Mental Illness and Substance Use Hospitalizations in New Hampshire,

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1 Mental Illness and Substance Use Hospitalizations in New Hampshire, May, 2008 Part of the Access New Hampshire: Living with Disability in the Granite State Project To learn more about the Access Project or to download the companion policy brief, please visit us at Questions / Comments: Please contact: Peter Antal, Ph.D. Melissa Mandrell, MSS, MLSP Institute on Disability/UCED Tel/TDD: Fax: Peter.Antal@unh.edu The contents of this document were in part developed by grants from the U.S. Department of Health and Human Services, Administration on Developmental Disabilities (90DD0618), the New Hampshire Department of Education, and the New Hampshire Department of Health and Human Services, Bureau of Developmental Services (13H080). However, these contents do not necessarily represent the policies or the endorsement of the federal government or the New Hampshire state government. The Institute on Disability at the University of New Hampshire was established in 1987 to provide a coherent university-based focus to improve knowledge, policies, and practices related to the lives of persons with disabilities and their families and to promote the inclusion of people with disabilities into their schools and communities. Institute on Disability/UCED 1

2 Overview The intent of this paper is to develop an informed understanding of hospital care utilization among New Hampshire residents with mental illness or substance use conditions. We have relied upon the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for the primary diagnosis, as well as the External Cause of Injury Code (E-Code) assigned by the hospital staff to identify hospital visits for patients with mental illness and/or substance use. Our review of data from provided insights into the following areas: Changes in the demographics of hospital patients including: an increase in youth with mental illness or substance use who are hospitalized, and increases in certain conditions, including bipolar and anxiety disorders. Patterns of utilization while repeat patients comprise only a small proportion of those seeking hospital care, repeat visitors were more likely to have co-occurring disorders of mental illness and substance use. Patterns of service including hospital admitting and discharge practices for patients with primary diagnoses of mental illness or substance use and differences in access to acute care depending upon geography. Patterns of charges and coverage rapidly escalating charges for hospital level care combined with a lack of increase in length of hospital stay, decreasing private insurance coverage for hospital visits for mental illness or substance use, and the long term financial impact for patients with co-morbid conditions of mental illness and substance use who repeatedly seek hospital care. Risks associated with a lack of health care coverage repeat patients are more likely to be self pay and thus may not be able to obtain effective long-term mental health care. Patterns of identification physicians at inpatient and ambulatory care facilities are more likely than they were 10 years ago to identify conditions related to mental illness or substance use as contributing factors for hospitalization. Although the focus of the report is on hospital data, this analysis provides important information about trends for diagnosis and treatment of mental illness and substance use. The number of individuals who seek hospital care for mental illness or substance use has increased, and the number of hospitals available to provide specialty care has decreased. Insurance coverage for individuals seeking hospital care most frequently for mental health and substance use issues is shifting from private to public carriers. These and other conclusions drawn in this report indicate that much remains to be done if New Hampshire is to successfully address the changing needs of its residents. 2

3 Mental Illness and Substance Use Hospitalizations in New Hampshire, Overview (p.2) Topics of Interest Identifying hospital visits for mental illness or substance use (p.4) I. What are some of the characteristics of patients who are hospitalized for mental illness or substance use conditions? (p.6) II. III. IV. Since 1997, how have hospitalization rates changed for conditions related to mental illness or substance use? (p.11) What are the charges incurred for mental illness and substance use hospital visits? What has changed over time? (p.18) What do the data tell us about those patients who have primary and secondary conditions related to both mental illness and substance use? (p.24) V. To what extent are mental illness and substance use identified as contributing factors for other medical conditions? (p.27) VI. How do hospitalization rates for mental illness or substance use vary across the state? (p.30) Report Summary (p.34) Appendix A: List of Mental Illness and Substance Use Conditions (p.36) Appendix B: List of New Hampshire Hospitals (p.41) Appendix C: Supplemental Tables for Figures (p.42) Appendix D: Rate of Hospital Visits Per 10,000 Population, Hospital Discharge Data (p.46) 3

4 Identifying Hospital Visits for Mental Illness or Substance Use This report focuses only on hospital utilization and does not address services or care provided in other settings. Information on other aspects of the state s mental health service system is available from the Legislative Commission on Mental Health, NH Center for Public Policy Studies, NAMI NH, the NH Hospital Task Force, NH Council on Developmental Disabilities, NH Council for Children and Adolescents with Chronic Health Conditions, and Granite State Independent Living. In Fall 2008, the Institute on Disability will release a study on consumer perspectives of the services provided by New Hampshire s Community Mental Health Centers. Unless otherwise noted, this report utilizes the primary diagnostic or E-Code field to define the reason for a particular hospital visit. Our decision to use the ICD-9 and E-codes to identify a mental illness or substance use visit was based on a review of the research literature, consultation with health statisticians, and input from the project s Advisory Board. The reader should note that the data considered for this brief do not include cognitive and personality changes secondary to medical conditions (e.g., Alzheimer s disease and other dementias, traumatic brain injury, hypothyroidism). Other areas commonly included in a set of DSM-IV criteria, such as sleep disorders, or conditions that may have a broader social interpretation (including a range of conditions related to sexuality), also are not included. The focus for this brief is on mental health conditions such as anxiety, depression, personality disorders, bipolar, paranoia, schizophrenia, other affective disorders, and substance use. Substance use includes conditions related to alcohol abuse and licit or illicit drug use, including alcohol dependence, alcoholic psychoses, drug dependence and psychoses, poisoning from drugs or alcohol, and toxic effects from alcohol. There is an overlap with certain codes used to identify mental illness (knowingly taking or overdosing on substances) or substance use (related to poisoning by opiates, sedatives, analgesics, psychotropic agents, and stimulants). This overlap, which accounts for 10% of ambulatory care visits for mental illness, does not have an appreciable effect on the larger context of co-occurrence of mental illness and substance use. A full list of the individual conditions and E-codes used to identify visits for mental illness or substance use are provided in Appendix A. Data Notes and Limitations Data presented in this report reflects information submitted to NH Department of Health and Human Services (NH DHHS) from the state s inpatient, ambulatory, and specialty hospital care settings from 1997 through Our data set includes: Inpatient data on patients at New Hampshire s 26 acute care hospitals, 10 of which currently provide dedicated beds for patients with mental illness. Length of stay for these hospital visits can vary from one to 300+ days. Ambulatory data primarily for users of emergency departments in New Hampshire hospitals. However, this also may include data on urgent care patients, patients seen for an outpatient service at a facility or who receive ambulatory surgery, as well as those admitted for inpatient observation. Length of stay for these visits is less than one day. Note that ambulatory care patients who are subsequently admitted for inpatient services are not included in this data. 4

