BACKGROUND/RATIONALE:
As a result of dramatic shifts in the location and delivery of health care services in the VHA, Congress enacted the Veterans Eligibility Reform Act in 1996 (VERA), an act that required the VHA to maintain specialized treatment capacity and rehabilitation services for disabled veterans. In order for the VHA to maintain capacity and meet the needs of this vulnerable, resource-intensive group, ongoing monitoring of their health care access, utilization, and outcomes is crucial. This study involves collaboration between investigators at SMITREC and at the Little Rock HSR&D Center for Mental Health Care and Outcomes Research (CeMHOR). This collaboration combines the unique strengths and expertise in mental health services research of these two VA research sites. Together, these two sites contribute skills in psychiatry, epidemiology, psychology, research methodology, and pharmacology. The two sites bring professional resources together with data and analytic resources to develop and test models predicting loss-to-care among veterans with psychoses.

OBJECTIVE(S):
The aims of this research are to identify and assess: 1) patterns of VA mental and physical health care and medication utilization in relationship to retention in VHA treatment; 2) modifiable factors associated with retention/lost-to-care; and 3) causes and predictors of mortality comparing those who were and were not lost-to-care.

METHODS:
The project has two major components: 1) development and testing of a predictive model of retention in VHA care for veterans with psychosis which emphasizes modifiable predictors (Aims 1 and 2), and 2) an epidemiologic characterization of mortality among veterans with psychosis (Aim 3). For the first component (predictors of retention), a model will first be developed based on analysis of existing data from SMITREC's National Psychosis Registry (NPR). Given the recognized limitations of model-building based solely on administrative data, we will conduct an in-depth review of a sample of medical records to cross-validate the administrative data and to supplement the model with information not in the administrative data sets (e.g., detailed medication management data, data on changes in provider and/or treatment team). Finally, we will test the predictive model in a second, independent sample of veterans with psychosis. For the second component (mortality), we will identify all deaths among NPR veterans, calculate crude, specific, and adjusted mortality rates, assess predictors of mortality, and compare predictors of mortality among veterans retained in VA care and those lost-to-VA-care.

FINDINGS/RESULTS:
Initial results were presented at the VA's 2004 HSR&D meeting and a manuscript was submitted to Medical Care in August 2004. Additional analyses are being carried out. Variables and constructs for in-depth analysis of the study hypotheses are being calculated. Ongoing analyses examine patient and facility characteristics associated with increased likelihood of dropping out of VA care. The chart-review arm of the study is completed, with analyses underway. A supplemental NDI request, for death status and cause of death, is in process.

IMPACT:
The results from this study will provide critical new knowledge to clinicians, managers, and policymakers about key predictors of retention and loss-to-care for one of the VHA's most vulnerable populations, veterans with psychosis. Maintaining capacity to care for veterans with psychosis is one of the critical issues facing the VHA today. Results from this project will inform the development of interventions to increase treatment retention and improve the quality of care for this at-risk patient population.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Fischer EP, McCarthy JF, Ignacio RV, Blow FC, Barry KL, Hudson TJ, Owen RR, Valenstein M. Longitudinal patterns of health system retention among veterans with schizophrenia or bipolar disorder. Community mental health journal. 2008 Oct 1; 44(5):321-30. [view]
2. Irmiter C, McCarthy JF, Barry KL, Soliman S, Blow FC. Reinstitutionalization following psychiatric discharge among VA patients with serious mental illness: a national longitudinal study. The Psychiatric quarterly. 2007 Dec 1; 78(4):279-86. [view]
3. McCarthy JF, Blow FC, Valenstein M, Fischer EP, Owen RR, Barry KL, Hudson TJ, Ignacio RV. Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers. Health services research. 2007 Jun 1; 42(3 Pt 1):1042-60. [view]

Conference Presentations

1. McCarthy JF, Barry KL, Blow FC, Fischer EP, Hudson TJ, Ignacio RV, Owen RR, Valenstein M. A national assessment of treatment retention among VA patients with serious mental illness. Paper presented at: VA QUERI National Meeting; 2004 Dec 1; Washington, DC. [view]
2. Bingham CR, Blow FC. Characterization and prediction of high mortality rates among veterans with serious mental illness. Paper presented at: VA HSR&D National Meeting; 2001 Feb 1; Washington, DC. [view]
3. Irmiter CA, McCarthy JF, Soliman SS, Barry KL, Blow FC. Reinstitutionalization Following Psychiatric Discharges of Patients with Serious Mental Illness: A National Longitudinal Study. Paper presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]
4. Irmiter CA, McCarthy JF, Barry KL, Soliman SS, Blow FC. Reinstitutionalization Following Psychiatric Discharges of Patients with Serious Mental Illness: A National Longitudinal Study. Paper presented at: Albert J. Silverman Research Annual Conference; 2007 Jun 6; Ann Arbor, MI. [view]
5. McCarthy JF, Barry K, Blow F, Fischer E, Hudson T, Ignacio R, Owen R, Valenstein M. Treatment Retention Among VA Patients with Psychoses: Health System Factors. Paper presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]
6. McCarthy JF, Barry KL, Blow FC, Fischer EP, Hudson TJ, Ignacio RV, Owen RR, Valenstein M. Treatment retention among VA patients with psychoses: Health system factors. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 25; San Diego, CA. [view]
7. McCarthy JF, Barry KL, Blow FC, Fischer EP, Hudson TJ, Ignacio RV, Owen RR. VA Health System treatment retention among patients with psychoses: A national assessment. Paper presented at: International Congress on Schizophrenia Research; 2005 Apr 1; Savannah, GA. [view]

DRA: Health Systems Science, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology
Keywords: Behavior (patient), Schizophrenia
MeSH Terms: none