Rosanna M. Coffey

Trends in inpatient detoxification services, 1992–1997

The paper examines trends in the use of inpatient substance abuse detoxification provided at general hospitals using data from the Healthcare Utilization and Cost Project - National Inpatient Survey. Most persons who received inpatient detoxification did not also receive rehabilitation while an inpatient. The percentage receiving rehabilitation declined between 1992 and 1997 from 38.9% to 21.1%. The decrease in the probability of receiving rehabilitation occurred across gender, age, region, insurance status, income levels, diagnoses, admission source, and discharge destination. Two other notable trends are that average length of stay for detoxification dropped by one third over the six-year period, from 7.7 days to 5.2 days and the percentage of admissions through the emergency room increased from 35.6% to 40.1%. Detoxification offers an opportunity to link patients with rehabilitation. This analysis indicates that those opportunities may be missed.

Factors associated with the receipt of treatment following detoxification

This paper examines the determinants of whether an individual received continuing treatment/rehabilitation services 30 days after receiving inpatient substance abuse detoxification. Data came from 1997-1999 employer health insurance claims. Only 49.4% of detoxification episodes were followed by continuing mental health or substance abuse treatment within 30 days after discharge. Some of the factors positively associated with receiving continuing treatment after receiving detoxification included: female gender, being in a behavioral health carve-out plan, and lower cost-sharing requirements for an outpatient substance abuse visit.

Future Funding For Mental Health And Substance Abuse: Increasing Burdens For The Public Sector

Spending on mental health (MH) and substance abuse (SA) treatment is expected to double between 2003 and 2014, to

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample

239 billion, and is anticipated to continue falling as a share of all health spending. By 2014, our projections of SA spending show increasing responsibility for state and local governments (45 percent); deteriorating shares financed by private insurance (7 percent); and 42 percent of SA spending going to specialty SA centers. For MH, Medicaid is forecasted to fund an increasingly larger share of treatment costs (27 percent), and prescription medications are expected to capture 30 percent of MH spending by 2014.

Transforming Mental Health and Substance Abuse Data Systems in the United States

Abstract Background: Some cerebrovascular events are not diagnosed promptly, potentially resulting in death or disability from missed treatments. We sought to estimate the frequency of missed stroke and examine associations with patient, emergency department (ED), and hospital characteristics. Methods: Cross-sectional analysis using linked inpatient discharge and ED visit records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases and 2008–2009 State ED Databases across nine US states. We identified adult patients admitted for stroke with a treat-and-release ED visit in the prior 30 days, considering those given a non-cerebrovascular diagnosis as probable (benign headache or dizziness diagnosis) or potential (any other diagnosis) missed strokes. Results: There were 23,809 potential and 2243 probable missed strokes representing 12.7% and 1.2% of stroke admissions, respectively. Missed hemorrhages (n=406) were linked to headache while missed ischemic strokes (n=1435) and transient ischemic attacks (n=402) were linked to headache or dizziness. Odds of a probable misdiagnosis were lower among men (OR 0.75), older individuals (18–44 years [base]; 45–64:OR 0.43; 65–74:OR 0.28; ≥75:OR 0.19), and Medicare (OR 0.66) or Medicaid (OR 0.70) recipients compared to privately insured patients. Odds were higher among Blacks (OR 1.18), Asian/Pacific Islanders (OR 1.29), and Hispanics (OR 1.30). Odds were higher in non-teaching hospitals (OR 1.45) and low-volume hospitals (OR 1.57). Conclusions: We estimate 15,000–165,000 misdiagnosed cerebrovascular events annually in US EDs, disproportionately presenting with headache or dizziness. Physicians evaluating these symptoms should be particularly attuned to the possibility of stroke in younger, female, and non-White patients.

National spending on mental health and substance abuse treatment by age of clients, 1997.

State efforts to improve mental health and substance abuse service systems cannot overlook the fragmented data systems that reinforce the historical separateness of systems of care. These separate systems have discrete approaches to treatment, and there are distinct funding streams for state mental health, substance abuse, and Medicaid agencies. Transforming mental health and substance abuse services in the United States depends on resolving issues that underlie separate treatment systems--access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers. This article discusses one aspect of transformation--the need for interoperable information systems. It describes current federal and state initiatives for improving data interoperability and the special issue of confidentiality associated with mental health and substance abuse treatment data. Some achievable steps for states to consider in reforming their behavioral health data systems are outlined. The steps include collecting encounter-level data; using coding that is compliant with the Health Insurance Portability and Accountability Act, including national provider identifiers; forging linkages with other state data systems and developing unique client identifiers among systems; investing in flexible and adaptable data systems and business processes; and finding innovative solutions to the difficult confidentiality restrictions on use of behavioral health data. Changing data systems will not in itself transform the delivery of care; however, it will enable agencies to exchange information about shared clients, to understand coordination problems better, and to track successes and failures of policy decisions.

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics

This article examines 1997 national expenditures on mental health and substance abuse (MH/SA) treatment by 3 major age groups: 0–17, 18–64, and 65 and older. Of the total

Disparities in Rates of Inpatient Mortality and Adverse Events: Race/Ethnicity and Language as Independent Contributors

82.4 billion in MH/SA expenditures, 13% went to children, 72% to adults, and 15% to older adults. MH/SA treatment expenditures made up 9% of total health care expenditures on children, 11% of total health care expenditures on adults, and 3% of total health care expenditures on older adults. Across the 3 age groups, distinct differences emerged in the distribution of MH/SA expenditures by provider-type. For example, about 85% of spending for youth was for specialty MH/SA providers, compared to 76% for adults and 51% for older adults. In addition, 33% of MH/SA spending for older adults went to nursing home care, while other age groups had almost no expenditures in nursing homes. Age-specific estimates enable policymakers, providers, and researchers to design programs and studies more appropriately tailored to specific age groups.

Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom?

Abstract Background: An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI. Methods: We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older. Results: We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses. Conclusions: Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

Inpatient Utilization for Persons With Co-occurring Disorders

Patients with limited English proficiency have known limitations accessing health care, but differences in hospital outcomes once access is obtained are unknown. We investigate inpatient mortality rates and obstetric trauma for self-reported speakers of English, Spanish, and languages of Asia and the Pacific Islands (API) and compare quality of care by language with patterns by race/ethnicity. Data were from the United States Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2009 State Inpatient Databases for California. There were 3,757,218 records. Speaking a non-English principal language and having a non-White race/ethnicity did not place patients at higher risk for inpatient mortality; the exception was significantly higher stroke mortality for Japanese-speaking patients. Patients who spoke API languages or had API race/ethnicity had higher risk for obstetric trauma than English-speaking White patients. Spanish-speaking Hispanic patients had more obstetric trauma than English-speaking Hispanic patients. The influence of language on obstetric trauma and the potential effects of interpretation services on inpatient care are discussed. The broader context of policy implications for collection and reporting of language data is also presented. Results from other countries with and without English as a primary language are needed for the broadest interpretation and generalization of outcomes.