5 Specialty data on patients who receive specialized rehabilitative treatment at one of nine New Hampshire hospitals. Length of stay for these hospital visits can vary from one to days. See Appendix B for a list of hospitals by type of setting. Prevalence rates based on patient counts have been adjusted based on population growth estimates provided by the NH DHHS Health Statistics and Data Management Section, Bureau of Disease Control and Health Statistics, and Division of Public Health Services. Unless otherwise noted, when information on visits (rather than patients) is presented, these numbers are provided as a raw count of visits. Charges have been adjusted for inflation based on the Consumer Price Index Urban (CPI-U-RS) with 2006=100. When reviewing the data, please note the following: The data do not offer a comprehensive assessment of the prevalence of mental illness or substance use in New Hampshire. The prevalence rate is much higher, as most mental illness and substance use treatment is provided at the community level by physicians, therapists, and mental health centers; data for community-based care is not captured in this report. Additionally, the stigma associated with mental illness and the cost of treatment may prevent many from seeking mental health care except in emergency situations. The data set includes visits by out-of-state patients who seek services in New Hampshire. In part, the inclusion of out-of-state patients offsets the number of in-state residents who go outside New Hampshire for their care. (Note that the data indicating town-based prevalence visit rates are only for patients who were able to be identified as New Hampshire residents.) Charge data do not reflect actual hospital care costs. The charge information provided on the hospital discharge files provides only a proxy indicator for costs which can be tracked over time. Based on work from the NH Public Policy Center, hospital charges were estimated to be more than double actual cost. 1 A number of files reviewed did not include a unique identifier or town name. For this reason, the true town prevalence hospitalization rate may be higher than what is presented here. Of note, visits with conditions related to mental illness or substance use were no more likely than all visits to be missing a unique identifier for their visit. Improved physician training resulting in better diagnosis of mental health conditions may account for some changes in how physicians code a particular condition over time. This may account for increased identification of secondary conditions. In several instances, numerical data in this report have been rounded to the closest whole number for the reader s convenience. Lastly, where there are graphical limitations on the number of data labels that can be placed on a particular graph, the underlying data tables are included within Appendix C. 1 New Hampshire Center for Public Policy Studies. (Mar. 2007). Financing New Hampshire Hospitals: Cost-Shifting in Concord, NH. 5

6 I. What are some of the characteristics of patients hospitalized for mental illness or substance use? This section provides an overview and comparison of patient characteristics based on whether the primary diagnosis related to the hospital visit was due to a mental illness, substance use, or all conditions. Areas of comparison include age, gender, admission source, primary payment source, and patient discharge information. Between , the combined ambulatory, inpatient, and specialty hospital visits that were associated with a primary diagnosis of mental illness or substance use were 74,531 and 30,077, respectively. For comparison, the total number of hospital visits in New Hampshire for this time period was 2.5 million. Age Group All Three Settings, Total Visits Review of data by patient age indicates several differences in hospital visits for patients with mental illness or substance use conditions as compared to the total patient population. For example, the percentage of ambulatory, inpatient, and specialty visits for patients age with mental illness or substance use conditions was greater than the general patient population. This was particularly true among 30 to 49 year olds; patients in this age group with a primary diagnosis of mental illness or substance use accounted for close to half of all inpatient care visits as compared to one in five of the general hospital population. Percent of Visits by Age Group Fig. 1: Age Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty to to to 29 0 to 14 Mental Illness Substance Use All 6

7 Gender All Three Settings, Total Visits Across all hospital settings and conditions, women represented a slightly higher proportion of visits than men. This gender disparity was greater among patients presenting with mental illness. However, for patients presenting with substance use, more men than women accounted for visits in all three hospital settings. Percent of Visits by Gender Fig. 2: Gender Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Male Female Mental Illness Substance Use All Source Of Admission to Hospital Inpatient Care Settings, Total Visits Table 1: Admission Source, Among visits with a mental illness Inpatient Care, condition admitted to inpatient care, Mental Substance 50% were transferred from an Admission Source Illness Use All emergency department, 38% were N 18,093 7, ,293 physician referrals, 8% were hospital Clinic referral 1.9% 0.6% 7.4% transfers, and 4% were from other sources. Among patients with a HMO referral 0.0% 0.0% 0.8% primary diagnosis of substance use, Not available 0.0% 0.0% 0.0% over three quarters of those admitted Physician referral 38.4% 19.4% 47.9% to inpatient care were transferred from the emergency department, 19% Transfer from ER 49.9% 76.3% 38.3% were physician referrals, 3% were Transfer from hospital 8.2% 3.3% 4.9% hospital transfers, and 1% were from Transfer from legal 0.4% 0.0% 0.0% other sources. Among all visits, 48% were due to physician referral, 38% Transfer from other health facility 0.8% 0.3% 0.4% were transfers from the ER, 7% were Transfer from SNF 0.4% 0.2% 0.3% due to clinic referral, 5% were a transfer from a hospital, and less than 2% were from other sources. 7

8 Specialty Care Settings, Total Visits Data from specialty hospitals includes a broader array of Table 2: Admission Source, Specialty Care, admission sources than data Mental Substance Admission Source Illness Use All available from inpatient hospitals. N 9,666 2,613 19,571 Among patients with a mental illness condition, 51% were Acute care hospital 17.6% 18.8% 46.6% referred by a mental health Community mental health center 5.5% 1.1% 3.0% professional, 18% by an acute Court/police 0.5% 0.5% 0.4% care hospital, 13% by a physician, Educational system 0.1% 0.0% 0.1% 6% by a transitional house setting, Employer 0.0% 0.2% 0.0% 5% from a community mental Family/friend 1.9% 4.1% 1.5% health center, and 7% from other HMO/PPO 1.9% 7.3% 2.0% sources. Among patients presenting with a substance use Media/advertisement 0.0% 0.2% 0.0% condition, 24% were referred by a Mental health professional 50.6% 21.4% 29.0% physician, 21% by a mental health Nursing home 0.0% 0.0% 0.1% professional, 20% from Other 0.2% 0.3% 0.2% transitional housing setting, 19% Other managed care 0.3% 1.0% 0.3% from an acute care hospital, 7% Physician 13.1% 24.4% 10.0% from an HMO/PPO, 4% from Prison 0.6% 0.2% 0.4% family/friends, and 4% from other. Among all patient visits, Psychiatric hospital 0.0% 0.0% 0.0% 47% were admitted from an acute Self 0.2% 0.1% 0.1% care hospital, 29% from mental Transitional housing setting 5.7% 20.0% 5.5% health professionals, 10% from physicians, 5% from transitional Unknown 1.4% 0.3% 0.8% housing settings, and 9% from other sources. Discharge Ambulatory Care Settings Table 3. Discharges, Ambulatory Care, The majority of visits for Discharge Type Mental Illness Substance Use All patients with primary Number of Visits 46,772 19,948 2,068,441 conditions related to mental Against Medical Advice 1.1% 2.4% 0.4% illness (79%) or with substance Assisted Living 2.0% 1.0% 0.1% use (88%) were discharged to Died 0.1% 0.0% 0.1% home to manage their own care. Home Health Service 0.2% 0.2% 0.2% In 12% of visits with mental Home, self care 78.6% 87.6% 96.5% illness and 4% of visits with a Intermediate Care 3.8% 2.5% 1.3% diagnosis of substance use, Patient left before treatment 0.7% 0.6% 0.5% patients were transferred to Redirected to appropriate provider 0.1% 0.3% 0.0% Transfer to inpatient in same hospital 1.1% 1.0% 0.4% another facility. The remaining Transfer to Other Facility 12.3% 4.5% 0.4% eight categories account for the rest of the discharges. Note that visits for patients with mental illness or substance use conditions 8

