Psychiatric Emergency Department Visits in California, 2005-2011 5/22/2018 Psychiatric Emergency Department Visits in California, 2005-2011 Session: Spatial Analysis, Paper # 1245 Esri User’s Conference San Diego, CA July 15, 2014

Participants Jim E. Banta, PhD, MPH 5/22/2018 Participants Jim E. Banta, PhD, MPH Mark G. Haviland, PhD (School of Medicine, Psychiatry) Nicole M. Gatto, PhD Sam Soret, PhD Ed Santos, MCSD

Background Why are psychiatric Emergency Department (ED) visits of interest?

They often lead to suboptimal treatment outcomes.3 Psychiatric ED visits often reflect inaccessible or unavailable psychiatric or primary-care options.1 They are increasing more rapidly than general ED visits,1 and accounted for an estimated 4.5 million ED visits nationally in 2010.2 They often lead to suboptimal treatment outcomes.3 CDC. MMWR. 2013;62(23):469-472. 2. CDC. Table 12. http://www.cdc.gov/nchs/data/ahcd/ nhamcs_emergency/2010_ed_web_tables.pdf. 3. Korn, et al. The Journal of Emergency Medicine. 2000;18(2):173-176.

Mental Health Services Act Psychiatric ED visits impose substantial economic burden on healthcare system.1 A study in North Carolina found psychiatric ED visits twice as likely to result in hospital admission compared to all other ED visits.2 Higher psychiatric inpatient rates often found in areas with greater poverty and a greater concentration of ethnic minorities, particularly African Americans.3 Mental Health Services Act Schneider, et al. Annals of Emergency Medicine. 2003;42(2):167-172. CDC. MMWR. 2013;62(23):469-472. Almog, et al. Social Science & Medicine. 2004;59(2):361-376.

Research Question: Within California are there area-based differences in psychiatric ED visits and subsequent hospitalizations (if yes, one could better identify where to expand outpatient treatment)

Method Secondary data analysis using administrative data and government-defined diagnostic coding scheme.

Data: Public-Use ED visit files from Office of Statewide Heath Planning and Development: http://www.oshpd.ca.gov/HID/Products/EmerDeptData/ All ED visits from community-based hospitals in California (348 with ED visits). Patient ZIP Code smallest level of geography. (1,669 valid ZIP Codes for analysis) Some demographic data is masked.

Psychiatric visits defined using 14 CCS categories: http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp Larger unit of area measure – Dartmouth Atlas Hospital Referral Regions (28 for California), available at: http://www.arcgis.com/home/item.html?id=00bc657ae97a424b9 2f7f9c38a178503 Hospital locations: http://www.hrsa.gov/data-statistics/index.html

Software: Analysis: ArcGIS 10.2.1 for Desktop SAS 9.3 for Windows Descriptives using SAS Mapping ED hospitalization rates by Hospital Referral Region Logistic regression for ED visits resulting in hospitalization Mapping significant ZIP Codes

Results During study period: 60.6 million ED visits 2.6 million of these had primary psychiatric diagnosis 2.53 million of these had good ZIP Code data

Disposition California Psychiatric ED Visits (2005-2011) N=2,531,811 Discharged to home or self-care (routine) 78.6 Hospitalized 17.9 Left against medical advice 2.3 Other 1.3 TOTAL: 100.0

 Hospitalization Type N=452,120 Discharged/Transferred (D/T) to a psychiatric hospital or psychiatric distinct part unit of a hospital 67.55 D/T to a short-term general hospital for inpatient care 21.82 D/T to a designated cancer center or children’s hospital 9.67 D/T to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part unit of a hospital 0.66 D/T to a Medicare certified long-term care hospital (LTCH) 0.23 D/T to a critical access hospital (CAH) 0.06 D/T to a hospital-based Medicare approved swing bed 0.01

