Patterns of Utilization of Outpatient Mental Services by Children George Gail
M. A.
Realmuto,
Bernstein,
M.D. M.D.
Marshall A. Maglothin, Rama S. Pandey, Ph.D.
M.S.
Although as many as one-fifth of children and adolescents may meet DSM-III criteria for at least one psychiatric diagnosis, data from the Minnesota Department of Human Services for 1988 show that only 20 to 38 percent of children and adolescents in the state who are eligible for medical assistance and who are potentially in need of psychiatric care are referredfor or seek treatment. A study ofpublicly funded mental health care for youths under 18 found that in 1988 the average costfor state-supported psychiatric services per outpatient case was $520, compared with $8,556 per inpatient case. However, overall cost of state-supported mental health services for youths under 18 increased by 28 percent between 1987 and 1988,
Dr.
Realmuto and Dr. Bernstein are associate professors in the division ofchild and adolescent psychiatry, Box 95, University of Minnesota Hospital and Clinic, Harvard Street Road, Minneapolis,
at
East River Minnesota
55455. Mr. Maglothin is a master’s-degree student at the University of Minnesota School of Public Health. Dr. Pandey is professor
of social
work
at the
Uni-
versity ofMinnesota School of Social Work. An earlier version of this paper was presented at the annual meeting of the American Academy ofChild and Adolescent Psychiatry in Chicago on October 27, 1990.
1218
Health and Adolescents
primarily due to increases in payments for inpatient care of patients with dual diagnoses of mental illness and chemical dependency.
Background Previous studies have suggested that the prevalence of psychiatric disorders among children and adolescents
ranges from 1 1 .8 to 22 percent. Anderson and associates (1) found an overall prevalence rate for psychiatric diagnosis of 1 7.6 percent in a large sample of children in New Zealand. In a study ofa general pediatric sampie in a large health maintenance organization in Pittsburgh, Costello (2) reported weighted prevalence rates for one or more DSM-lIl diagnoses of 1 1 .8 percent based on parent interviews, 1 3.8 percent based on child interviews, and 22 percent based on data from both parents and children. Kashani and associates (3) reported that 18.7 percent of 150 nonreferred adolescents sampled from public schools in Columbia, Missouri, had at least one psychiatric diagnosis and were judged to be functionally impaired and in need of treatment. McGee and associates (4) assessed nearly 1 ,000 1 5-year-olds in New Zealand; 22 percent of the sample met criteria for at least one psychiatnc disorder. A follow-up by Rutter and associates (5) ofan earlier study of children and adolescents on the Isle of Wight reported a corrected prevalence estimate of 2 1 percent for psychiatric disorder. Similarly, Offord and associates (6) estimated that 19 percent of boys and 22 percent of girls aged 1 2 to 1 6 in an Ontario sample had a psychiatric diagnosis. Several studies have indicated that only a small percentage of children with psychiatric disorders are referred for or seek treatment. A study of services for children in Ontario showed that only 16. 1 percent of children with a clinical disorder received mental health services (6). In the study by Anderson and associates (1), parents of 29 percent of children with disorders sought treatment for their children, more often
December
Hospital
Recent epidemiological studies using DSM-III criteria have revealed that as many as one-fifth of children and adolescents in the general population have at least one psychiatric diagnosis. Yet public funding for mental health services for children and adolescents is clearly limited, and the use ofmore costly care in private hospitals and residential treatment centers has increased dramatically in the last 20 years. Research examining the delivery of outpatient services for children and adolescents is needed. Understanding the utilization of children’s mental health services can facilitate identification ofunderserved youths. Knowledge about utilization patterns may also help direct the allocation of limited resources toward efforts such as specialized prevention programs that may reduce the incidence ofmental illness in this population. This paper presents data on utilization of publicly funded outpatient mental health care in Mmnesota by youths under the age of 18. Data from the Minnesota Department of Human Services for the penod fromJanuary 1985 through June 1989 are used to address questions about the percentage of children with psychiatric disorders who received services, cost and sources of care, and the relationship between patients’ age, gender, and race and utilization of services.
1992
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12
and
Community
Psychiatry
for offspring with multiple diagnoses or particular diagnoses, such as attention-deficit hyperactivity disorden. Pediatricians diagnosed current psychiatric disorder in 5 .7 percent of the children in the study by Costello (2) but had referred only half of these children (2.9 percent) for mental health services in the year before the study. Much effort has focused on evaluating genetic and environmental factors that might identify populations ofchildren at risk for psychiatnc illness (7,8). Despite interest in identification ofpredisposing factors and the high prevalence rates of psychiatnic disorders in children and adolescents, public funding for services has been sparse and sporadic. The Joint Commission on the Mental Health of Children recognized the paucity of services in the late 1960s. In response, the Community Mental Health Centers Act of 1970 earmarked federal funds for children’s mental health services (7). However, this mandate was repealed two years later. In 1980 the Mental Health Systems Act authorized only $10 million nationally for treatment of seriously disturbed children and adolescents. This funding initiative, which involved monies for community mental health centers, was cut hack in 1 981 leaving the states responsible for most mental health care. Subsequent legislation, including that authorizing the Alcohol, Drug Abuse, and Mental Health block grant, did not target funds specifically for children’s mental health services. Current funding mandates for children’s services derive from a 1985 federal bill requiring that 10 percent of the portion of the block grant designated for mental health be set aside for “new or expanded programs for children and other underserved areas and populations” (7). Thus this 10 percent must finance programs for homeless persons, elderly persons, and other populations as well as for children (9). Between 1970 and 1980, the rate of admission of children to private psychiatric hospitals increased by almost 200 percent; since 1980 the rate of admission of adolescents to
those facilities has accelerated even faster (10). From 1969 to 1981, residential treatment centers more than doubled admissions ofchildren from 1 1 .4 to 28.3 per 100,000 children; at the same time, hospitalization rates for children and adolescents in state and county psychiatric hospitals declined by 30 percent (10,1 1). Although use of costly inpatient and residential care has expanded over the past 20 years, communitybased outpatient care for children appears to be underutilized. Only 3.2 percent of children under age 18 made an outpatient mental health visit in 1980, about half the rate of adult visits for outpatient psychiatric services (1 1). Our study ofutilization of publicly funded outpatient mental health services in Minnesota was designed to determine the percentage of children who received outpatient psychiatnic care among those who were eligible for publicly funded medical assistance. We also wanted to clarify how age, gender, and race relate to utilization of services. In addition, we wanted to assess the costs per case ofservices for patients receiving state support and the diagnostic categories represented by those patients and determine the sources ofcare for this sample and the amount of reimbursements received by providers.
ders in the study
Methods The study used demographic data and data on use of services collected by the Minnesota Department of Human Services on children up to age 1 8 who received reimbursements for outpatient mental health services from any of several medical assistance programs, including Aid to Families With Dependent Children (AFDC), Medical Assistance Needy
GAMC.
