Patient Care

Health Care Utilization of Veterans With Serious Mental Illness

Fed Pract. 2017 March;34(suppl 2):14S-19S

References

1. Substance Abuse and Mental Health Services Administration. Results From the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS publication SMA 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

2. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164(1):150-153.

3. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482.

4. Lee SE, Fonseca VP, Wolters CL, et al. Health care utilization behavior of veterans who deployed to Afghanistan and Iraq. Mil Med. 2015;180(4):374-379.

5. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023-1032.

6. Kramarow EA, Pastor PN. The health of male veterans and nonveterans aged 25-64: United States, 2007-2010. NCHS Data Brief. 2012;(101):1-8.

7. Elbogen EB, Wagner HR, Johnson SC, et al. Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv. 2013;64(2):134-141.

8. Bermudes RA, Keck PE Jr, Welge JA. The prevalence of the metabolic syndrome in psychiatric inpatients with primary psychotic and mood disorders. Psychosomatics. 2006;47(6):491-497.

9. Newcomer JW. Metabolic syndrome and mental illness. Am J Manag Care. 2007;13(7 suppl):S170-S177.

10. Toalson P, Ahmed S, Hardy T, Kabinoff G. The metabolic syndrome in patients with severe mental illnesses. Prim Care Companion J Clin Psychiatry. 2004;6(4):152-158.

11. Khatana SA, Kane J, Taveira TH, Bauer MS, Wu WC. Monitoring and prevalence rates of metabolic syndrome in military veterans with serious mental illness. PLoS One. 2011;6(4):e19298.

12. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52-77.

13. Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust. 2003;178(suppl):S67-S70.

14. Osborn DP, Nazareth I, King MB. Physical activity, dietary habits, and coronary heart disease risk factor knowledge amongst people with severe mental illness: a cross sectional comparative study in primary care. Soc Psychiatry Psychiatr Epidemiol. 2007;42(10):787-793.

15. Newcomer JW. Medical risk in patients with bipolar disorder and schizophrenia. J Clin Psychiatry. 2007;67(suppl 9):25-30, discussion 36-42.

16. Chwastiak LA, Rosenheck RA, Kazis LE. Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans. Psychosomatics. 2011;52(3):230-236.

17. Cohen BE, Gima K, Bertenthal D, Kim S, Marmar CR, Seal KH. Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

18. Chwastiak LA, Rosenheck RA, Kazis LE. Utilization of primary care of veterans with psychiatric illness in the national Department of Veterans Affairs Health Care System. J Gen Intern Med. 2008;23(11):1835-1840.

19. VA Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative. Mental health. QUERI fact sheet. http://www.hsrd.research.va.gov/publications/internal/mh_factsheet.pdf. Published December 2008. Accessed January 13, 2017.

20. Cradock-O’Leary J, Young AS, Yano EM, Wang M, Lee ML. Use of general medical services by VA patients with psychiatric disorders. Psychiatr Serv. 2002;53(7):874-878.

21. Di Leone BA, Vogt D, Gradus JL, Street AE, Giasson HL, Resick PA. Predictors of mental health care use among male and female veterans deployed in support of the wars in Afghanistan and Iraq. Psychol Serv. 2013;10(2):145-151.

22. Vogt DS, Barry AA, King LA. Toward gender-aware health care: evaluation of an intervention to enhance care for female patients in the VA setting. J Health Psychol. 2008;13(5):624-638.

23. Marshall RP, Jorm AF, Grayson DA, O’Toole BI. Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans. Psychiatr Serv. 1998;49(12):1609-1611.

24. Rosenheck R, Massari L. Wartime military service and utilization of VA health care services. Mil Med. 1993;158(4):223-228.

25. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M. Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans. J Psychiatr Res. 2008;42(10):858-867.

26. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482.

27. Fasoli DR, Glickman ME, Eisen SV. Predisposing characteristics, enabling resources and need as predictors of utilization and clinical outcomes for veterans receiving mental health services. Med Care. 2010;48(4):288-295.

28. Maguen S, Schumm JA, Norris RL, et al. Predictors of mental and physical health service utilization among Vietnam veterans. Psychol Serv. 2007;4(3):168-180.

