Mental Illness Hikes Hospitalization Risk

Abstract

Miriam E. Tucker is a senior writer with Elsevier Global Medical News. NATIONAL HARBOR, MD. — Nursing home residents with dementia or severe mental illness face excess risk of being hospitalized for conditions that could be prevented or treated in nursing homes. Despite growing interest in reducing avoidable hospitalizations, little research has examined when nursing home care could have made the difference. Neither have researchers studied the role of mental illness in such hospitalizations, said Marion Becker, PhD, RN, in a poster presentation at the annual meeting of the Gerontological Society of America. Dr. Becker and her associates at the University of South Florida, Tampa, analyzed Medicaid claims data for 72,251 residents from 647 Florida nursing homes that had a median of 63% Medicaid-enrolled residents. Just over 40% had a diagnosis of dementia, 26% had a serious mental illness, and 36% had a major comorbidity. Almost all the facilities had at least one occupant who was hospitalized for a condition that could have been addressed in the nursing home—called an ambulatory care-sensitive (ACS) condition—during the 3-year study. ACS conditions include urinary tract infections, pneumonia, and ear, nose, or throat infections. There were 8,191 ACS hospitalizations among 6,872 residents, accounting for 15% of all hospitalizations. Excess risk was associated with diagnoses of dementia and serious mental illness. Odds ratios were 1.5 for major psychotic disorder, 1.8 for bipolar disorder, and 1.45 for major depressive disorder. Some facility characteristics correlated with more ACS hospitalizations. For-profit status increased the risk (OR 1.1), whereas belonging to a chain decreased it (OR 0.9). Having a number of beds below the median decreased risk (OR 0.8), while occupancy rate, number of quality-survey citations, and registered nurse staffing ratios had no significant impact, Dr. Becker and her associates reported. The findings suggest that many ACS hospitalizations could be avoided by “targeted preventive interventions,” the researchers concluded. “Given the high cost of hospitalizations, such interventions could well be a cost-effective option.” “That people are inappropriately transferred to the hospital isn't exactly news in long-term care,” said James Lett II, MD, CMD, who chairs the work group creating AMDA's clinical practice guideline on transitions of care. “It appears that the study authors here only looked at claims data, and it doesn't really show how they determined that hospitalizations are inappropriate,” he noted. Dr. Lett observed that the study probably occurred in a fee-for-service setting that encourages hospitalizations. “There is no payment for on-site treatment for many acute conditions in the long-term care facility. At the same time, if residents are sent to the hospital and return, they come back with a skilled benefit, which provides better reimbursement. These provide fiscal incentives to transfer residents with acute conditions to the hospital,” he explained. He added, “Liability concerns also make facilities hesitant to treat various conditions on-site.” A current and detailed advance directive may include a “do-not-hospitalize” directive, Dr. Lett noted. AMDA's upcoming CPG will discuss the pros and cons of the DNH order, he said. There is a need for more detailed and practical studies, said Dr. Lett. “We need more studies that look specifically at why patients are inappropriately hospitalized and what we can do—or not do—in long-term care facilities to avoid unnecessary hospitalizations.”