9 were three to six times more likely to result in a discharge against the medical advice of the attending physician than all visits. Discharge findings for patients with mental illness and substance use conditions contrast sharply with the general population where 96% of ambulatory care visits result in discharges to self care at home. 2 Inpatient Settings Patients seeking inpatient care for mental illness were much more likely (78% vs. 63%) to be discharged to self care at home than all inpatient visits. Patients with a substance use condition were slightly more likely than all patients (64% vs. 63%) to be discharged to home. For both patients with mental illness and substance use, the next most likely source for discharges were transfer to another facility (8% of MI, 15% of SU) and Intermediate Care (6% of MI, 7% of SU). Patients with mental illness or substance use Table 4. Discharges, Inpatient Care, Discharge Type Mental Illness Substance Use All Number of Visits 18,093 7, ,293 Against medical advice 3.5% 6.6% 0.7% Assisted living 2.7% 1.8% 0.9% Died 0.3% 1.6% 2.2% Home health service 2.3% 4.3% 16.2% Home, self care 77.6% 64.0% 63.0% Intermediate care 5.9% 7.1% 14.2% Transfer to other facility 7.8% 14.7% 2.7% conditions were much more likely to be discharged against medical advice as compared to all conditions. Specialty Care Settings Among specialty care settings, patients with mental illness or substance use conditions were much more likely to be discharged to self care at home than all visits. Among patients with mental illness, 85% were discharged to home, 7% to assisted living, 2% to intermediate care or partial hospitalization, 2% were discharged against medical advice, and less than 1% were transferred to other facilities or home health services. Among patients with substance use conditions, 88% were discharged to home, 5% discharged against medical advice, 4% to assisted living, Table 5: Discharges, Specialty Care, Source Mental Illness Substance Use All N 9,666 2,613 19,571 Against medical advice 2.5% 4.7% 2.2% Assisted living 6.7% 3.8% 4.2% Died 0.0% 0.0% 0.1% Home health service 0.2% 0.3% 16.4% Home, self care 85.5% 88.4% 63.5% Intermediate care 2.4% 1.9% 11.9% Partial hospitalization 2.1% 0.1% 1.1% Transfer to other facility 0.7% 1.0% 0.6% 2% to intermediate care, and less than 1% to partial hospitalization or home health services. Among all patients, this group was less likely to be discharged to self care at home (63%) and much more likely to be discharged to a home health service or to intermediate care. 2 Individuals who are discharged to self care at home may still seek mental health and substance treatment services through available community resources. 9

10 Payment Source Payment Source, All Three Settings, Total Visits Private payors (e.g. Anthem, Harvard Pilgrim) represented the largest payment source for patients with a diagnosis of mental illness or substance use. However, among ambulatory and inpatient care visits, the proportion of visits paid for by private payors was less than all visit types combined. Of note, inpatient visits that were categorized as self-pay made up one in four of substance use visits, one in six of mental illness visits, and only one in 20 visits among all patients. Percent of Visits by Payor Fig. 3: Payor Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Self Pay Private Other Medicare Medicaid Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Mental Illness Substance Use All Section Summary Compared to all patients, important differences were found among patients presenting with mental illness or substance use. In general, patients with these conditions were more likely to be admitted to inpatient care as a result of a transfer from the emergency department (rather than a physician or clinic referral) and to be discharged from ambulatory care settings to other services. Patients in this group were less likely than all groups combined to have their visits covered by private insurance. Patients with mental illness were more likely to be women and more likely than other groups to be transferred from another hospital to inpatient care, or referred by a mental health professional for specialized care. Additionally, they were more likely than other groups to be discharged from inpatient care to self care at home. Patients with substance use conditions were more likely to be men or were more likely to be admitted to specialty hospitals via referrals from physicians, transitional housing settings, HMO/PPO, or family and friends. 10

11 II. Since 1997, how have hospitalization rates changed for conditions related to mental illness or substance use? In this section we provide an overview of utilization rates across the three care settings ambulatory, inpatient, and specialty with a focus on considering what factors may be driving the changes in utilization rates. Areas reviewed include patient age, repeat visits, and specific conditions presenting at the time of admission. It is important to note that the closure of specialty hospitals has resulted in a substantial drop in the number of New Hampshire patients seen in specialty care settings. Over the past decade, the following specialty hospitals have closed: Seaborne Hospital (Dublin, CLOSED 1998), Seminole Point Hospital (Sunapee, CLOSED 1998), Charter Brookside Behavioral Health Systems (Nashua, CLOSED 2000), and Beech Hill Hospital (Dublin, CLOSED 2002). Hospitalizations for Mental Illness or Substance Use In New Hampshire the rate of all patients, regardless of condition, receiving services in an inpatient, ambulatory, or specialty care setting between 1997 and 2006 increased by 12%, from 2,622 to 2,943 per 10,000 people (accounting for over ¼ of the state s population). During this same period, patients receiving care for a mental illness condition increased from 89 to 101 per 10,000 (+13%) and patients admitted for substance use appears to have decreased from 51 to 49 per 10,000 (-4%). Rate Per 10,000 Population Fig. 4: Patients Hospitalized for Mental Illness or Substance Use, Inpatient, Ambulatory, and Specialty Hospital Settings, Year Average Mental Illness Substance Use Analyzing the data by hospital setting, we found a shift in the provision of care from the more intensive specialty and inpatient services to ambulatory care settings. Between 1997 and 2006, hospital rates for mental illness held relatively stable among inpatient settings (averaging 30 per 10,000 residents) and dropped in specialty settings (from 22 to 17 per 10,000). Within ambulatory settings, however, the prevalence rate increased substantially, from 55 to 76 per 10,000 people. Rate Per 10,000 Population Fig. 5: Patients Hospitalized for Mental Illness by Hospital Setting Year Average Specialty Inpatient Ambulatory 11

