177 Disparities in Admission or Transfer for Inpatient Treatment after Emergency Mental Health Visits

Abstract

While it is widely recognized that disparities exist in access to mental health (MH) care, the emergency department (ED) should serve as the safety net where all patients can access necessary care. We examine whether there are disparities based on patient race/ethnicity and insurance status in disposition to inpatient settings (admission or transfer) for adolescents and young adults with MH ED visits. We perform multivariate regression analysis of all MH ED visits from 2010 to 2014 reported to the Healthcare Cost and Utilization Project’s State emergency department and State Inpatient Discharge Databases for Arizona, Florida, New York, New Jersey, North Carolina, Maryland, Nevada, Kentucky, Rhode Island, and Iowa for 10-29 year olds. MH ED visits were defined as visits with a primary MH or substance abuse diagnosis or a secondary or tertiary diagnosis of suicidal ideation or attempt. We examine the probability that a MH ED visit results in an admission or transfer for further treatment and report predicted probabilities by primary payer and race/ethnicity. Regressions also control for age, sex, year, hospital location, and median income of the patient’s home address. We also perform diagnosis-specific regressions for encounters related to suicide, serious mental illness, substance use, or alcohol use. We report comparisons of predicted probabilities using Bonferroni-corrected critical values. 2.6 million MH ED visits were analyzed. For MH ED visits, the probability of admission or transfer for MH ED visits varied by the patient’s insurance and race/ethnicity (see Table). When all MH ED visits were analyzed, significantly more visits by privately insured (33.1%) than self-pay patients (25.8%) resulted in an inpatient disposition (p<0.01). Disposition after MH ED visits also varied by patient race/ethnicity. A significantly higher proportion of MH ED visits by white patients (34.0%) than black (30.8%, p<0.01), Native American (30.7%, p<0.01) or Hispanic (30.4%, p<0.01) patients resulted in admission or transfer. Differences in disposition were seen for all MH disorders analyzed, including for suicide-related visits. When compared with suicide-related visits by whites, a significantly smaller proportion of suicide-related visits by blacks, Hispanics and Native Americans resulted in admission or transfer (p<0.01 for all comparisons). Suicide-related visits by uninsured patients were significantly less likely than those by patients with private insurance, Medicaid or Medicare to result in admission or transfer (p<0.01 for all comparisons). We demonstrate sizeable disparities in disposition to inpatient settings after MH ED visits based on patient race/ethnicity and insurance status. Psychiatric inpatient beds are limited and socioeconomic disparities in access to this resource are concerning, particularly in ED patients who may have limited access to outpatient psychiatric care. Future research should focus on identifying and mitigating the underlying causes of these disparities.TablePredicted probabilities of ED disposition of admission or transfer.All Mental Health % (95% CI)Suicide-Related % (95% CI)Serious Mental Illness % (95% CI)Alcohol Use % (95% CI)Substance Use % (95% CI)PayerPrivate Insurance33.1 (33.0-33.2)66.4 (66.2-66.7)58.3 (58.0-58.6)7.2 (7.0-7.4)22.8 (22.5-23.0)Medicare36.5 (36.3-36.8)70.9 (70.2-71.6)58.7 (58.2-59.3)11.7 (10.9-12.6)25.9 (24.8-26.9)Medicaid35.7 (35.6-35.8)67.9 (67.7-68.1)58.1 (57.9-58.3)14.6 (14.3-14.9)25.5 (25.2-25.7)Self-Pay25.8 (25.7-25.9)55.2 (54.9-55.5)45.1 (44.7-45.4)5.4 (5.3-5.5)15.3 (15.1-15.6)Race/EthnicityWhite34.0 (33.9-34.0)65.8 (65.6-66.0)57.0 (56.7-57.2)9.5 (9.4-9.7)22.8 (22.6-23.0)Black30.8 (30.7-30.9)62.4 (62.0-62.7)54.6 (54.4-54.9)6.1 (6.0-6.3)15.2 (14.8-15.6)Hispanic30.4 (30.2-30.5)63.2 (62.8-63.6)54.7 (54.4-55.1)7.1 (6.9-7.3)18.8 (18.4-19.3)Asian33.5 (33.1-33.9)67.2 (66.1-68.2)61.6 (60.6-62.6)5.3 (4.7-6.0)19.1 (17.6-20.6)Native American30.7 (30.2-31.3)60.6 (59.3-62.0)57.5 (55.5-59.5)6.1 (5.6-6.5)21.2 (19.4-22.9) Open table in a new tab