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Author List:
McCarthy JF (VA National Serious Mental Illness Treatment Research & Evaluation Center)
Barry KL (VA National Serious Mental Illness Treatment Research & Evaluation Center)
Blow FC (VA National Serious Mental Illness Treatment Research & Evaluation Center)
Fischer EP (HSR&D Center for Mental Healthcare & Outcomes Research)
Hudson TJ (HSR&D Center for Mental Healthcare & Outcomes Research)
Ignacio RV (VA National Serious Mental Illness Treatment Research & Evaluation Center)
Owen RR (HSR&D Center for Mental Healthcare & Outcomes Research)
Valenstein M (VA National Serious Mental Illness Treatment Research & Evaluation Center)
Objectives:
Treatment retention and continuity are essential components of quality care for patients with schizophrenia and bipolar disorder. Psychosis treatment guidelines recommend at least three outpatient contacts per year. In order to target interventions, this study seeks to identify characteristics of patients at increased risk for loss to VA care.
Methods:
Using the VA’s National Psychosis Registry, we identified 162,830 patients with diagnoses of schizophrenia or bipolar disorder during fiscal year 1998 (FY98) who were alive at the start of FY99. We assessed time to first 12-month gap in VA utilization during FY99-FY01. Using multivariate survival analysis, we evaluated the influence of patient and health system factors. Patient measures included age, gender, race/ethnicity, marital status, miles to nearest VA medical center (VAMC), psychiatric diagnosis, Charlson comorbidity score and setting of last utilization in FY98. Facility measures included academic affiliation, region, and an index of mental health services delivery. We controlled for days since last VA contact at the start of FY99. Robust variance estimates adjusted for the nested nature of the data.
Results:
Over three years, 10,099 patients had a 12-month gap in care (6.2%). By comparison, 8.0% died before a gap was observed. Patients were at increased risk (p<0.001, unless otherwise noted) of a gap if they were younger; male; black, Hispanic, or Native American; had bipolar disorder; or lived farther from VAMCs (p<0.05). Patients with greater medical morbidity were less likely to have a gap (p<0.01). However, those whose final treatment of FY98 occurred in an inpatient psychiatric setting had greater risk than those treated in ambulatory or non-psychiatric (p<0.05) institutional settings. Patients at facilities in the West, with greater academic affiliation, or that provided more mental health services were more likely to experience gaps in care (p<0.05).
Implications:
Sustainable efforts to improve health system treatment retention require specifying patient subpopulations at highest risk. Among patients with psychotic disorders, those with the greatest need for psychiatric treatment may be most likely to fall out of care.
Impacts:
The VA should consider targeting its efforts to improve retention of high-risk patients, particularly after psychiatric discharges.
