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.
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.
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.
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.
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.
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- 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.
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- 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.
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- 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.
- 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.
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- 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.
- Garrido MM, Prigerson HG. The end-of-life experience: modifiable predictors of caregivers' bereavement adjustment. Cancer. 2014 Mar 15; 120(6):918-25.
- Garrido MM. Propensity scores and palliative care. Journal of palliative medicine. 2014 Mar 1; 17(3):261.
- 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.
Mental, Cognitive and Behavioral Disorders, Health Systems
Treatment - Observational, Treatment - Comparative Effectiveness