12 A similar pattern was found among patients with substance use conditions. Between 1997 and 2006, hospital rates for substance use held relatively stable among inpatient settings (averaging 15 per 10,000 residents) and dropped in specialty settings (from 15 to 5 per 10,000). Within ambulatory settings, the prevalence rate increased from 26 to 35 per 10,000 people. Rate Per 10,000 Population Fig. 6: Patients Hospitalized for Substance Use by Hospital Setting Year Average Specialty Inpatient Am bulatory A Look at Repeat Users of Hospital Services, All Three Settings During the period , 80% of 85,028 patients with a primary diagnosis of mental illness and 85% of 45,342 patients with a primary diagnosis of substance use came in for ambulatory care only one to two times. 17% of patients with mental illness came in 3-9 times vs. 13% of patients with substance use conditions. Less than 5% in each group came in 10 or more times over this 10 year period. Percent of Repeat Visits 100% 80% 60% 40% 20% 0% Fig. 9: Percent of Patients with Repeat Hospitalizations for Mental Illness or Substance Use, All Hospital Settings, % 84.6% 17.1% 13.5% 3.1% 1.9% Low Incidence, (1-2 Visits) Medium Incidence (3-9 Visits) High Incidence (10+ Visits) Mental Illness, N=85,028 Substance Use, N=45,342 12

13 Over time, patients with mental illness conditions were not more likely to make repeated visits to ambulatory care settings. The number of patients in this category who made only one ambulatory care visit in a year increased by 1,406. The number of those who made two or more ambulatory care visits increased by 1,079. Number of Patients 10,000 8,000 6,000 4,000 2,000 0 Fig. 10: Patients with Mental Illness Conditions, Repeat Hospitalizations Per Year, All Hospital Settings 7,635 7,776 7,956 8,298 8,481 8,740 8,801 9,041 1,744 1,718 1,820 1,974 2,129 2,206 2,316 2,379 1,339 1,332 1,386 1,464 1,564 1,665 1, Year Average 1,782 1 Visit 2 Visits 3+ Visits Those with substance use conditions who had two or more ambulatory care visits in a year increased by 55 patients vs. an increase of 241 patients who had only one ambulatory care visit in a year. Number of Patients 10,000 8,000 6,000 4,000 2,000 Fig. 11: Patients with Substance Use Conditions, Repeat Hospitalizations Per Year, All Hospital Settings 4, , , , , , ,930 5, Year Average 1 Visit 2 Visits 3+ Vis its 13

14 A Focus on Ambulatory Care Settings Differences by Age Group Even though the statewide prevalence rate for ambulatory care patients with diagnoses with mental illness increased from 55 to 76 per 10,000, there were marked differences in prevalence rates based on the age of patients. The greatest increase was among year olds (+50 per 10,000) followed by 30 to 49 year olds (+24), 50 to 64 (+14), 0 to 14 (+6), and those over 65 (+2.4). Rate Per 10,000 Population Fig. 7: Patients Hospitalized for Mental Illness, Ambulatory Care Per 10,000 Population by Age Group to to to to Year Average Our findings were similar for patients with a primary diagnosis of substance use. The greatest increase was among year olds (+22 per 10,000) followed by 30 to 49 year olds (+10), and 50 to 64 year olds (+9). Less then 2 points of increase was seen in those over 65 and those under 14 years of age. Rate Per 10,000 Population Fig. 8: Patients Hospitalized for Substance Use, Ambulatory Care Per 10,000 Population by Age Group to to to to Year Average 14

15 Differences in Conditions Tables 5 and 6 compare changes in ambulatory care visits for mental illness and substance use related conditions for the time period and In reviewing these tables, the reader should note that counts for emergency department visits that result in an inpatient admission are not included in this table. This is particularly relevant as 50% of mental illness and 76% of substance use inpatient admissions are transfers from hospital emergency departments. Table 5 Change in Ambulatory Care Mental Illness Visits, vs Group Change in Visits Percent Change Disturbance of Emotions Childhood % Bipolar Affective Disorders 1,523 3,186 1, % Other Non-Organic Psychoses 961 1, % Depressive Disorders 8,351 13,350 4, % Schizophrenic Disorders 1,271 2, % Paranoid Delusional % Personality and Anxiety Disorders 9,825 14,609 4, % Poisoning by Substances 3,081 4, % Self Inflicted* 2,322 3, % Disturbance of Conduct % Adjustment Reaction 1,951 2, % Physiological Malfunction Arising from Mental Factors % Other** % Total 31,273 46,772 15,499 * Self Inflicted includes late effect of self injury. ** Other includes: special symptoms not specified, and psychoses with or specific to childhood As shown in Table 5, visits for disturbance of emotions in childhood and bipolar affective disorders more than doubled since the time period. Areas increasing by about 50% or more include: other non-organic psychoses (81%), depressive disorders (60%), schizophrenic disorders (57%), paranoid delusional (55%), and personality and anxiety disorders (49%). Other areas of increase include: poisoning by substances (31%), self inflicted injuries (30%), disturbance of conduct (28%), adjustment reaction (12%), and physiological malfunction arising from mental factors (1%). All other mental illness condition types increased by 24%. Table 6 documents that the greatest proportional change among substance use visits occurred among those identified with drug psychoses (169%). Close to a 50% increase was observed among conditions for drug use (55%), drug dependence (52%), and alcohol use (48%). Other areas of increase included alcoholic psychoses (29%), self-inflicted poisoning (16%), and other (43%). One category showed a drop in visits. Codings for alcohol dependence dropped by 19% (possibly as a result of being coded under the alcohol use category). 15

16 Table 6. Change in Ambulatory Care Substance Use Visits, vs Group Change in Visits Percent Change Drug Psychoses* 610 1,642 1, % Drug Use 3,976 6,169 2, % Drug Dependence % Alcohol Use 4,860 7,175 2, % Alcoholic Psychoses % SI Poisoning % Alcohol Dependence 3,077 2, % Other** % Total 14,328 19,868 5,540 * Of note, while ambulatory care settings demonstrated a substantial increase in Drug Psychoses over time, there was a drop in these visits within the inpatient and specialty care settings. ** Other includes: alcohol/drug pregnancy/fetus, poisoning by alcohol deterrents, and tobacco use disorder Section Summary While the rate of hospitalization for mental illness has been on par with all conditions, the rates for substance use appear to have declined. Our data from the three hospital settings documents a shift in care. During the past 10 years, hospitalization rates for specialty care have dropped substantially, inpatient care has kept pace with population growth, and ambulatory care visits have increased dramatically, particularly among patients presenting with mental illness or substance use conditions. While ambulatory care rates across all conditions increased by 17%, the rate of patients with conditions related to mental illness or substance use increased by 39% and 37% respectively. A closer review of the ambulatory care data for patients presenting with mental illness or substance use shows that patient visits among most age groups have been consistent with population growth. However, ambulatory care visits among patients with mental illness or substance use age and have increased at a much faster rate. The data appear to indicate that repeat visitors are not the major driver in the increase in hospitalizations. In reviewing 10 years of data, 80% of patients with mental illness and 85% of patients with substance use conditions sought ambulatory care only 1-2 times during the ten year period (note however that this information is skewed as patients who are admitted to the emergency department but then transferred to inpatient care are not counted as ambulatory care patients). 3 Less than 5% of patients with mental illness or substance use came in for care 10 or more times in the period studied. Our review found little change in the distribution of specific conditions that are subsets of mental illness and substance use. Over one in four of visits for patients with mental illness were related to either personality and anxiety disorders or depressive disorders. Among patients with substance use conditions, about one in three visits were for drug or alcohol use. Alcohol dependence accounted 3 Of the 9,025 inpatient visits transferred from ER between : depressive disorders accounted for 35%, poisoning by drugs (21%), schizophrenic disorders (8%). All other categories were under 5%. 16

