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
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).
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.36Statistical 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.
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.
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).
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.
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.
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.
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.
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.
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.
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- 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.
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