Hospital
December
,
and Community
Psychiatry
(MA
Needy),
ability mental General
(GAMC).
Social
Security
Dis-
Insurance (SSDI), SuppleSecurity Income (551), and Assistance Medical Care
The
demographic
and
diagnostic data spanned the fourand-a-half-year period from January 1, 1985, throughJune 30, 1989, but financial data were available for only 1987 and 1988. Previous epidemiological findings were used to estimate the prevalence rates ofaxis I psychiatric disor-
1992
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43
No.
12
population. We applied these rates to the number of children eligible for medical assistance during 1988, the last year for which we had complete data, to estimate the number of potential candidates for mental health services. Utilization of services was analyzed by comparing the number of eligible children with the number of children who actually received publicly funded mental health benefits. The age, gender, and ethnicity of children utilizing services were evaluated. DSM-III diagnoses assigned to patients by mental health providens were analyzed, and the relationships between duration of treatment and patients’ gender and diagnoses were examined. The cost of inpatient services was compared with the cost of outpatient services. Distnibution of outpatient services by various types ofproviders and reimbursement to those providers are reported. Results Utilization ofoutpatient mental health services. In 1 988 a total of 2 1 7 ,040 children and adolescents were eligible for medical assistance in Minnesota. This total included 1 62,033 children and adolescents who were eligible for AFDC, 52,011 who were eligible for MA Needy, 2,275 for SSDI or SSI, and 721 for
Reported
prevalence
rates of
psychiatric disorder among children and adolescents range from 1 1 .8 percent (2) to 22 percent (4). If these rates are applied to this sample, then 26,045 to 47,748 children and adolescents who were eligible for mcdical assistance were potential candidates for mental health services. In 1988 a total of 9,916 children and adolescents received publicly funded outpatient mental health services. The totals represent 20 to 38 percent of the children and adolescents potentially in need of care. Over the four-and-a-half-year study period, a total of 22,573 childnen and adolescents received publicly funded outpatient mental health care. A total of3.9 percent of those children were under five years old, 23.2 percent were five to nine years old, 31.3 percent were nine to 1 3 years old, and 4 1 .5 percent were
1219
Table
1
Diagnoses of children and (N= 18,291) who received
funded outpatient vices in Minnesota 1985
andJune
adolescents publicly
mental health serbetween January
1989
%
Diagnosis Adjustment
49.9
disorder
Emotional
problems
Impulse
control
duct
ofchildren1
disorders,
22.4
con-
disorder
10.8
disorders dysthymia,
Attention-deficit
Anxiety disorders, somatoform disorders Specific developmental
5.5
3.4 disorders
2.1 5.8
Other2 1
Includes tive
reactive
mutism,
disorder,
attachment identity
disorder,
disorder, disorder,
overanxious defiant disorder Includes major depression,
dcc-
avoidant and opposi-
tional
2
schizophrenia, person-
pervasive developmental disorders, ality disorders, tic disorders, and disorder
Tourette’s
treatment, regardless ofthein length. Diagnoses. During the study penod, 18,291 children receiving outpatient services were given a single diagnosis, and an additional 4,282 children received multiple diagnoses. Only cases with a single diagnosis were considered in this analysis. As Table 1 shows, halfofall cases had a diagnosis ofadjustment disonden. Diagnoses ofanother 22 percent were classified as emotional problems of children. Major depression represented only .9 percent and schizophrenia only 1 percent of the diagnoses reported. Duration oftreatment. Of the 22,573 children with one or more diagnoses who received publicly funded outpatient mental health care during the study period, most (61.4 percent) used outpatient services for one year or less. One-fourth used senvices for one to two years, 8.3 percent for two to three years, 3.3 percent for up to four years, and 1 1 percent for a longer period. The duration of treatment for children and adolescents with a single diagnosis is shown in Table 2. Males had a longer average duration of treatment than females. This difference grew from 9 percent during the first 1 2 months of the study to 1 7 percent during the last 12 months, with males overnepresented in the group receiving longer courses of treatment at all points in the study. .
.
1 3 to 1 8 years old. The ratio of child cases (patients under age 1 3) to adolescent cases (patients age 1 3 to 18 years old) was 1 .4 to 1. A total of 57. 1 percent ofthe outpatient cases treated in 1985 involved male youths. The percentage ofmale youths treated decreased each year of the study period to 52.8 percent in 1 989. Males constituted an estimated 5 1 .3 percent of the population of Minnesota under age 1 8 in 1989. Therefore, their representation among users of mental health outpatient services during the study period was slightly higher than in the general population. During the study period, 20 percent of the 22,573 children and adolescents who received medical assistance for outpatient mental health services were members of minority groups (6 percent were Native American, 8 percent were black, and 6 percent were members of other minority groups). The United States census estimates that minority groups constitute 4.7 percent of the total Minnesota population; thus mi nority children were overrepresented in our sample. The number of minority children in the sample is based on an unduplicated count of individuals rather than episodes of
1220
Costs of services. As Table 3 shows, in 1987 the cost of state-supported inpatient and outpatient mental health care in Minnesota for patients ofall ages was $47,694,800. The cost of services for children and adolescents was $12,192,800, which represented 26 percent ofall costs. In 1988 the cost ofchildnen’s inpatient and outpatient services was 28 percent higher than in 1987. The difference was accounted for pnimarily by a $3,300,000 increase in the cost of inpatient psychiatric care, about $3 million of which constituted payments under a new statefunded program for youngsters with a dual diagnosis ofmental illness and chemical dependence. State costs for treatment of adults increased by 23 percent between 1987 and 1988, largely due to a $6,953,500 increase in inpatient costs. Table 4 shows the volume and cost of publicly funded outpatient mental health care for children and adults delivered by various providers in 1988. Licensed psychologists were the most frequent providers of cane and received the largest reimbursement per case ($438). Mean reimbursement for psychologists was higher than for psychiatrists for several reasons, including reimbursement for psychological testing in addition to subsequent treatment. The average cost to the state per outpatient child and adolescent case in 1988 was $520. Because some pa-
Table 2 Duration oftreatment ofchildren and adolescents with who received publicly funded outpatient mental health three years betweenJanuary 1985 andJune 1989
Diagnosis
Adjustmentdisorder
One to two years
Two to three
N
N
N
%
49.0
ofchildren1 Conduct disorder Attention-deficit hyperactivity disorder
2,874 1 ,397
22.0 10.8
Other2
1,586
12,888
100.0
All diagnoses
%
2,138
%
454
53.0
986 479
23.6 1 1 .5
195 88
22.8 10.3
5.3
234
5.6
12.9
388
8.1
80 44 861
8.2 5.7 100.0
and Tourette’s
Vol. 43
elective
mutism,
100.0
disorder, and oppositional defiant disorder major depression, schizophrenia, pervasive developmental
1992
disorder,
4,225
reactive
tic disorders,
attachment
682
overanxious
December
years
51.2
Includes
orders,
17,974) for up to
One year or less
6,349
2 Includes
diagnosis(N= in Minnesota
problems
Emotional
1
a single services
identity
disorder, disorders,
avoidant
disorder,
personality
disorder
No.