17 for 12% of visits while drug dependence accounted for 4%. Eight percent of visits involved drug psychoses compared to only 4% for alcohol psychoses. For the period between and , the overall distribution of specific conditions did not change substantially. The exception to this was alcohol dependence, which made up 21.4% of visits in the period and only 12.5% of visits in the period. Of note, the actual number of ambulatory care visits increased by over 1,000 in the following areas: personality and anxiety disorders, bipolar disorder, depression, alcohol use, drug use, and drug psychoses. 17

18 III. What are the charges incurred for mental illness and substance use hospital visits? What has changed over time? In our study we looked at the fiscal impact of providing care for patients with mental illness or substance use conditions. The reader should note that there may be wide variation between the charge associated with a hospital visit and the actual cost. In an analysis of audited financial data 4, Doug Hall of the NH Center for Public Policy Studies found the ratio of gross charges divided by total operating expenses had increased from 1.5 in 1997 to 1.9 in In other words, by 2004, total charges were nearly double that of operating expenses incurred by hospitals. In addition to variance by hospital, the charge vs. cost ratio may also vary widely based on the condition addressed. We reviewed changes in total charges over time and across hospital care settings. We analyzed charges for ambulatory and inpatient visits, focusing on coverage of total visits by payor type (private insurance, Medicare, Medicaid, self-pay, and other) and changes to the average charge per visit by payor type. Total Charges Over Time For primary diagnoses related to mental illness or substance use, total charges across the three hospital settings has dropped over 10 years, from $144 to $136 million among patients with mental illness and from $48 to $44 million among patients presenting with substance use conditions. During this same time period, hospital charges for all conditions have increased substantially, from $2 billion in to $3.6 billion in the period. Since the period, specialty care hospital visits have dropped from 22 to 17 per 10,000 among patients with mental illness, and 15 to five per 10,000 among patients with substance use conditions. The change in charges for this population of patients is in large part driven by the cut in services offered through specialty care settings. Charges in specialty care settings for patients with mental illness have dropped by $35 million during this time period (-40%), while charges for inpatient care have increased by $17 million (+34%) and for ambulatory care, by $10 million (+165%). Total Charges Fig. 9: Total Charges of Mental Illness Hospital Visits, by Setting $100,000,000 $80,000,000 $60,000,000 $40,000,000 Specialty Inpatient Ambulatory $20,000,000 $ Year Average 4 Provided by NH Hospital Association of NH hospitals (does not include rehab hospitals or the NH State Hospital). 18

19 Specialty care charges for patients with a primary diagnosis of substance use have dropped by $20 million (-76%). During this period inpatient charges increased by $10 million (+55%) and ambulatory care increased by $6 million (+133%). Total Charges Fig. 10: Total Charges of Substance Use Hospital Visits, by Setting , $40,000,000 $30,000,000 $20,000,000 Specialty Inpatient Ambulatory $10,000,000 $ Year Average A Focus on Inpatient Care and Payor Source Mental Illness While inpatient mental illness visits have been increasing over time, coverage of these visits by private payors has fallen. Between the time periods and , total visits covered by private payors dropped from 2,050 to 1,967 (-4%), while all other groups experienced an increase: Medicare (+7%), Medicaid (+13%), self pay (+42%), and other (+91%). Total Visits 2,500 2,000 1,500 1, Fig. 11: Total Mental Illness Visits by Payor, Inpatient Care Settings 2,050 2,067 2,098 2,115 2,102 2,070 2,0031,967 1,758 1,695 1,706 1,712 1, ,790 1, ,847 1,886 1, ,088 1, Medicaid Medicare Other Private Self Pay 3 Year Average Average charges for mental illness inpatient visits have been steadily increasing among most payor types. Medicare received the highest average charge per visit ($14,879 for the period). Other payor sources were more consistent, averaging $9,570 for the time period. Average Charge $15,000 $12,000 $9,000 $6,000 Fig. 12: Average Charge Per Mental Illness Visit by Payor, Inpatient Care Settings Medicaid Medicare Other Private Self Pay $3,000 $ Year Average 19

20 The difference in average charges may be attributed in part to the fact that Medicare patients typically have longer lengths of stay (8.8 days on average in ) as compared to patients using other payors (5.1 days on average). Across all payor types, the average length of stay for inpatient care has been gradually decreasing, from 6.6 in to 6.2 days in Average Length of Stay (Days) Fig. 13: Length of Stay for Mental Illness Visits by Payor, Inpatient Care Settings Medicaid Medicare Other Private Self Pay Substance Use Fig. 14: Total Substance Use Visits by Payor, Inpatient Care Settings Over 10 years, total inpatient visits for substance use conditions dropped slightly, from 2,717 to 2,505, and has been holding fairly steady for the past few years. During private payors covered the most visits (853), followed by self pay (692), Medicare (546), Medicaid (366), and other sources (48). Total Visits 1,500 1, Medicaid Medicare Other Private Self Pay 3 Year Average Although total substance use visits did not change substantially, average charges rose between 53% and 76%, with the rate of increase relatively consistent among most groups. For the period, Medicare had the highest yearly average charge ($12,724), followed by Medicaid ($11,900), other ($10,914), private ($10,469), and self pay ($9,814). Average Charge $15,000 $12,000 $9,000 $6,000 $3,000 Fig. 15: Average Charge Per Substance Use Visit by Payor, Inpatient Care Settings Medicaid Medicare Other Private Self Pay $ Year Average 20

