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Mental illness and length of inpatient stay for Medicaid recipients with AIDS

Health Services Research, Oct, 2004 by Donald R. Hoover, Usha Sambamoorthi, James T. Walkup, Stephen Crystal

Minimizing length of stay (LOS) for hospitalized patients infected with AIDS without reducing quality of care or increasing frequency of hospitalization is desirable. Besides being expensive (Van Haastrecht et al. 1996), hospitalization days put AIDS patients at risk for nosocomial infections and disrupt their economic and social lives. To this end, many studies have found substantial (i.e., of two to four days) reductions in hospital LOS for patients infected with HIV have occurred since the mid-1980s (Grabau, Kaufman, and Han 1991; Markson, Turner, and Fanning 1992; Paul et al. 1999; Kelly, Ball, and Turner 1989; Stein 1994; Bonuck and Arno 1997).

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Recently several studies have suggested that psychiatric comorbidities may substantially increase the time required to treat and discharge HIV patients (Uldall et al. 1994; Uldall et al. 1998; Cheng et al. 2001). Uldall and others (Uldall et al. 1994; Uldall et al. 1998) found from 1990 to 1992 that nearly 30 percent of AIDS inpatient hospital admissions involved patients with psychiatric (including substance abuse) problems and that these patients had mean LOS 2-6 days longer (and also had shorter times to readmission to new hospital visits) than did patients without psychiatric illness. Cheng et al. (2001) found psychiatric diagnoses were associated with increased risk of > 90 days hospitalization for patients with advanced HIV disease.

These previous studies suggested that psychiatric comorbidities might increase the time needed to treat HIV conditions through various mechanisms (Uldall et al. 1994; Uldall et al. 1998; Cheng et al. 2001). For example, manifestations of psychiatric illness could impede delivery of appropriate care to AIDS patients (Uldall et al. 1994), perhaps due to inability of the patient to work with the treatment team and comply with treatment (Uldall et al. 1998). Alternatively, underlying mental illness (in particular, depression) could lower immune function and thereby increase length of hospitalization (Uldall et al. 1998). More frequent readmission to hospitals could also result if mental illness caused HIV patients to have an inappropriately short LOS (i.e., be prematurely discharged) at a previous visit (Uldall et al. 1998).

Indeed, if psychiatric illness increased hospital utilization for HIV conditions by hindering their treatment or discharge or by increasing frequency for which HIV-related care is sought, this would have major clinical significance. But other explanations for associations of mental illness with greater length of stay and more frequent readmissions of HIV patients are also possible.

Most notably, AIDS patients with psychiatric comorbidity need to be treated for two conditions (mental illnesses and HIV disease) while those without mental illness have only one condition (HIV disease) and, thus, the former might, for this reason, be expected to have greater LOS and shorter time to readmission. For example, patients experiencing acute psychiatric episodes (such as those that constitute the primary diagnosis for the hospitalization) may have more complex postdischarge care needs irrespective of HIV infection or AIDS. The need to arrange such placements might delay discharge of such patients (Bonuck and Arno 1997; Uldall et al. 1994; Uldall et al. 1998; Cheng et al. 2001; Uldall and Berghuis 1997). If this is the case, one would expect to observe greater LOS for hospitalizations of AIDS patients who are also diagnosed with a severe mental illness.

As is always the case with observational studies, confounding factors, such as access to care and severity of AIDS, may differ between persons with and without mental illness. These differences, rather than direct interaction of a patient's mental illness with HIV treatment and discharge, may influence LOS. For example, being under treatment for a mental illness may facilitate earlier recognition of HIV (Goulet et al. 2000), resulting in hospitalized HIV persons with mental illness tending to have mild-HIV conditions that require shorter LOS. To avoid biased estimates, demographic characteristics such as age and race/ethnicity also need to be controlled for, as they may be associated both with psychiatric comorbidity and length of stay.

Injection drug use (IDU) and other substance abuse further complicate direct measurement of the impact of mental illness on LOS. For example, physical illnesses that are more prevalent in this population, such as tuberculosis (GoLhib et al. 1997) and hepatitis C viral infection (Bodsworth et al. 1996), can influence hospital costs and utilization. Compared to non-IDUs with HIV, HIV patients who inject drugs had more frequent and longer hospitalizations, and greater propensity for mental illness (Stein 1994; Seage et al. 1993 ;Johnston, Smith, and Stall 1994). Substance abuse (SA) is associated with many costly and disabling mental disorders (Solomon et al. 1991; Mor et al. 1992; Solomon et al. 1998) and has been shown to influence length and frequency of hospitalizations due to overdose and other acute SA-related conditions (Seage et al. 1993;Johnston, Smith, and Stall 1995). Other potential confounders are gender, insurance coverage, social economic status, and season, all of which have been found to be associated with psychiatric illness (Eastwood and Stiasny 1978; Takei et al. 1992; Sturm and Wells 2000; McA1pine and Mechanic 2000; Stoskopf, Kim, and Glover 2001; Dal Pan, Skolasky, and Moore 1997; Fleishman and Mor 1993; Hellinger 1993; Federman et al. 2000). Among these characteristics, some studies have found: neurological disorders caused by HIV (Dal Pan, Skolasky, and Moore 1997) and insurance coverage (Fleishman and Mor 1993) were associated with increased length of stay; women received fewer hospital resources (Hellinger 1993); nonwhite patients had longer lengths of stay (Kelly, Ball, and Turner 1989; Stein 1994; Bonuck and Arno 1997); and admissions in the spring and summer had shorter LOS (Markson, Turner, and Fanning 1992). Longer LOS may increase the chance for a patient to be diagnosed with a psychiatric comorbidity as a secondary diagnosis (Cheng et al. 2001; Glesby and Hoover 1996).

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Mental illness and length of inpatient stay for Medicaid recipients with AIDS

Health Services Research, Oct, 2004 by Donald R. Hoover, Usha Sambamoorthi, James T. Walkup, Stephen Crystal

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