12
Hospital
and
Community
Psychiatry
dis-
Table State
3 spending
for inpatient
and outpatient
mental
health
services
in Minnesota,
1987 Child
1988 and adolescent
Service
Amount
Inpatient
$ 7,135,600
Adult %
59
5,057,200
41
Total
$12,192,800
100
tients
sought services from more one provider, this cost is higher the reimbursement rate for any individual category of provider. In contrast, the cost ofinpatient cane for children and adolescents was $8,556 per case in 1988.
than than
Discussion and conclusions The cost to the state ofMinnesota for outpatient mental health services for children and adolescents in 1988 was a modest $5,165,000. The average reimbursement by the state was $520 per outpatient case, in sharp contrast to $8,556 per inpatient hospitalization. Although severe psychiatric symptoms and the need for multiple specialized services are often best addressed in a hospital setting, less costly outpatient services have clear budgetary advantages. This study was not designed to address the efficacy ofoutpatient versus inpatient care. Attention to this issue in future studies will provide a better perspective on costs. Between 1987 and 1988, dollars spent on inpatient care increased 46 percent for children and adolescents, compared with 32 percent for adults. Most of the increased costs for children and adolescents were due to new inpatient programs for patients with concurrent mental illness and chemical dependency. These programs were supported by funds allocated by new state legislation. The programs should be evaluated for efficacy, and less costly intensive outpatient services that may decrease the need for inpatient treatment of dually diagnosed children and adolescents should be explored. Such services indude day treatment, partial hospitalization, and improved aftercare services.
and Community
Psychiatry
Child
Amount
Outpatient
Hospital
1987-88
%
and adolescent
Adult %
Amount
Amount
$21,446,500
60
$10,429,500
68
$28,400,000
14,055,500
40
5,160,000
32
15,400,000
100
$15,589,500
100
$35,502,000
Adolescents (age 1 3 to 1 8) constituted 41 .5 percent ofall children who received publicly funded mental health services during the study penod. Children under five represented a small percentage of outpatient cases (3.9 percent). Fewer young children may have been treated because younger children have yet to proceed through developmental periods during which the risk ofmental illness is high. Other factors contributing to the low number of young children treated may include the paucity of mental health professionals specializing in infant mental health, children’s lack of contact with adults who are knowledgeable about normal and abnormal child development, and underfunding and consequent poor quality ofsome child day care services that might otherwise be able to make a referral. We suggest that organizations of mental health professionals augment their educational programs and lobby for improved standards for the training ofchild care providers to encourage identification, referral, and assessment ofyoung children with mental health problems. Few early identification and intervention programs are available for children with mental health problems. The high proportion of adolescent cases in this sample is consistent with other reports of mental health service utilization. In a study of all high school students in a semirural county near New York City, 35.1 percent of students with psychiatric disorders received some kind of assistance for their problems (1 2). In another study, 48 percent of teenagers with disorders sought help from some source either on their own on on their parents’ initiative (4). In that
December
1992
VoL 43
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12
$43,800,000
% 65 35
100
study, 20 percent of female adolescents and 7 percent of male adolescents without disorders also reported seeking help for mental problems. These utilization rates are higher than those for the child population (1,2). There are several reasons for the high utilization ofmental health services by adolescents. Adolescents are a very visible population in modern American society, and awareness of their mental health problems is widespread. The marketing of mental health services for adolescents, especially inpatient services, may improve casefinding and referral for all levels of care. However, Offord and associates (6) found no difference in utilization rates between children four to 1 1 years old and teenagers 12 to 16 years old. Further studies cxamining the prevalence of mental disorders and the utilization of services by different age groups would be helpful in identifying gaps in the service delivery system. In our study, only slightly more males than females in all age groups were seen for psychiatric care. Epidemiologic studies suggest that the ratio ofmales to females with psychiatnic diagnoses depends partly on the age ofthe subjects. Anderson and associates (1 ) observed a male-to-female ratio of I .7 to 1 among 1 i-yearold children with psychiatric disorders. On the other hand, Costello (2) found nearly equal numbers of boys and girls (seven to 1 1 years old) with psychiatric disorders. However, in two studies of adolescents, females were more likely than males to have a psychiatric diagnosis. McGee and colleagues (4) found that 1 .4 times as many females as males had a psychiatnic diagnosis. Kashani and as-
1221
Table 4 Number ofpatients
seen and reimbursements
received
by outpatient
mental
health
Total
Psychologist Psychiatrist Community
mental
Mean reimbursement
Amount
4,830
$438
$2,120,000
%
Amount
%
4,565
265
1,212,000
23
$ 4,294,000 4,032,000
28 26
4,320
250
1,081,000
21
4,827,000
31
700,000
2,422
289
-
-
Total
9,916
A total of 1,219
3 Unduplicated
For adults
41
outpatient
service
1
19881
reimbursement
and adolescents seen
Other2
2 Includes
in Minnesota,
health
center Hospital-based
providers
For children and adolescents
N children
Provider
service
nurses
inpatient and physical patient
hospitalizations
$520 in 1988.
occurred
13 1 100
52,000 $5,165,000 The mean
reimbursement
per
hospitalization
1,655,000 541,000 $15,359,000
11
4 100
was $8,556.