21 Patients with substance use conditions experienced a slight drop in average length of stay (from 3.75 in to 3.72 in ). For , Medicare patients had slightly longer inpatient stays, on average (4.6 days), followed by Medicaid (3.9), self pay (3.4), private (3.3), and other (3.2). Average Length of Stay (Days) Fig. 16: Length of Stay for Substance Use Visits by Payor, Inpatient Care Settings Medicaid Medicare Other Private Self Pay Year Average A Focus on Ambulatory Care and Payor Source Mental Illness In comparing payor sources for ambulatory care charges for patients with mental illness, the greatest increase was in visits covered by private payors (increased by 1,568 visits), followed by self-pay (1,243), Medicaid (1,226), Medicare (998), and other (131). Total Visits 6,000 4,000 2,000 4,234 Fig. 17: Total Mental Illness Visits by Payor, Ambulatory Care Settings 4,531 5,030 2,859 2,259 2,363 2,539 2,403 2,180 2,317 2,081 1,819 1,995 2,172 1,723 5,557 5,946 5,978 5,904 5,803 3,465 3,502 3,127 3,362 2,778 3,080 2,416 2,573 2,513 2,744 2,949 2,318 Medicaid Medicare Other Private Self Pay Year Average Between the and periods, the number of visits charged to private payors rose substantially. However, since , visits charged to private insurers dropped by 144. Since this period, visits covered by other payors increased: Medicare (+664 visits), Medicaid (+631), self pay (+375), and other (+37). For mental illness conditions, average charges increased by 77%, with most of the increase occurring since 2001 across all payor groups. In 2001, the average charge for a mental illness visit was $625; by 2006, average charges per visit had increased to $1,184. Average Charge $1,200 $900 $600 Fig. 18: Average Charge Per Mental Illness Visit by Payor, Ambulatory Care Settings Medicaid Medicare Other Private Self Pay $300 $ Year Average

22 Substance Use Over the ten year period studied, substance use ambulatory care visits increased for all payors: private (+643), self pay (+505), Medicaid (+347), Medicare (+313), and other (+48). Similar to visits for mental illness conditions, visits covered by private payors have flattened out since the 2003, increasing by only 4%. All other payors have experienced increased visits from 11% to 39%. Total Visits 3,000 2,500 2,000 1,500 1, ,799 1,724 Fig. 19: Total Substance Use Visits by Payor, Ambulatory Care Settings 1,828 1,792 1,931 1,841 2,151 2,000 2,284 2,286 2,367 2,294 2,071 2,184 2,235 2, Medicaid Medicare Other Private Self Pay 3 Year Average Average charges for visits for substance use were only $956 during the period but increased from $1,166 to $1,600 between the and periods. Average Charge $2,000 $1,600 $1,200 $800 Fig. 20: Average Charge Per Substance Use Visit by Payor, Ambulatory Care Settings Medicaid Medicare Other Private Self Pay $400 $ Year Average Section Summary Over the last few years, total charges for inpatient care for either mental illness or substance use conditions have continued to rise and have overtaken charges incurred by specialty hospital units (this is due primarily to a major decrease in the number of specialty care facilities in the state). For , yearly inpatient total charges for mental illness amounted to $67.2 million; inpatient charges for patients with substance use conditions were $27.6 million. During this same period, ambulatory care charges for patients with mental illness and substance use conditions were $16.7 million and $10.7 million respectively. While charges continued to increase across the board, average length of stay has tended to drop over time. Within inpatient settings, length of stay for mental illness visits dropped from 6.58 to 6.23 and for substance use there was a slight decrease from 3.75 to For patients receiving care at 22

23 specialty hospitals, length of visits for mental illness dropped from 19.9 to and for substance use, from to 5.3. Average inpatient charges for patients with mental illness increased dramatically since The total number of inpatient and ambulatory care visits increased for all payor groups except private insurance since that time. The highest average charges per visit were for Medicare patients; this is not surprising given that this group had longer inpatient hospital stays than those covered by other payors. For inpatient hospitalizations among those with substance use conditions, total visits across all payor groups held relatively stable over the last five years; average charges for this group increased, while average lengths of stay dropped slightly. Within ambulatory care settings, there was a small proportional increase among number of charges to private payors; all other payor groups saw more substantial increases. The recent decrease in inpatient visits among individuals who are privately insured is concerning. Looking at data for 2006, across all hospital settings, 87,800 patients were covered by Medicare (187,251 visits), 54,438 by self pay (100,469 visits), 31,661 by Medicaid (75,172 visits), and 28,133 by other sources (37,784 visits). During 2006, private insurance covered 208,894 patients making 314,809 visits to hospital settings. Given the larger number of people covered under private insurance as well as the continuing population growth, we anticipated an increase in private insurance coverage to meet the needs of a growing population. Instead, we documented a drop in visits covered by private insurance for mental illness and only a slight increase in substance use visits between the and time periods. The substantial increase for mental illness or substance use charges in ambulatory care settings (+167% / +134%) was surprising since the total number of mental illness and substance use visits increased only by 50% and 40% respectively. Furthermore, our study found that over time an increasing number of patients were paying out of pocket for their health care (or were uninsured). 23

24 IV. What do the data tell us about those patients who have primary and secondary conditions related to both mental illness and substance use? The Substance Abuse and Mental Health Services Administration (SAMHSA) research on cooccurrence of mental illness and substance use indicates 20-50% of those treated in mental health settings have a co-occurring substance use disorder and 50-75% of those with a substance use disorder have a co-occurring mental illness disorder. 5 To determine if New Hampshire was in line with these national co-occurrence rates, we reviewed data across hospital settings for a 10-year period from We found that 75% of patients with a primary diagnosis of mental illness who had at least 10 hospital visits over 10 years had substance use as a secondary or contributing diagnosis for one or more of these visits 6 7. On average, 24% of all visits for patients with a primary diagnosis of mental illness included a secondary diagnosis of substance use. 8 Table 8. Patients with Primary Diagnosis of Mental illness: Inpatient, Specialty and Ambulatory Care, # Visits Patients Total Visits Total Charge Avg. Charge Incurred During Period Per Visit Avg. Charge Incurred During Period Per Patient # Patients w/ Substance Use Secondary in Any Mental Illness Visits by Patient % of Patients # Mental Illness Visits with Substance Use Identified as Secondary Condition % of All Mental Illness Visits 1 49,851 49,851 $255,874,652 $5,133 $5,133 8, % 8, % 2 13,709 27,418 $158,728,380 $5,789 $11,578 4, % 5, % 3 5,464 16,392 $103,773,132 $6,331 $18,992 2, % 3, % 4 2,883 11,532 $74,354,851 $6,448 $25,791 1, % 2, % 5 1,694 8,470 $61,559,498 $7,268 $36, % 2, % 6 1,193 7,158 $54,007,613 $7,545 $45, % 1, % ,166 $37,463,125 $7,252 $50, % 1, % ,344 $32,038,639 $7,375 $59, % 1, % ,032 $28,076,108 $6,963 $62, % 1, % 10+ 2,310 45,619 $319,507,545 $7,004 $138,315 1, % 11, % 5 Substance Abuse and Mental Health Services Administration, (2005, February 2). Many Patients Have Co-Occurring Disorders: Both Must Be Addressed for Successful Treatment. Retrieved March 23, 2008, from Join Together web site: 6 To avoid duplicate counts in Tables 8 and 9, the series of poison codes which were used to identify mental illness and substance use visits in other sections of this report were removed from the definition for a mental illness visit. 7 The percent of patients with mental illness and substance use may actually be higher. Tables 8 and 9 document secondary conditions only among those patients with a primary condition of mental illness. A patient with one primary visit for mental illness and who is seen on a different date for a primary visit for substance use, would not show up in our data as having a history of substance use. 8 For example, for the 1,193 patients who had 6 hospital visits during this period, an average of 1.5 of those visits included a secondary diagnosis of substance use. 24