% of category hospitalized  Clinical Classifications Software (CCS) Categories All mental N= 2,531,811 % of category hospitalized 651 Anxiety disorders 24.2 5.9 660 Alcohol-related disorders 20.8 4.4 657 Mood disorders 14.6 33.1 659 Schizophrenia and other psychotic disorders 10.4 42.7 662 Suicide and intentional self-inflicted injury 8.8 47.8 661 Substance-related disorders 6.1 670 Miscellaneous disorders; 4.2 3.7 663 Screening and history of mental health and substance abuse codes 3.6 36.2

% of category hospitalized  Clinical Classifications Software (CCS) Categories All mental N= 2,531,811 % of category hospitalized 662 Suicide and intentional self-inflicted injury 8.8 47.8 659 Schizophrenia and other psychotic disorders 10.4 42.7 663 Screening & history of mental health and substance abuse codes 3.6 36.2 657 Mood disorders 14.6 33.1 656 Impulse control disorders, NEC 0.1 32.0 658 Personality disorders 0.2 29.5 652 Attention-deficit, conduct, and disruptive behavior disorders 0.8 26.8 654 Developmental disorders 0.7 22.1 Overall Average   17.9

Hospital Referral Region % of Census 2010 % of mental visits % visits hospitalized Los Angeles 26.5 25.4 19.4 San Diego 10.0 8.7 17.3 San Bernardino 8.4 8.1 19.6 Sacramento 6.9 17.9 Orange County 8.8 6.7 18.2 San Francisco 3.9 5.4 12.5 San Jose 4.7 5.0 14.3 Alameda County 4.2 4.9 26.4 Fresno 3.3 23.1 Contra Costa County 2.8 3.1 32.2 Bakersfield 3.0 8.9 Modesto 2.4 2.7 16.3 Ventura 2.3 2.0 14.4

% of category hospitalized   All Mental N=2,531,811 % of category hospitalized Gender Male 46.5 17.4 Female 45.5 17.8 Masked 7.9 20.8 Age 1 to 17 10.3 23.1 18 to 44 33.5 17.9 45 to 64 47.0 65 plus 7.0 12.2 2.2 19.2

% of category hospitalized   All Mental N=2,531,811 % of category hospitalized Race / ethnicity Hispanic 23.9 13.6 Asian 2.1 18.3 Black 8.8 24.4 White 45.7 18.0 Other race 5.8 16.0 Masked race 13.7 21.3 Payer Source Self-pay 27.4 15.9 Medicaid 22.6 20.6 Medicare 14.6 19.5 Other 6.9 14.9 Private insurance 28.5 17.5

Adding patient ZIP Code 0.835 8.5 Adding Hospital ID 0.853 5.1 Receiver Operator Curve analysis.1 Based on Logistic regression, where 0=not hospitalized, 1=hospitalized (N= 2,182,796 ).   AUROC % explained variation No variables 0.500 0.0 Year only 0.522 6.2 Adding demographics 0.580 16.4 Adding insurance 0.592 3.4 Adding diagnosis 0.805 60.3 Adding patient ZIP Code 0.835 8.5 Adding Hospital ID 0.853 5.1 Banta, et al. Critical Care Medicine. 2012;40(11):2960-2966.

Conclusion Within California, there is area- based variation in psychiatric ED visits and subsequent hospitalizations.

There is modest spatial variation in population- based rates of psychiatric ED visits. There is more dramatic spatial variation in the percentage of psychiatric ED visits resulting in hospitalization. There are some similarities in these findings to earlier spatial analyses of psychiatric hospitalizations in California.1 Some of the spatial differences in percentage of hospitalizations is due to socio-demographics. Banta, et al. The Journal of Behavioral Health Services & Research. 2008;35(2):179-194.

Limitations Administrative data Masked/missing demographics Using visits, not persons ZIP Codes as unit of geography.

Future Directions Sub-group analyses based on demographics / diagnosis. Use other area-based measures of socio-demographics, such as Tapestry. Cluster analysis vs. spatial regression.