therapists
count
sociates (3) reported a female-tomale ratio of 1 .3 to 1. Minority youngsters were overrepresented, relative to their representation in the state population, among the children and adolescents who received outpatient mental health services. This finding may reflect the overrepresentation of minonity families among those eligible for medical assistance programs. The percentages of minority children among those who were eligible for care through medical assistance programs and among those who utilized care are not available. However, such data could be useful in future studies of the influence of cultural and ethnic issues on access to and utilization ofmental health services. Although adjustment disorder was the most frequent diagnosis reported, this label may not reflect patients’ true conditions. Many clinicians consider adjustment disorder a benign diagnosis and may select it for billing purposes to avoid stigmatizing their patients. According to DSM-III-R, adjustment disorder does not continue for more than six months and thus cannot be an accurate diagnosis for a child in treatment for more than a year (13). Despite this criterion, many patients with this diagnosis were treated for several years, as Table 2 shows. These patients may be misdiagnosed or aSflicted with a comorbid condition
that
should be identified and given treatment. For example, the diagnosis of major depression represented only .9 percent of cases, suggesting marked underdiagnosis of this disorder. This study has several limitations. First, although we can be confident that the number ofchildren and adolescents who received publicly funded mental health services was accurate, the percentage ofthe population eligible for medical assistance who required care could only be estimated. Therefore, the utilization rates we report are estimates. In fact, the rates ofutilization may be overestimated because rates of psychiatric illness may be higher in samples drawn from lower socioeconomic groups. A study comparing utilization of services among different socioeconomic groups is needed. Also, it should be noted that some children with psychiatric diagnoses do not require referral for outpatient mental health services. For example, children with simple phobias may not be referred for treatment unless marked functional impairment is present. In future studies, the validity of diagnoses given to patients should be closely evaluated. Factors influencing diagnostic decisions, including concerns about labeling and stigma, differences in the diagnostic skills of practitioners, and the variety of psy-
chiatric symptoms expressed by children under chronic stress, all affect diagnostic validity. Our findings on the costs of mental health services show a dramatic increase in state allocation for inpatient care for children and adolescents with comonbid diagnoses of mental illness and chemical dependency. However, the data are limited to a two-year period, and therefore firm conclusions about patterns of cost for inpatient versus outpatient services cannot be made. Future studies evaluating costs of children’s mental health services in the years after the study period (1989-92) will determine ifthis trend continues. Because the study sample cornpnised patients who used public funds to pay for mental health care, questions must be raised about the generalizability of our findings to other populations. Further understanding of utilization rates may be derived from comparisons of clinic attendance in urban versus rural, wealthy versus poor, economically stable versus changing, and servicerich versus service-poor localities.
1222
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1992
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12
Acknowledgments work was partly supported by the Wisniewski fellowship of the Office of Mental Retardation of the State of New York. The authors thank Lois Laitinen for help in preparing the manuscript. This
and Community
Psychiatry
References 1. AndersonJC, Williams 5, McGee R, etal: DSM-III disorders in preadolescent children: prevalenceinalargesamplefrom the general population. Archives of General Psychiatry
44:69-76,
1987
2. Costello EJ: Child psychiatric disorders and their correlates: a primary care pediatric sample. Journal of the American Academy ofChild and Adolescent Psychiatry 28:851-855, 1989 3. KashaniJH,BeckNC,HoeperEW,etal: Psychiatric disorders in acommunity sample of adolescents. American Journal of Psychiatry 144:584-589, 1987 4. McGee R, Feehan M, Williams 5, et al: DSM-III disorders in a large sample of adolescents.
Journal
of the
Indicators in Three
The authors departments
are affiliated with the of psychiatry and at the Medical in Milwaukee and medicine
College of and the services
psychiatry of the Veterans Affairs Medical Center, 5000 West National Ayeflue, Milwaukee, Wisconsin Address
correspondence
to Dr. Rudman.
Hospital
6. Offord
1 1 . Taube Health,
and Community
DR, Boyle MH, Szatmari P. et al: child health study: II. six-month ofdisorder and rates of service utilization. ArchivesofGeneral Psychiatry 44:832-836, 1987 7. Saxe L, Cross T, Silverman N: Children’s Ontario prevalence
mental
health: and what
the
gap
between
what
know we do. American ogist 43:800-807, 1988 8. Tuma J: Mental health services dren: the chologist
9. Inouye
state of the 44:188-199,
Psycholfor chil-
art. American 1989
sues.
D: Children’s mental American Psychologist
816,
1988
we
Psy-
health is43:813-
Vikan
A: Psychiatric
epidemiology
sampleof
1,5 10 ten-year-old prevalence. Journal ofChild and Psychiatry and Allied 21:55-75, 1985
in a
children: I. Psychology Disciplines
CA, Barrett SA (eds): United States, 1985.
Mental DHHS
pub no(ADM) 85-1378. Rockville,Md, National Institute of Mental Health,
12.
1985 Whitaker Uncommon
A,JohnsonJ, troubles
Shaffer in
young of selected
D, et al: people:
prevalence estimates psychiatric disorders in a nonrefrred adolescent population. Archives of General Psychiatry
47:487-496,
1990
I 3. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC, American Psychiatric Association, 1987
of Adverse Somatic Outcome Veterans Affairs Nursing Homes
Frequencies of undernutrition, bedsores, and deterioration in activities of daily living were cornpared in three Veterans Affairs nursing homes serving both chronic psycbiatricpatients and medical or neurologicalpatients. The threefacilities varied in the proportions of patients with adverse outcomes, with one home having noticeably higher rates for both subgroups of patients. In each home, the two subgroups were equally likely to show evidence of adverse outcome,
53295.
10.
American
Luca Alverno, M.D. Dale E. Mattson, Ph.D. Daniel Rudman, M.D.
medicine Wisconsin
AcademyofChild and Adolescent Psychi29:61 1-619, 1990 5. Rutter M, lizard J, Yule W, et al: Isle of Wight studies, 1964-1974. Psychological Medicine 6:31 3-332, 1976 atry
Psychiatry
suggesting that differences in the requency of adverse outcomes among the facilities were accountedfor by extrinsic factors rekited to quality ofcare rather than intrinsic factors related to patient characteristics.
f
Q
uality assurance examines three dimensions of health care systems: structure (physical facilities and staffing), process (how care is delivened), and outcome (what happens to the patient). The Institute of Mcdicine and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) have recommended that quality assurance activities in nursing homes give more attention to monitoring of adverse physical outcomes (1,2). The goal of the study reported here was to investigate three types of adverse somatic outcome-undernutrition, bedsores, and loss of activities of daily living-among residents of three nursing homes opcrated by the Department of Veterans Affairs (VA). Adverse outcomes may have intrinsic or extrinsic causes
December
1992
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43
No.