25 Similarly, we found that 93% of repeat patients with a primary diagnosis of substance use have a cooccuring mental illness condition. On average, about 39% of all substance use hospital visits included a mental illness condition as a secondary diagnosis. Table 9. Patients with Primary Diagnosis of Substance Use: Inpatient, Specialty and Ambulatory Care, # Substance # Visits Patients Total Visits Total Charge Avg. Charge Incurred During Period Per Visit Avg. Charge Incurred During Period Per Patient # Patients w/ Mental Illness Secondary in Any Substance Use Visits by Patient % of Patients Use Visits with Mental Illness Identified as Secondary Condition % of All Substance Use Visits 1 31,476 31,476 $152,890,873 $4,857 $4,857 10, % 10, % 2 6,884 13,768 $66,984,367 $4,865 $9,730 3, % 5, % 3 2,679 8,037 $38,480,975 $4,788 $14,364 1, % 2, % 4 1,343 5,372 $25,046,131 $4,662 $18, % 2, % ,890 $17,525,868 $4,505 $22, % 1, % ,288 $14,553,580 $4,426 $26, % 1, % ,415 $10,566,441 $4,375 $30, % 1, % ,968 $8,394,166 $4,265 $34, % % ,683 $7,228,499 $4,295 $38, % % ,880 $51,214,159 $3,442 $59, % 5, % In looking at the charges associated with hospital visits for mental illness or substance use, we found the overall and average charges among those who repeatedly use hospital services to be quite high. Over the 10-year period, 2,310 repeat patients accounted for a total of $320 million in hospital charges. This pattern also held true for patients with a primary diagnosis of substance use. Those 856 patients with repeated hospital visits for substance use incurred $51 million in charges over the course of 10 years. Of note, when comparing payment sources among patients with a high number of hospital visits (at least 10+ in the period studied), medium visits (3-9) and few visits (1-2), we found that payor sources changed as the frequency of hospital visits increased. As illustrated in Figs. 21 and 22, charges for low incidence patients are typically covered by private insurance (47% of all visits among patients with either mental illness or substance use conditions). Percent of Visits 100% 80% 60% 40% 20% 0% Fig. 21: Low, Medium and High Users of Hospital Services with Primary Diagnosis of Mental Illness by Payor, % 17.6% 11.9% 22.2% 17.7% 40.5% 3.7% 4.1% 2.8% Low Incidence (< 3 Visits) Medium Incidence (3-9 Visits) High Incidence (10+ Visits) 47.3% 37.1% 20.2% 21.5% 19.4% 11.1% Medicaid Medicare Other Private Self Pay

26 However, for repeated users of hospital services for mental illness, Medicare (40% of all visits) and Medicaid (23%) are the largest payors, followed by private (21%), self pay (11%), and other payors (4%). Among patients with substance use conditions, charges to self payors make up the majority (37%), followed by Medicare (23%), private (21%), Medicaid (17%), and other (2%). Percent of Visits 100% 80% 60% 40% 20% 0% Fig. 22: Low, Medium and High Users of Hospital Services with Primary Diagnosis of Substance Use by Payor, % 13.5% 9.6% 23.1% 17.7% 13.7% 2.2% 2.1% 2.5% Low Incidence (< 3 Visits) Medium Incidence (3-9 Visits) High Incidence (10+ Visits) 46.7% 36.7% 36.1% 30.6% 20.6% 27.5% Medicaid Medicare Other Private Self Pay Section Summary In our review we found that the co-occurrence of mental illness and substance use was particularly high among those patients who were repeat hospital users. Of those patients with mental illness who visited at least 10 times over 10 years, 75% also had a substance use identified as a secondary condition. Similarly, 93% of patients with a primary condition of substance use had mental illness as a diagnosed secondary condition. High users of hospital services account for a disproportionate share of overall charges incurred. The 3% of patients with mental illness conditions who were hospitalized 10+ times over 10 years accounted for 25% of total visits for mental illness and 28% of total charges. The 2% of patients with substance use conditions who were high end users accounted for 17% of all visits and 13% of total charges. We also found that hospital services for repeat users were much less likely to be covered by private insurance (only 21% of patients with mental illness or substance use conditions) and much more likely to be covered by Medicare or Medicaid. For repeat hospital users with mental illness, 11% of visits were self pay; for repeat users with substance use conditions, 37% of visits were self pay. 26

27 V. To what extent are mental illness and substance use identified as contributing factors for other medical conditions? As noted in the second section, the population prevalence rates based on a primary diagnosis or E- code across all hospital settings for mental illness has increased from 89 to 101 per 10,000 people. Among those presenting with a primary diagnosis or E-code of substance use, the rate declined slightly from 51 to 49 per 10,000 (again, in large part due to the in a decrease in specialty care services in our state). However, these rates are solely based on the primary diagnosis or E-code field and do not account for the role that mental illness or substance use conditions may have as a contributing factor for other hospital visits. Figs. 23 and 24 illustrate the prevalence rate across hospital settings when the primary, E-code, and all secondary diagnostic fields are reviewed for conditions related to mental illness or substance use. While the 300 specialty care hospital rate declines for 250 both mental illness and substance use, rates for inpatient and ambulatory care have increased dramatically over time. For patients with conditions related to mental illness, inpatient rates increased from 81 to 121 per 10,000 and ambulatory care rates increased from 96 to 220 per 10,000. Rate Per 10,000 Population Fig. 23: Rate of Patients Hospitalized for Mental Illness by Hospital Setting, All Diagnostic & E-code Fields Reviewed Year Average Specialty Inpatient Ambulatory Among patients with substance use related conditions, inpatient rates increased from 87 to 105 per 10,000 and ambulatory care rates increased from 91 to 266 per 10,000. Rate Per 10,000 Population Fig. 24: Rate of Patients Hospitalized for Substance Use by Hospital Setting, All Diagnostic & E-code Fields Reviewed Year Average Specialty Inpatient Am bulatory 27

