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CDP 12-255 – HSR&D Study

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CDP 12-255
Impact of Mental Illness on Veteran's Palliative Care Access and Outcomes (CDA 11-201)
Melissa M Garrido PhD
James J. Peters VA Medical Center, Bronx, NY
Bronx, NY
Funding Period: October 2012 - September 2017

BACKGROUND/RATIONALE:
Veterans have high rates of life-limiting physical illnesses. Many patients with these illnesses also suffer from depression and/or anxiety (DEP/ANX), which are associated with symptom exacerbation, poor pain control, reduced quality of life, and poor treatment adherence. In non-Veterans, DEP/ANX are associated with increased likelihood of intensive care unit (ICU) admission and readmission and higher care costs. There is some evidence that DEP/ANX treatment might reduce costs and unnecessary care utilization. Palliative care (PC), team-based symptom management for individuals with life-limiting diseases, includes a psychosocial component. It is unclear, however, whether the psychosocial support offered as part of PC is sufficient to address DEP/ANX among Veterans with life-limiting illnesses, and in which cases mental health care (MHC) (medications and/or psychotherapy) is needed in addition to PC.

OBJECTIVE(S):
Our goals were to quantify the magnitude of the relationship between pre-existing and newly diagnosed DEP/ANX and outcomes (ICU admissions and costs of care) in Veterans with life-limiting physical illnesses, and to explore the extent to which these relationships were moderated by receipt of PC and/or MHC. We also sought to develop a case-finding intervention that identifies which Veterans receiving PC may exhibit reduced symptom burden and reduced ICU use following a MHC consult.

METHODS:
Retrospective analysis of administrative data (Medical SAS Inpatient and Outpatient Datasets, Decision Support System National Data Extract Clinical Files, Vital Status Files, and Health Economics Resource Center files) for 35,094 Veterans across the nation with advanced cancer, HIV/AIDS, or congestive heart failure or chronic obstructive pulmonary disease who were hospitalized between fiscal years 2012-2015 and who had past-year hospital or ICU admissions.

FINDINGS/RESULTS:
During the index hospitalization, one-fifth of the patients in our sample had a recorded mental illness or substance use disorder (54% in the past year), and 10% of the sample had DEP/ANX (39% in the past year). Of those who had DEP/ANX during the hospitalization but who did not have a diagnosis in the past year, 80% received MHC before discharge. During the hospitalization, 30% received hospice or palliative care and 26% were admitted to an ICU. The median hospitalization costs were $14,135 (interquartile range: $7,991-$27,313).

Contrary to expectations, depression was associated with lower odds of ICU use, and anxiety was not significantly associated with ICU use in bivariate analyses. In models adjusting for MHC, PC and hospice care, mental and physical comorbidities, and sociodemographic characteristics, past-year and hospital-only depression remained associated with reduced ICU admission (past-year: adjusted odds ratio [AOR] = 0.85, 95% confidence interval [CI] = 0.80, 0.91; hospital-only: AOR = 0.62, 95% CI = 0.50, 0.76). In adjusted models, past-year anxiety, but not hospital-only anxiety, was associated with greater risk of ICU admission (past year: AOR = 1.12, 95% CI = 1.04, 1.21; hospital-only: AOR = 1.09, 95% CI = 0.71-1.68). These relationships persisted after accounting for site-level fixed effects.

Both depression and anxiety were associated with significantly lower median costs in Kruskal-Wallis tests, but these relationships were no longer significant in multivariable models that adjusted for ICU admission.

IMPACT:
Mental illnesses are common among seriously ill Veterans who are near the end of life, and many Veterans with DEP/ANX receive antidepressant or anxiolytic medication while hospitalized. In our sample, Veterans with DEP/ANX had fewer ICU admissions than Veterans without DEP/ANX. One of our goals was to use administrative data present at the time of a Veteran's hospitalization to identify who would be most likely to benefit from a specialty mental health care consult or additional palliative care. Our results suggest that administrative diagnosis and treatment codes are insufficient for this purpose, at least within the scope of a single hospitalization. To identify short-term risks, more sensitive measures of both psychosocial symptoms and outcomes of interest to Veterans may be needed. Understanding relationships among illness characteristics and need for MHC in addition to the psychosocial support provided as part of PC is important for the VHA's abilities to prioritize care improvement efforts and provide Veteran-centered care.

PUBLICATIONS:

Journal Articles

  1. May P, Garrido MM, Del Fabbro E, Noreika D, Normand C, Skoro N, Cassel JB. Does Modality Matter? Palliative Care Unit Associated With More Cost-Avoidance Than Consultations. Journal of pain and symptom management. 2018 Mar 1; 55(3):766-774.e4.
  2. Garrido MM, Allman RM, Pizer SD, Rudolph JL, Thomas KS, Sperber NR, Van Houtven CH, Frakt AB. Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2446-2451.
  3. Penrod JD, Garrido MM, McKendrick K, May P, Aldridge MD, Meier DE, Ornstein KA, Morrison RS. Characteristics of Hospitalized Cancer Patients Referred for Inpatient Palliative Care Consultation. Journal of palliative medicine. 2017 Dec 1; 20(12):1321-1326.
  4. May P, Garrido MM, Aldridge MD, Cassel JB, Kelley AS, Meier DE, Normand C, Penrod JD, Smith TJ, Morrison RS. Prospective Cohort Study of Hospitalized Adults With Advanced Cancer: Associations Between Complications, Comorbidity, and Utilization. Journal of hospital medicine. 2017 Jun 1; 12(6):407-413.
  5. Ornstein KA, Penrod J, Schnur JB, Smith CB, Teresi JA, Garrido MM, McKendrick K, Siu AL, Meier DE, Morrison RS. The Use of a Brief 5-Item Measure of Family Satisfaction as a Critical Quality Indicator in Advanced Cancer Care: A Multisite Comparison. Journal of palliative medicine. 2017 Jul 1; 20(7):716-721.
  6. May P, Garrido MM, Cassel JB, Kelley AS, Meier DE, Normand C, Smith TJ, Morrison RS. Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from? Palliative Medicine. 2017 Apr 1; 31(4):378-386.
  7. Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Bollens-Lund E, Siu AL, Langa KM, Kelley AS. The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses. Journal of pain and symptom management. 2017 Feb 1; 53(2):178-187.e1.
  8. Garrido MM, Prigerson HG, Neupane S, Penrod JD, Johnson CE, Boockvar KS. Mental Illness and Mental Healthcare Receipt among Hospitalized Veterans with Serious Physical Illnesses. Journal of palliative medicine. 2017 Mar 1; 20(3):247-252.
  9. May P, Garrido MM, Cassel JB, Morrison RS, Normand C. Using Length of Stay to Control for Unobserved Heterogeneity When Estimating Treatment Effect on Hospital Costs with Observational Data: Issues of Reliability, Robustness, and Usefulness. Health services research. 2016 Oct 1; 51(5):2020-43.
  10. Garrido MM, Dowd B, Hebert PL, Maciejewski ML. Understanding Treatment Effect Terminology in Pain and Symptom Management Research. Journal of pain and symptom management. 2016 Sep 1; 52(3):446-52.
  11. Garrido MM, Prigerson HG, Bao Y, Maciejewski PK. Chemotherapy Use in the Months Before Death and Estimated Costs of Care in the Last Week of Life. Journal of pain and symptom management. 2016 May 1; 51(5):875-881.e2.
  12. May P, Garrido MM, Cassel JB, Kelley AS, Meier DE, Normand C, Stefanis L, Smith TJ, Morrison RS. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Cost-saving is larger for patients with higher numbers of comorbidities. Health affairs (Project Hope). 2016 Jan 1; 35(1):44-53.
  13. Higgins PC, Garrido MM, Prigerson HG. Factors Predicting Bereaved Caregiver Perception of Quality of Care in the Final Week of Life: Implications for Health Care Providers. Journal of palliative medicine. 2015 Oct 1; 18(10):849-57.
  14. May P, Garrido MM, Cassel JB, Kelley AS, Meier DE, Normand C, Smith TJ, Stefanis L, Morrison RS. Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2015 Sep 1; 33(25):2745-52.
  15. Prigerson HG, Bao Y, Shah MA, Paulk ME, LeBlanc TW, Schneider BJ, Garrido MM, Reid MC, Berlin DA, Adelson KB, Neugut AI, Maciejewski PK. Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. JAMA oncology. 2015 Sep 1; 1(6):778-84.
  16. Nathaniel JD, Garrido MM, Chai EJ, Goldberg G, Goldstein NE. Cost Savings Associated With an Inpatient Palliative Care Unit: Results From the First Two Years. Journal of pain and symptom management. 2015 Aug 1; 50(2):147-54.
  17. Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Meier DE, Kelley AS. Association Between Hospice Use and Depressive Symptoms in Surviving Spouses. JAMA internal medicine. 2015 Jul 1; 175(7):1138-46.
  18. Garrido MM, Balboni TA, Maciejewski PK, Bao Y, Prigerson HG. Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives. Journal of pain and symptom management. 2015 May 1; 49(5):828-35.
  19. Garrido MM, Harrington ST, Prigerson HG. End-of-life treatment preferences: a key to reducing ethnic/racial disparities in advance care planning? Cancer. 2014 Dec 15; 120(24):3981-6.
  20. Garrido MM, Prigerson HG, Penrod JD, Jones SC, Boockvar KS. Benzodiazepine and Sedative-hypnotic Use Among Older Seriously Ill Veterans: Choosing Wisely? Clinical therapeutics. 2014 Nov 4; 36(11):1547–1554.
  21. Garrido MM. Propensity scores: a practical method for assessing treatment effects in pain and symptom management research. Journal of pain and symptom management. 2014 Oct 1; 48(4):711-8.
  22. Garrido MM, Boockvar KS. Perceived symptom targets of antidepressants, anxiolytics, and sedatives: the search for modifiable factors that improve adherence. The journal of behavioral health services & research. 2014 Oct 1; 41(4):529-38.
  23. Garrido MM, Kelley AS, Paris J, Roza K, Meier DE, Morrison RS, Aldridge MD. Methods for constructing and assessing propensity scores. Health services research. 2014 Oct 1; 49(5):1701-20.
  24. Garrido MM, Penrod JD, Prigerson HG. Unmet need for mental health care among veterans receiving palliative care: assessment is not enough. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2014 Jun 1; 22(6):540-4.
  25. Ant Ozok A, Wu H, Garrido M, Pronovost PJ, Gurses AP. Usability and perceived usefulness of Personal Health Records for preventive health care: a case study focusing on patients' and primary care providers' perspectives. Applied ergonomics. 2014 May 1; 45(3):613-28.
  26. Garrido MM, Prigerson HG. The end-of-life experience: modifiable predictors of caregivers' bereavement adjustment. Cancer. 2014 Mar 15; 120(6):918-25.
  27. Garrido MM. Propensity scores and palliative care. Journal of palliative medicine. 2014 Mar 1; 17(3):261.
Journal Other

  1. Garrido MM. Covariate Adjustment and Propensity Score. [Letter to the Editor]. JAMA : the journal of the American Medical Association. 2016 Apr 12; 315(14):1521-2.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational, Treatment - Comparative Effectiveness
Keywords: Career Development
MeSH Terms: none

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