12
(1). Intrinsic causes are related to patient characteristics such as age, sex, level ofdependency, and the natune and severity ofpnimany and secondary morbid conditions. Extrinsic causes are related to the quality of the patient’s environment, which includes physical, psychosocial, and clinical care. To learn more about the relative effect on outcome ofintninsic and cxtninsic factors, we compared the incidence in the three nursing homes of undernutrition, bedsores, and loss of activities ofdaily living. Within each home, we compared the incidence of those outcomes among patients with medical or neurologic conditions and among psychiatric patients. The majority of the patients in each home had a chronic medical or neurologic condition. However, as a consequence of the depopulation of the state mental hospitals in the 1 960s (3-5), a substantial number of chronic psychiatric patients also received care in the nursing homes. The homes provide medical, psychiatnic, nursing, dietetic, rehabilitative, and recreational services to their residents.
1223
M. A.
Realmuto,
Bernstein,
M.D. M.D.
Marshall A. Maglothin, Rama S. Pandey, Ph.D.
M.S.
Although as many as one-fifth of children and adolescents may meet DSM-III criteria for at least one psychiatric diagnosis, data from the Minnesota Department of Human Services for 1988 show that only 20 to 38 percent of children and adolescents in the state who are eligible for medical assistance and who are potentially in need of psychiatric care are referredfor or seek treatment. A study ofpublicly funded mental health care for youths under 18 found that in 1988 the average costfor state-supported psychiatric services per outpatient case was $520, compared with $8,556 per inpatient case. However, overall cost of state-supported mental health services for youths under 18 increased by 28 percent between 1987 and 1988,
Dr.
Realmuto and Dr. Bernstein are associate professors in the division ofchild and adolescent psychiatry, Box 95, University of Minnesota Hospital and Clinic, Harvard Street Road, Minneapolis,
at
East River Minnesota
55455. Mr. Maglothin is a master’s-degree student at the University of Minnesota School of Public Health. Dr. Pandey is professor
of social
work
at the
Uni-
versity ofMinnesota School of Social Work. An earlier version of this paper was presented at the annual meeting of the American Academy ofChild and Adolescent Psychiatry in Chicago on October 27, 1990.
1218
Health and Adolescents
primarily due to increases in payments for inpatient care of patients with dual diagnoses of mental illness and chemical dependency.
Background Previous studies have suggested that the prevalence of psychiatric disorders among children and adolescents
ranges from 1 1 .8 to 22 percent. Anderson and associates (1) found an overall prevalence rate for psychiatric diagnosis of 1 7.6 percent in a large sample of children in New Zealand. In a study ofa general pediatric sampie in a large health maintenance organization in Pittsburgh, Costello (2) reported weighted prevalence rates for one or more DSM-lIl diagnoses of 1 1 .8 percent based on parent interviews, 1 3.8 percent based on child interviews, and 22 percent based on data from both parents and children. Kashani and associates (3) reported that 18.7 percent of 150 nonreferred adolescents sampled from public schools in Columbia, Missouri, had at least one psychiatric diagnosis and were judged to be functionally impaired and in need of treatment. McGee and associates (4) assessed nearly 1 ,000 1 5-year-olds in New Zealand; 22 percent of the sample met criteria for at least one psychiatnc disorder. A follow-up by Rutter and associates (5) ofan earlier study of children and adolescents on the Isle of Wight reported a corrected prevalence estimate of 2 1 percent for psychiatric disorder. Similarly, Offord and associates (6) estimated that 19 percent of boys and 22 percent of girls aged 1 2 to 1 6 in an Ontario sample had a psychiatric diagnosis. Several studies have indicated that only a small percentage of children with psychiatric disorders are referred for or seek treatment. A study of services for children in Ontario showed that only 16. 1 percent of children with a clinical disorder received mental health services (6). In the study by Anderson and associates (1), parents of 29 percent of children with disorders sought treatment for their children, more often
December
Hospital
Recent epidemiological studies using DSM-III criteria have revealed that as many as one-fifth of children and adolescents in the general population have at least one psychiatric diagnosis. Yet public funding for mental health services for children and adolescents is clearly limited, and the use ofmore costly care in private hospitals and residential treatment centers has increased dramatically in the last 20 years. Research examining the delivery of outpatient services for children and adolescents is needed. Understanding the utilization of children’s mental health services can facilitate identification ofunderserved youths. Knowledge about utilization patterns may also help direct the allocation of limited resources toward efforts such as specialized prevention programs that may reduce the incidence ofmental illness in this population. This paper presents data on utilization of publicly funded outpatient mental health care in Mmnesota by youths under the age of 18. Data from the Minnesota Department of Human Services for the penod fromJanuary 1985 through June 1989 are used to address questions about the percentage of children with psychiatric disorders who received services, cost and sources of care, and the relationship between patients’ age, gender, and race and utilization of services.
1992
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and
Community
Psychiatry
for offspring with multiple diagnoses or particular diagnoses, such as attention-deficit hyperactivity disorden. Pediatricians diagnosed current psychiatric disorder in 5 .7 percent of the children in the study by Costello (2) but had referred only half of these children (2.9 percent) for mental health services in the year before the study. Much effort has focused on evaluating genetic and environmental factors that might identify populations ofchildren at risk for psychiatnc illness (7,8). Despite interest in identification ofpredisposing factors and the high prevalence rates of psychiatnic disorders in children and adolescents, public funding for services has been sparse and sporadic. The Joint Commission on the Mental Health of Children recognized the paucity of services in the late 1960s. In response, the Community Mental Health Centers Act of 1970 earmarked federal funds for children’s mental health services (7). However, this mandate was repealed two years later. In 1980 the Mental Health Systems Act authorized only $10 million nationally for treatment of seriously disturbed children and adolescents. This funding initiative, which involved monies for community mental health centers, was cut hack in 1 981 leaving the states responsible for most mental health care. Subsequent legislation, including that authorizing the Alcohol, Drug Abuse, and Mental Health block grant, did not target funds specifically for children’s mental health services. Current funding mandates for children’s services derive from a 1985 federal bill requiring that 10 percent of the portion of the block grant designated for mental health be set aside for “new or expanded programs for children and other underserved areas and populations” (7). Thus this 10 percent must finance programs for homeless persons, elderly persons, and other populations as well as for children (9). Between 1970 and 1980, the rate of admission of children to private psychiatric hospitals increased by almost 200 percent; since 1980 the rate of admission of adolescents to
those facilities has accelerated even faster (10). From 1969 to 1981, residential treatment centers more than doubled admissions ofchildren from 1 1 .4 to 28.3 per 100,000 children; at the same time, hospitalization rates for children and adolescents in state and county psychiatric hospitals declined by 30 percent (10,1 1). Although use of costly inpatient and residential care has expanded over the past 20 years, communitybased outpatient care for children appears to be underutilized. Only 3.2 percent of children under age 18 made an outpatient mental health visit in 1980, about half the rate of adult visits for outpatient psychiatric services (1 1). Our study ofutilization of publicly funded outpatient mental health services in Minnesota was designed to determine the percentage of children who received outpatient psychiatnic care among those who were eligible for publicly funded medical assistance. We also wanted to clarify how age, gender, and race relate to utilization of services. In addition, we wanted to assess the costs per case ofservices for patients receiving state support and the diagnostic categories represented by those patients and determine the sources ofcare for this sample and the amount of reimbursements received by providers.
ders in the study
Methods The study used demographic data and data on use of services collected by the Minnesota Department of Human Services on children up to age 1 8 who received reimbursements for outpatient mental health services from any of several medical assistance programs, including Aid to Families With Dependent Children (AFDC), Medical Assistance Needy
GAMC.