28 While the rate of increase in inpatient settings across all diagnostic fields shows a slight increase in rate vs. using only primary field and E-code, the ambulatory discharge data indicates a possible change in how physicians in ambulatory care settings are diagnosing mental illness and substance use. As shown in Fig. 25, physicians are much more likely to identify a secondary condition related to mental illness than they were 10 years ago. A similar pattern was found in the review of data for patients with a primary diagnosis of substance use. Rate Per 10,000 Population Fig. 25: Rate of Patients Hospitalized with Mental Illness, Ambulatory Care Per 10,000 Population, Comparison of Review Types Primary Diagnosis and E- Code Only Primary/Secondary Diagnosis & Ecode Year Average To better understand the interactions between mental and physical illnesses, we reviewed inpatient 9 care files to identify the secondary conditions that were most common among patients with either a primary diagnosis of mental illness or substance use. Tables 10 and 11 show the secondary health conditions for patients who were presenting with either a primary diagnoses of mental illness or substance use. 10 Table 10. Primary Diagnosis of Mental Illness in Inpatient Settings, Percent of Visits With Specified Secondary Condition Secondary Diagnosis Condition Visits 18,093 Mental Disorders 83.3% Endocrine, nutritional and metabolic diseases, and immunity disorders 32.6% Diseases of the circulatory system 26.0% Symptoms, signs, and ill-defined conditions 24.5% Diseases of the respiratory system 18.8% Diseases of the musculoskeletal system and connective tissue 18.7% Diseases of the digestive system 16.9% Injury and Poisoning 14.4% Diseases of the nervous system 13.1% Diseases of the genitourinary system 8.1% Infectious and parasitic diseases 5.7% 9 Ambulatory care files were not included in this review; ambulatory care staff are more likely to be focused on the presenting reason for a hospital visit while inpatient staff have additional time and resources to document a more complete case history of a patient and are more likely to consistently identify co-morbid conditions. 10 Does not account for patients who present at a different time with a primary condition other than mental illness or substance use. 28

29 Among the 18,093 visits by individuals with a primary diagnosis of mental illness, over 80% of those receiving services in an inpatient setting had secondary conditions related to a range of other conditions within the mental disorder ICD-9 grouping. One in three had conditions related to endocrine, nutritional, and metabolic diseases and immunity disorders. About one in four had conditions related to diseases and immunity disorders. About one in four had conditions related to diseases of the circulatory system or symptoms, signs, and other ill-defined conditions. Less than 20% had conditions related to: diseases of the respiratory, musculoskeletal, and digestive system, injury and poisoning, diseases of the nervous or genitourinary system, or infectious and parasitic diseases. Among the 7,516 visits with a primary diagnosis of substance use, most (87%) had secondary conditions which fell under the broad category of mental disorders. Approximately 42% had secondary diagnoses related to symptoms, signs, and ill-defined conditions; 36% had conditions related to endocrine, nutritional and metabolic diseases, and immunity disorders; and 34% had diseases of Table 11. Primary Diagnosis of Substance Use in Inpatient Settings, Percent of Visits With Specified Secondary Condition Secondary Diagnosis Condition the circulatory system. About one in four had conditions related to diseases of the digestive or respiratory systems or conditions related to injury and poisoning. Less than 20% had conditions related to: diseases of the musculoskeletal system, diseases of the blood and blood forming organs, infectious and parasitic diseases, and diseases of the genitourinary system or nervous system. Section Summary Visits 7,516 Mental Disorders 87.5% Symptoms, signs, and ill-defined conditions 41.8% Endocrine, nutritional and metabolic diseases, and immunity disorders 36.4% Diseases of the circulatory system 33.8% Diseases of the digestive system 26.9% Injury and Poisoning 25.3% Diseases of the respiratory system 22.4% Diseases of the musculoskeletal system and connective tissue 14.1% Diseases of the blood and blood-forming organs 14.0% Infectious and parasitic diseases 11.1% Diseases of the genitourinary system 9.6% Diseases of the nervous system 8.4% Our research found that ambulatory care staff are increasingly likely to identify mental illness or substance use conditions as a secondary condition for an ambulatory care visit. This may indicate an increased awareness by health care providers of the interaction of mental and physical conditions. In looking at co-occurring conditions for patients with a primary diagnosis of mental illness or substance use receiving inpatient care, one quarter also presented with symptoms, signs, and illdefined conditions and more than one in ten had conditions related to endocrine, nutritional and metabolic diseases, and immunity disorders; diseases of the circulatory system; and injury and poisoning. Patients with substance use disorders were even more likely to present with co-occurring conditions including diseases of the circulatory, respiratory, and digestive systems; and endocrine, nutritional and metabolic diseases, and immunity disorders. Findings indicate that further research using an expanded review of diagnostic fields to study the connection between mental illness or substance use and other health conditions is merited. 29

30 VI. How do hospitalization rates for mental illness or substance use vary across the state? In order to develop town-by-town prevalence rates for hospitalizations for mental health and substance use conditions, we worked with the New Hampshire Bureau of Health Statistics to obtain hospitalization information not only for our own state, but also for residents who sought care in Maine, Vermont, and Massachusetts. The reader should note that the accompanying maps showing prevalence rates by town are based on number of hospital visits per 10,000 population, rather than a unique count of patients. 11 Total visits are drawn from hospital discharge data; in our review we looked at only the primary diagnostic and E-code fields. Data points for individual towns are included in Appendix D. 12 The maps below illustrate the geographic distribution of hospitalizations for mental illness and substance use and include a listing of New Hampshire towns with hospitals with dedicated resources available to care for patients with mental illness conditions. We have divided prevalence rates for towns into quintiles, 20% of towns with the lowest rates are in the first quintile and 20% of towns with the highest prevalence rates are in the fifth quintile. Specialty hospitals are designated with an (S), hospitals which provide services for alcohol/drug treatment are indicated with a (D), and hospitals which provide alcohol/drug treatment only when there is a primary mental illness condition present are designated by (DP). Figs. 26 and 27 show the rate of visits per 10,000 population for primary diagnoses of mental illness in ambulatory care and inpatient settings. The highest rate for ambulatory care visits were found in towns that have a hospital providing mental health care and in eastern and northwestern regions of the state. These areas, as well as Keene and surrounding communities, also had high rates of inpatient care visits. Figs. 28 and 29 show the rate of visits per 10,000 population for primary diagnoses of substance use in ambulatory care and inpatient settings. Within ambulatory care settings, low versus high rate communities were scattered somewhat randomly across the state. Towns with higher rates of inpatient care included those in the Lakes Region, those in the eastern region of the state, and in Berlin and Gorham in the North Country. 11 Use of a visit count is due to a limitation in the data provided by surrounding states. Many of these hospital files lacked a unique ID for each patient, particularly for New Hampshire residents seeking services in either Vermont or Maine. As a result, findings would be skewed towards providing higher prevalence rates in the southern tier of the state than in the northern, eastern, or western regions. 12 Readers should interpret town level data with caution, particularly for areas with small population counts (e.g. under 1,000). Even though data is aggregated over a four year period in order to help address this issue, small changes in the count of visits can still result in major changes in the overall prevalence rate. 30

31 31

32 32

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