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

2. 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

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

4. 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 million ED visits nationally in
They often lead to suboptimal treatment outcomes.3
CDC. MMWR. 2013;62(23):
2. CDC. Table nhamcs_emergency/2010_ed_web_tables.pdf.
3. Korn, et al. The Journal of Emergency Medicine. 2000;18(2):

5. 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):
CDC. MMWR. 2013;62(23):
Almog, et al. Social Science & Medicine. 2004;59(2):

6. 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)

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

8. Data: Public-Use ED visit files from Office of Statewide Heath Planning and Development:
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.

9. Psychiatric visits defined using 14 CCS categories:
Larger unit of area measure – Dartmouth Atlas Hospital Referral Regions (28 for California), available at:
2f7f9c38a178503
Hospital locations:

10. 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

11. 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

13. 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

14.  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

15. % 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

16. % 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

17. 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

19. % 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

20. % 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

21. Adding patient ZIP Code 0.835 8.5 Adding Hospital ID 0.853 5.1
Receiver Operator Curve analysis 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):

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

24. 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):

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

26. 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.