Hospital
December
,
and Community
Psychiatry
(MA
Needy),
ability mental General
(GAMC).
Social
Security
Dis-
Insurance (SSDI), SuppleSecurity Income (551), and Assistance Medical Care
The
demographic
and
diagnostic data spanned the fourand-a-half-year period from January 1, 1985, throughJune 30, 1989, but financial data were available for only 1987 and 1988. Previous epidemiological findings were used to estimate the prevalence rates ofaxis I psychiatric disor-
1992
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12
population. We applied these rates to the number of children eligible for medical assistance during 1988, the last year for which we had complete data, to estimate the number of potential candidates for mental health services. Utilization of services was analyzed by comparing the number of eligible children with the number of children who actually received publicly funded mental health benefits. The age, gender, and ethnicity of children utilizing services were evaluated. DSM-III diagnoses assigned to patients by mental health providens were analyzed, and the relationships between duration of treatment and patients’ gender and diagnoses were examined. The cost of inpatient services was compared with the cost of outpatient services. Distnibution of outpatient services by various types ofproviders and reimbursement to those providers are reported. Results Utilization ofoutpatient mental health services. In 1 988 a total of 2 1 7 ,040 children and adolescents were eligible for medical assistance in Minnesota. This total included 1 62,033 children and adolescents who were eligible for AFDC, 52,011 who were eligible for MA Needy, 2,275 for SSDI or SSI, and 721 for
Reported
prevalence
rates of
psychiatric disorder among children and adolescents range from 1 1 .8 percent (2) to 22 percent (4). If these rates are applied to this sample, then 26,045 to 47,748 children and adolescents who were eligible for mcdical assistance were potential candidates for mental health services. In 1988 a total of 9,916 children and adolescents received publicly funded outpatient mental health services. The totals represent 20 to 38 percent of the children and adolescents potentially in need of care. Over the four-and-a-half-year study period, a total of 22,573 childnen and adolescents received publicly funded outpatient mental health care. A total of3.9 percent of those children were under five years old, 23.2 percent were five to nine years old, 31.3 percent were nine to 1 3 years old, and 4 1 .5 percent were
1219
Table
1
Diagnoses of children and (N= 18,291) who received
funded outpatient vices in Minnesota 1985
andJune
adolescents publicly
mental health serbetween January
1989
%
Diagnosis Adjustment
49.9
disorder
Emotional
problems
Impulse
control
duct
ofchildren1
disorders,
22.4
con-
disorder
10.8
disorders dysthymia,
Attention-deficit
Anxiety disorders, somatoform disorders Specific developmental
5.5
3.4 disorders
2.1 5.8
Other2 1
Includes tive
reactive
mutism,
disorder,
attachment identity
disorder,
disorder, disorder,
overanxious defiant disorder Includes major depression,
dcc-
avoidant and opposi-
tional
2
schizophrenia, person-
pervasive developmental disorders, ality disorders, tic disorders, and disorder
Tourette’s
treatment, regardless ofthein length. Diagnoses. During the study penod, 18,291 children receiving outpatient services were given a single diagnosis, and an additional 4,282 children received multiple diagnoses. Only cases with a single diagnosis were considered in this analysis. As Table 1 shows, halfofall cases had a diagnosis ofadjustment disonden. Diagnoses ofanother 22 percent were classified as emotional problems of children. Major depression represented only .9 percent and schizophrenia only 1 percent of the diagnoses reported. Duration oftreatment. Of the 22,573 children with one or more diagnoses who received publicly funded outpatient mental health care during the study period, most (61.4 percent) used outpatient services for one year or less. One-fourth used senvices for one to two years, 8.3 percent for two to three years, 3.3 percent for up to four years, and 1 1 percent for a longer period. The duration of treatment for children and adolescents with a single diagnosis is shown in Table 2. Males had a longer average duration of treatment than females. This difference grew from 9 percent during the first 1 2 months of the study to 1 7 percent during the last 12 months, with males overnepresented in the group receiving longer courses of treatment at all points in the study. .
.
1 3 to 1 8 years old. The ratio of child cases (patients under age 1 3) to adolescent cases (patients age 1 3 to 18 years old) was 1 .4 to 1. A total of 57. 1 percent ofthe outpatient cases treated in 1985 involved male youths. The percentage ofmale youths treated decreased each year of the study period to 52.8 percent in 1 989. Males constituted an estimated 5 1 .3 percent of the population of Minnesota under age 1 8 in 1989. Therefore, their representation among users of mental health outpatient services during the study period was slightly higher than in the general population. During the study period, 20 percent of the 22,573 children and adolescents who received medical assistance for outpatient mental health services were members of minority groups (6 percent were Native American, 8 percent were black, and 6 percent were members of other minority groups). The United States census estimates that minority groups constitute 4.7 percent of the total Minnesota population; thus mi nority children were overrepresented in our sample. The number of minority children in the sample is based on an unduplicated count of individuals rather than episodes of
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Costs of services. As Table 3 shows, in 1987 the cost of state-supported inpatient and outpatient mental health care in Minnesota for patients ofall ages was $47,694,800. The cost of services for children and adolescents was $12,192,800, which represented 26 percent ofall costs. In 1988 the cost ofchildnen’s inpatient and outpatient services was 28 percent higher than in 1987. The difference was accounted for pnimarily by a $3,300,000 increase in the cost of inpatient psychiatric care, about $3 million of which constituted payments under a new statefunded program for youngsters with a dual diagnosis ofmental illness and chemical dependence. State costs for treatment of adults increased by 23 percent between 1987 and 1988, largely due to a $6,953,500 increase in inpatient costs. Table 4 shows the volume and cost of publicly funded outpatient mental health care for children and adults delivered by various providers in 1988. Licensed psychologists were the most frequent providers of cane and received the largest reimbursement per case ($438). Mean reimbursement for psychologists was higher than for psychiatrists for several reasons, including reimbursement for psychological testing in addition to subsequent treatment. The average cost to the state per outpatient child and adolescent case in 1988 was $520. Because some pa-
Table 2 Duration oftreatment ofchildren and adolescents with who received publicly funded outpatient mental health three years betweenJanuary 1985 andJune 1989
Diagnosis
Adjustmentdisorder
One to two years
Two to three
N
N
N
%
49.0
ofchildren1 Conduct disorder Attention-deficit hyperactivity disorder
2,874 1 ,397
22.0 10.8
Other2
1,586
12,888
100.0
All diagnoses
%
2,138
%
454
53.0
986 479
23.6 1 1 .5
195 88
22.8 10.3
5.3
234
5.6
12.9
388
8.1
80 44 861
8.2 5.7 100.0
and Tourette’s
Vol. 43
elective
mutism,
100.0
disorder, and oppositional defiant disorder major depression, schizophrenia, pervasive developmental
1992
disorder,
4,225
reactive
tic disorders,
attachment
682
overanxious
December
years
51.2
Includes
orders,
17,974) for up to
One year or less
6,349
2 Includes
diagnosis(N= in Minnesota
problems
Emotional
1
a single services
identity
disorder, disorders,
avoidant
disorder,
personality
disorder
No.