29. Office of Public Health, Veterans Health Administration. Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans—Revised. http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2012-qtr3.pdf. Revised December 2012. Accessed February 6, 2017.

30. Wagner TH, Sinnott P, Siroka AM. Mental health and substance use disorder spending in the Department of Veterans Affairs, fiscal years 2000-2007. Psychiatr Serv. 2011;62(4):389-395.

Group Differences by Marital Status

Mean number of visits. An ANCOVA analysis was used to determine differences among the marital status groups (married, divorced, never married) in mean number of outpatient visits per year with age as a covariate. With age accounted for, there were significant differences among the marital status groups (F[3, 11,130] = 104.37, P < .01). Married veterans averaged fewer visits per year (mean, 4.6; SD, 5.2) than did divorced veterans (mean, 6.2; SD, 9.9, P < .01) and never-married veterans (mean, 9.8; SD, 18.8, P < .01).

Nonpsychiatric hospitalizations. An ANCOVA analysis was used to determine group differences in nonpsychiatric hospitalizations per year with marital status as the independent variable and age as a covariate. With age accounted for, there were significant differences among the marital status groups (F[3, 11,130] = 43.97, P < .01). Married veterans averaged fewer nonpsychiatric hospitalizations per year (mean, 0.27; SD, 1.52) than did divorced veterans (mean, 0.47; SD, 1.30, P < .01) and never-married veterans (mean, 0.75; SD, 2.08, P <.01) Last, married veterans averaged fewer nonpsychiatric hospitalizations than did veterans with other/unknown marital status (mean, 0.5; SD, 1.5, P < .01).

Psychiatric hospitalizations. An ANCOVA analysis was used to determine group differences in mean number of psychiatric hospitalizations per year with marital status as the independent variable and age as a covariate. With age accounted for, there were significant differences among the marital status groups (F[3, 11,130] = 68.94, P < .01). Married veterans averaged fewer psychiatric hospitalizations per year (mean, 0.23; SD, 0.86) than did divorced veterans (mean, 0.55; SD, 1.58, P < .01) and nevermarried veterans (mean, 0.86; SD, 2.53, P < .01).

Predictors of Hospitalization

Regression analyses revealed that age, sex, divorced status, never-married status, mean number of visits, bipolar disorders, MDD, mood disorders NOS, unspecified psychotic disorders, residential MH treatment, ancillary services, and combat flag were all significant predictors of total number of both psychiatric hospitalizations (adjusted R2 = .15, F[128.56] = .00) and nonpsychiatric hospitalizations (adjusted R2 = .09, F[82.07] = .00) (Tables 3 & 4).

Discussion

This study examined medical and psychiatric service utilization in veterans with SMI diagnoses. For this population, 85.5% of the total number of VA visits were for MH services, and 52.1% of hospitalizations were for psychiatric care. Medical visits accounted for only 6.9% of outpatient services provided. Although the high utilization of psychiatric services by this SMI population may not be striking in itself, the considerably lower utilization of medical services is notable given the high rates of medical comorbidities associated with SMI. This result confirms findings from other studies. ^8-10,20 Possibly, VA health care guidelines may account for the lower medical service utilization. For example, the outpatient MH service has a metabolic syndrome clinic with psychiatrist prescribing guidelines for treating veterans who meet the criteria for metabolic syndrome.

The total number of outpatient visits varied widely. The largest percentage of veterans (29%) averaged 6 or more visits per year, followed by 2, 3, 1, and 4 visits. These findings suggest many patients are frequently utilizing services. The implications for inpatient hospitalization are notable, as the study’s data also suggest veterans with more total outpatient visits are at increased risk for hospitalization. The higher number of visits may be attributable to the SMI population’s increased health care needs and may suggest a need to target heavy users of outpatient services with more intensive programs to minimize costly hospitalizations. Mean number of outpatient visits was associated with a slightly higher risk for psychiatric hospitalization, possibly because of increased accessibility to care. Outpatient visits increased the risk for overall hospitalization, and psychiatric hospitalization specifically.