help to reduce the risks of hospitalization by either preventing the onset of an illness or condition, controlling an acute episodic illness or condition, or managing a chronic disease or condition.”4

In the current article by Helmer and colleagues, published in this issue of American Health & Drug Benefits, the researchers studied the “association between depression, anxiety, and serious mental illness and hospitalizations for ACSC among veterans with diabetes after controlling for demographics and comorbidities.”5

Not surprisingly, the association between acute ACSC and increased rates of hospitalizations for these potentially avoidable admissions was seen in the data. However, “mental health conditions were not associated with hospitalizations for chronic ACSC” in this analysis.5 The latter finding might have resulted from some unique aspect of how the VA system manages chronic conditions compared with the private sector, but that hypothesis needs to be the subject of future investigation. Overall, it is safe to conclude that special attention needs to be given to the population of patients (in this case, in the VA system) with diabetes and mental health conditions to avoid potentially unnecessary hospitalizations.

PAYERS: With the continued rising cost of healthcare, avoiding unnecessary admissions to inpatient hospital care is an area of major focus in the VA system as well as in the private sector. According to the Centers for Medicare & Medicaid Services, of the more than $3.5 trillion spent on US healthcare in 2017, almost 33% ($1.1 trillion) was for hospitalizations.6 Estimates of how much of this cost is preventable vary widely, and no good studies are available to pinpoint this cost precisely. Even if we use a conservative figure that $1 of every $10 spent on hospitalization is potentially avoidable, this amounts to about $110 billion of avoidable cost in the healthcare system.

The information in the current article by Helmer and colleagues adds more insight into one area of potential action, namely, the impact of mental health conditions on patients with diabetes and avoidable hospitalizations, and, by implication, the cost associated with the management of these patients. This study speaks for improved awareness of the prevalence of mental health conditions and chronic illnesses.

Payers, health systems, and physicians all need to better understand this potential link and begin to develop programs to focus on this patient population. We can potentially avoid poorer outcomes, excess morbidity and mortality, as well as realize the potential for substantial cost-savings. As we learn more about how to approach these populations better, our care management programs must evolve, as new data provide insight on where to focus to gain these efficiencies.

  1. Frayne SM, Halanych JH, Miller DR, et al. Disparities in diabetes care: impact of mental illness. Arch Intern Med. 2005;165:2631-2638.
  2. Siddiqui N, Dwyer M, Stankovich J, et al. Hospital length of stay variation and comorbidity of mental illness: a retrospective study of five common chronic medical conditions. BMC Health Serv Res. 2018;18:498. doi.org/10.1186/s12913-018-3316-2.
  3. Owens PL, Heslin KC, Fingar KR, Weiss AJ. Co-occurrence of physical health conditions and mental health and substance use conditions among adult inpatient stays, 2010 versus 2014. HCUP Statistical Brief #240. June 2018. Revised October 2018. Rockville, MD: Agency for Healthcare Research and Quality. www.hcup-us.ahrq.gov/reports/statbriefs/sb240-Co-occurring-Physical-­Mental-Substance-Conditions-Hospital-Stays.pdf. Accessed March 30, 2020.
  4. Billings J, Zeitel L, Lukomnik J, et al. Impact of socioeconomic status on hospital use in New York City. Health Aff (Millwood). 1993;12:162-173.
  5. Helmer DA, Dwibedi N, Rowneki M, et al. Mental health conditions and hospitalizations for ambulatory care sensitive conditions among veterans with diabetes. Am Health Drug Benefits. 2020;13(2):61-71.
  6. Centers for Medicare & Medicaid Services. National Health Expenditures 2017 highlights. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-­Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed March 31, 2020.
Related Items
Analysis of Stakeholder Engagement in the Public Comments of ICER Draft Evidence Reports
Jean A. Gerlach, Brian Snow, PharmD, Katherine M. Prioli, MS, Ronald Vertsman, PharmD, Julie Patterson, PharmD, PhD, Laura T. Pizzi, PharmD, MPH
September 2020 Vol 13, No 4 published on September 17, 2020 in Original Research
Knee Osteoarthritis Treatment Costs in the Medicare Patient Population
Gerard Malanga, MD, Faizan Niazi, PharmD, Vasco Deon Kidd, DHSc, MPH, MS, PA-C, Edmund Lau, MS, Steven M. Kurtz, PhD, Kevin L. Ong, PhD, PE, Andrew L. Concoff, MD, FACR, CAQSM
September 2020 Vol 13, No 4 published on September 17, 2020 in Original Research
Real-World Treatment Patterns, Healthcare Resource Utilization, and Costs for Patients with Newly Diagnosed Systolic versus Diastolic Heart Failure
Chi Nguyen, PhD, Xian Zhang, PhD, Thomas Evers, PhD, Vincent J. Willey, PharmD, Hiangkiat Tan, MS, BSPharm, Thomas P. Power, MD, FACC, MRCPI
September 2020 Vol 13, No 4 published on September 17, 2020 in Clinical, Original Research
Budget Impact Analysis of a Home-Based Nutrition Program for Adults at Risk for Malnutrition
Suela Sulo, PhD, MSc, David Lanctin, MPH, Josh Feldstein, BA, Bjoern Schwander, MA, RN, Jamie Partridge, PhD, MBA, Wendy Landow, MPH, York F. Zöllner, MSc
June 2020 Vol 13, No 3 published on July 1, 2020 in Business, Original Research
A National Assessment of Diagnostic Test Use for Patients with Advanced NSCLC and Factors Influencing Physician Decision-Making
Madison M. Wempe, BS, Mark D. Stewart, PhD, Daniel Glass, PhD, Laura Lasiter, PhD, Diana Merino Vega, PhD, Nisha Ramamurthy, Jeff Allen, PhD, Ellen V. Sigal, PhD
June 2020 Vol 13, No 3 published on July 1, 2020 in Clinical, Original Research
Last modified: August 12, 2020
Copyright © Engage Healthcare Communications, LLC. All rights reserved.