12
Hospital
and
Community
Psychiatry
dis-
Table State
3 spending
for inpatient
and outpatient
mental
health
services
in Minnesota,
1987 Child
1988 and adolescent
Service
Amount
Inpatient
$ 7,135,600
Adult %
59
5,057,200
41
Total
$12,192,800
100
tients
sought services from more one provider, this cost is higher the reimbursement rate for any individual category of provider. In contrast, the cost ofinpatient cane for children and adolescents was $8,556 per case in 1988.
than than
Discussion and conclusions The cost to the state ofMinnesota for outpatient mental health services for children and adolescents in 1988 was a modest $5,165,000. The average reimbursement by the state was $520 per outpatient case, in sharp contrast to $8,556 per inpatient hospitalization. Although severe psychiatric symptoms and the need for multiple specialized services are often best addressed in a hospital setting, less costly outpatient services have clear budgetary advantages. This study was not designed to address the efficacy ofoutpatient versus inpatient care. Attention to this issue in future studies will provide a better perspective on costs. Between 1987 and 1988, dollars spent on inpatient care increased 46 percent for children and adolescents, compared with 32 percent for adults. Most of the increased costs for children and adolescents were due to new inpatient programs for patients with concurrent mental illness and chemical dependency. These programs were supported by funds allocated by new state legislation. The programs should be evaluated for efficacy, and less costly intensive outpatient services that may decrease the need for inpatient treatment of dually diagnosed children and adolescents should be explored. Such services indude day treatment, partial hospitalization, and improved aftercare services.
and Community
Psychiatry
Child
Amount
Outpatient
Hospital
1987-88
%
and adolescent
Adult %
Amount
Amount
$21,446,500
60
$10,429,500
68
$28,400,000
14,055,500
40
5,160,000
32
15,400,000
100
$15,589,500
100
$35,502,000
Adolescents (age 1 3 to 1 8) constituted 41 .5 percent ofall children who received publicly funded mental health services during the study penod. Children under five represented a small percentage of outpatient cases (3.9 percent). Fewer young children may have been treated because younger children have yet to proceed through developmental periods during which the risk ofmental illness is high. Other factors contributing to the low number of young children treated may include the paucity of mental health professionals specializing in infant mental health, children’s lack of contact with adults who are knowledgeable about normal and abnormal child development, and underfunding and consequent poor quality ofsome child day care services that might otherwise be able to make a referral. We suggest that organizations of mental health professionals augment their educational programs and lobby for improved standards for the training ofchild care providers to encourage identification, referral, and assessment ofyoung children with mental health problems. Few early identification and intervention programs are available for children with mental health problems. The high proportion of adolescent cases in this sample is consistent with other reports of mental health service utilization. In a study of all high school students in a semirural county near New York City, 35.1 percent of students with psychiatric disorders received some kind of assistance for their problems (1 2). In another study, 48 percent of teenagers with disorders sought help from some source either on their own on on their parents’ initiative (4). In that
December
1992
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$43,800,000
% 65 35
100
study, 20 percent of female adolescents and 7 percent of male adolescents without disorders also reported seeking help for mental problems. These utilization rates are higher than those for the child population (1,2). There are several reasons for the high utilization ofmental health services by adolescents. Adolescents are a very visible population in modern American society, and awareness of their mental health problems is widespread. The marketing of mental health services for adolescents, especially inpatient services, may improve casefinding and referral for all levels of care. However, Offord and associates (6) found no difference in utilization rates between children four to 1 1 years old and teenagers 12 to 16 years old. Further studies cxamining the prevalence of mental disorders and the utilization of services by different age groups would be helpful in identifying gaps in the service delivery system. In our study, only slightly more males than females in all age groups were seen for psychiatric care. Epidemiologic studies suggest that the ratio ofmales to females with psychiatnic diagnoses depends partly on the age ofthe subjects. Anderson and associates (1 ) observed a male-to-female ratio of I .7 to 1 among 1 i-yearold children with psychiatric disorders. On the other hand, Costello (2) found nearly equal numbers of boys and girls (seven to 1 1 years old) with psychiatric disorders. However, in two studies of adolescents, females were more likely than males to have a psychiatric diagnosis. McGee and colleagues (4) found that 1 .4 times as many females as males had a psychiatnic diagnosis. Kashani and as-
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Table 4 Number ofpatients
seen and reimbursements
received
by outpatient
mental
health
Total
Psychologist Psychiatrist Community
mental
Mean reimbursement
Amount
4,830
$438
$2,120,000
%
Amount
%
4,565
265
1,212,000
23
$ 4,294,000 4,032,000
28 26
4,320
250
1,081,000
21
4,827,000
31
700,000
2,422
289
-
-
Total
9,916
A total of 1,219
3 Unduplicated
For adults
41
outpatient
service
1
19881
reimbursement
and adolescents seen
Other2
2 Includes
in Minnesota,
health
center Hospital-based
providers
For children and adolescents
N children
Provider
service
nurses
inpatient and physical patient
hospitalizations
$520 in 1988.
occurred
13 1 100
52,000 $5,165,000 The mean
reimbursement
per
hospitalization
1,655,000 541,000 $15,359,000
11
4 100
was $8,556.
therapists
count
sociates (3) reported a female-tomale ratio of 1 .3 to 1. Minority youngsters were overrepresented, relative to their representation in the state population, among the children and adolescents who received outpatient mental health services. This finding may reflect the overrepresentation of minonity families among those eligible for medical assistance programs. The percentages of minority children among those who were eligible for care through medical assistance programs and among those who utilized care are not available. However, such data could be useful in future studies of the influence of cultural and ethnic issues on access to and utilization ofmental health services. Although adjustment disorder was the most frequent diagnosis reported, this label may not reflect patients’ true conditions. Many clinicians consider adjustment disorder a benign diagnosis and may select it for billing purposes to avoid stigmatizing their patients. According to DSM-III-R, adjustment disorder does not continue for more than six months and thus cannot be an accurate diagnosis for a child in treatment for more than a year (13). Despite this criterion, many patients with this diagnosis were treated for several years, as Table 2 shows. These patients may be misdiagnosed or aSflicted with a comorbid condition
that
should be identified and given treatment. For example, the diagnosis of major depression represented only .9 percent of cases, suggesting marked underdiagnosis of this disorder. This study has several limitations. First, although we can be confident that the number ofchildren and adolescents who received publicly funded mental health services was accurate, the percentage ofthe population eligible for medical assistance who required care could only be estimated. Therefore, the utilization rates we report are estimates. In fact, the rates ofutilization may be overestimated because rates of psychiatric illness may be higher in samples drawn from lower socioeconomic groups. A study comparing utilization of services among different socioeconomic groups is needed. Also, it should be noted that some children with psychiatric diagnoses do not require referral for outpatient mental health services. For example, children with simple phobias may not be referred for treatment unless marked functional impairment is present. In future studies, the validity of diagnoses given to patients should be closely evaluated. Factors influencing diagnostic decisions, including concerns about labeling and stigma, differences in the diagnostic skills of practitioners, and the variety of psy-
chiatric symptoms expressed by children under chronic stress, all affect diagnostic validity. Our findings on the costs of mental health services show a dramatic increase in state allocation for inpatient care for children and adolescents with comonbid diagnoses of mental illness and chemical dependency. However, the data are limited to a two-year period, and therefore firm conclusions about patterns of cost for inpatient versus outpatient services cannot be made. Future studies evaluating costs of children’s mental health services in the years after the study period (1989-92) will determine ifthis trend continues. Because the study sample cornpnised patients who used public funds to pay for mental health care, questions must be raised about the generalizability of our findings to other populations. Further understanding of utilization rates may be derived from comparisons of clinic attendance in urban versus rural, wealthy versus poor, economically stable versus changing, and servicerich versus service-poor localities.
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1992
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Acknowledgments work was partly supported by the Wisniewski fellowship of the Office of Mental Retardation of the State of New York. The authors thank Lois Laitinen for help in preparing the manuscript. This
and Community
Psychiatry
References 1. AndersonJC, Williams 5, McGee R, etal: DSM-III disorders in preadolescent children: prevalenceinalargesamplefrom the general population. Archives of General Psychiatry
44:69-76,
1987
2. Costello EJ: Child psychiatric disorders and their correlates: a primary care pediatric sample. Journal of the American Academy ofChild and Adolescent Psychiatry 28:851-855, 1989 3. KashaniJH,BeckNC,HoeperEW,etal: Psychiatric disorders in acommunity sample of adolescents. American Journal of Psychiatry 144:584-589, 1987 4. McGee R, Feehan M, Williams 5, et al: DSM-III disorders in a large sample of adolescents.
Journal
of the
Indicators in Three
The authors departments
are affiliated with the of psychiatry and at the Medical in Milwaukee and medicine
College of and the services
psychiatry of the Veterans Affairs Medical Center, 5000 West National Ayeflue, Milwaukee, Wisconsin Address
correspondence
to Dr. Rudman.
Hospital
6. Offord
1 1 . Taube Health,
and Community
DR, Boyle MH, Szatmari P. et al: child health study: II. six-month ofdisorder and rates of service utilization. ArchivesofGeneral Psychiatry 44:832-836, 1987 7. Saxe L, Cross T, Silverman N: Children’s Ontario prevalence
mental
health: and what
the
gap
between
what
know we do. American ogist 43:800-807, 1988 8. Tuma J: Mental health services dren: the chologist
9. Inouye
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of Adverse Somatic Outcome Veterans Affairs Nursing Homes
Frequencies of undernutrition, bedsores, and deterioration in activities of daily living were cornpared in three Veterans Affairs nursing homes serving both chronic psycbiatricpatients and medical or neurologicalpatients. The threefacilities varied in the proportions of patients with adverse outcomes, with one home having noticeably higher rates for both subgroups of patients. In each home, the two subgroups were equally likely to show evidence of adverse outcome,
53295.
10.
American
Luca Alverno, M.D. Dale E. Mattson, Ph.D. Daniel Rudman, M.D.
medicine Wisconsin
AcademyofChild and Adolescent Psychi29:61 1-619, 1990 5. Rutter M, lizard J, Yule W, et al: Isle of Wight studies, 1964-1974. Psychological Medicine 6:31 3-332, 1976 atry
Psychiatry
suggesting that differences in the requency of adverse outcomes among the facilities were accountedfor by extrinsic factors rekited to quality ofcare rather than intrinsic factors related to patient characteristics.
f
Q
uality assurance examines three dimensions of health care systems: structure (physical facilities and staffing), process (how care is delivened), and outcome (what happens to the patient). The Institute of Mcdicine and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) have recommended that quality assurance activities in nursing homes give more attention to monitoring of adverse physical outcomes (1,2). The goal of the study reported here was to investigate three types of adverse somatic outcome-undernutrition, bedsores, and loss of activities of daily living-among residents of three nursing homes opcrated by the Department of Veterans Affairs (VA). Adverse outcomes may have intrinsic or extrinsic causes
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1992
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(1). Intrinsic causes are related to patient characteristics such as age, sex, level ofdependency, and the natune and severity ofpnimany and secondary morbid conditions. Extrinsic causes are related to the quality of the patient’s environment, which includes physical, psychosocial, and clinical care. To learn more about the relative effect on outcome ofintninsic and cxtninsic factors, we compared the incidence in the three nursing homes of undernutrition, bedsores, and loss of activities ofdaily living. Within each home, we compared the incidence of those outcomes among patients with medical or neurologic conditions and among psychiatric patients. The majority of the patients in each home had a chronic medical or neurologic condition. However, as a consequence of the depopulation of the state mental hospitals in the 1 960s (3-5), a substantial number of chronic psychiatric patients also received care in the nursing homes. The homes provide medical, psychiatnic, nursing, dietetic, rehabilitative, and recreational services to their residents.
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